Arthritis and Rheumatism Associates, P.C.

YOGA at Shady Grove!

Yoga is used to maintain or gain muscle tone, balance, strength and an improved frame of mind. Yoga also benefits posture, decreases pain, and increases range of motion and flexibility.

Instructor: Margaret Brozen, RYT 500
Margaret is an experienced gentle yoga teacher and believes anyone can do yoga. In her classes she encourages students to quiet the mind through breathing, flowing through gentle postures and ends the class in deep relaxation. She modifies each and every class to meet her student’s needs.

Her training has included 200 hours teacher training with Yogiraj, Alan Finger (ISHTA), and 300 hours teacher training, Susan Bowen, Thrive Yoga Studio. She has also completed certificates in Reiki 1 and 2 and Mindful Yoga Therapy for Veterans Coping with Trauma. Her gentle classes include techniques from Sarah Meeks and Dr. Loren Fishman and Ellen Saltonstall (Yoga for Osteoporosis and Arthritis). She helped develop yoga classes at Walter Reed