While working on a 1,000-piece puzzle of our country’s national parks (a 2020 Christmas present from my sister—and yes, I intend to finish soon!), I wondered how these great lands came to be protected for all to enjoy. I learned that President Theodore Roosevelt in 1901 spent significant time and resources to develop the U.S. Forest Service and lay the groundwork for what would become the National Park System. “We have fallen heirs to the most glorious heritage a people ever received, and each one must do his part if we wish to show that the nation is worthy of its good fortune,” he said.1
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During his tenure, President Roosevelt protected 230 million acres of public land. In 1915–16, a handful of conservation advocates amassed support and successfully lobbied Congress to develop the National Park System, which now comprises more than 85 million acres, roughly 3% of U.S. land.2,3
The men (since of course it was all men at that time) who protected the U.S. wildlands knew that having a seat at the table—whether in an office or in the park—was necessary to make bold strides in advocating for public lands.2 The same is true for moving health policy forward in 2022. Consider making a RheumPAC investment this year to help enable nonpartisan meetings with lawmakers working on issues that impact rheumatology patients and our profession.
In my final year as chair of the Government Affairs Committee (GAC), I would like to give an immense thank you to our GAC members, patients, physicians and interprofessional team members for making virtual advocacy a huge success. I also feel extraordinarily lucky to work with our ACR advocacy team, including Lennie Shewmaker McDaniel, JD, director of congressional affairs; Amanda Grimm Wiegrefe, MScHSRA, director of regulatory affairs; and Dan Redinger, director of political affairs and engagement, in Washington, D.C., and Joseph Cantrell, JD, senior manager of state affairs; Adam Cooper, vice president of practice, advocacy and quality; and the rest of the team in the Atlanta office.
As we look to 2022, we can expect the second year of the 117th Congress to be shaped by our 2021 experiences with large spending bills and top-down legislation formulated in the midst of the COVID-19 pandemic.
2022 Physician Fee Schedule Final Rule
Each year, the Centers for Medicare & Medicaid Services (CMS) releases rules on physician reimbursement. It uses recommendations from the AMA Relative Value Schedule Update Committee (RUC) to guide decisions on how to pay physicians from a single pot of money. In 2021, the CMS increased the value of certain Current Procedural Terminology (CPT) codes, including those often used by subspecialties, and modified documentation requirements to reduce administrative burdens. In the 2022 Physician Fee Schedule (PFS) Final Rule, rheumatologists maintained a boost in reimbursement. In this zero-sum game, other specialties were not as fortunate, with losses in surgery, radiology and physical therapy.
Workforce advances came on multiple fronts. The Resident Physician Shortage Reduction Act (H.R. 2256/S. 834), which would fund 14,000 slots over several years, has 154 cosponsors in the House. The House-passed Build Back Better Act (BBB) added 5,000 graduate medical education (GME) positions; however, the BBB Act is currently stalled in the Senate.
Pediatric rheumatology fellowship slots are filled around 50% of the time, while adult rheumatology fellowship slots must turn away applicants. The cap on Medicare support for GME included in the Balanced Budget Act of 1997 was repealed in the final COVID-19 relief package of 2020, which added 1,000 new Medicare-funded GME full-time equivalent residency positions beginning in fiscal year 2023. The Pediatric Subspecialty Loan Repayment Program (PSLRP) was authorized by the CARES Act, and both the House and the Senate passed appropriations for $25-30 million to fund it. Alas, Congress has been funding the government through a series of continuing resolutions, which extend the previous budget agreement that did not include this funding, so we are waiting on the passage of the budget omnibus (i.e., the government’s funding package) for the program to start helping residents. The PSLRP legislation addresses the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met.
Progress has also been made at the state level on workforce issues. In 2021, Washington became the first state to allow pediatric rheumatologists to participate in its state-administered loan forgiveness programs. Georgia reintroduced the ACR-supported bill that would establish a state-based loan repayment program for all cognitive specialists; that bill will carry over into 2022.
Telehealth: Parity & Access
Prior to the pandemic, telehealth was practiced only by a few providers, primarily due to low reimbursement and geographic and originating site restrictions. With the easing of these constraints during the pandemic, we have now learned and implemented virtual options to continue to care for patients. The CMS recognizes that telehealth is here to stay. The 2022 PFS addresses elements of telehealth to facilitate patient access to care. We are tracking two pieces of legislation, the Telehealth Modernization Act (S. 368/H.R. 1332) and the Protecting Access to Post COVID-19 Telehealth Act (H.R. 366), which eliminate restrictions impacting access to telehealth care.
Regarding step therapy, the Safe Step Act (S. 464/H.R. 2163) has 108 bipartisan cosponsors in the House and would create a clear process for patients who have Employee Retirement Income Security Act (ERISA) health plans to seek exceptions to step therapy. The prior authorization bill (H.R. 3173/S. 3018), with 252 House cosponsors, streamlines prior authorization processes, including using electronic formats and minimizing use for routine treatments. The prior authorization legislation will protect patients in Medicare Advantage plans and supports reporting back to the CMS how often Medicare Advantage plans approve or deny medications and services.
Five states passed step therapy reform this year, bringing the total number of states with step therapy legislation up to 30. Additionally, Georgia, Oregon and Texas passed prior authorization reform bills. The Texas legislation included a gold card that allows providers with a 90% approval rate to be exempt from prior authorization requirements. It is the first legislation of its kind and we will work for this to serve as a model for other states moving forward.
We have sent letters to Congress urging medical research support for the National Institutes of Health (NIH) in the infrastructure legislative package and emergency funding of $10 billion to be sent to the NIH. Additionally, we have worked to dedicate a line item for arthritis in the Department of Defense Congressionally Directed Medical Research Program, as well as to request $10 billion in funding for the Centers for Disease Control & Prevention (CDC), with money directed toward the CDC Arthritis Program.
How Can You Help?
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As we look ahead in 2022, the ACR government affairs team will continue moving forward with the policies outlined above, as well as tackling some additional issues noted below.
Pharmacy benefit managers (PBMs) operate without fiduciary responsibility to patients and through opaque practices. The PBM Accountability Study Act (S. 298/H.R. 1819) would require PBMs to report to the Government Accountability Office and would study PBM practices for future legislative fixes.
Additionally, the Build Back Better Act, as passed by the House (and in the version currently stalled in the Senate), would require pharmacy benefit managers to report compensation, costs, fees and rebates every six months to group health plan sponsors. This encouraging move demonstrates an appetite for such transparency measures in Congress.
Reimbursement & Access to Care
This is one of the more pressing issues to act on. At the very end of 2021, the House of Medicine was facing cumulative 9.75% cuts to Medicare reimbursement. In the last minute of legislating, these cuts were averted by the Protecting Access to Medicare Act, but only temporarily. In the coming year, these cuts will be phased back in, and members of Congress will need to hear our voices describing how these cuts will affect patient access to care. Watch for action alerts in your inbox to add your voice to these efforts.
I look forward to an ongoing conversation about how advocacy and health policy affects you and your patients and how you can help. Please join us for an advocacy event—we would love to see you! And consider investing in RheumPAC to support nonpartisan meetings with legislators about issues that impact rheumatology patients and providers.
Wishing you and yours a happy new year full of adventure—and maybe a hike.
Blair Solow, MD, is chair of the ACR’s Government Affairs Committee and an assistant professor of medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center in Dallas.
- Theodore Roosevelt and conservation. National Park Service. https://www.nps.gov/thro/learn/historyculture/theodore-roosevelt-and-conservation.htm. 2017 Nov 16.
- Our history. National Parks Conservation Association. https://www.npca.org/campaigns/our-history.
- National Park System. National Park Service. https://www.nps.gov/aboutus/national-park-system.htm. 2021 Dec 8.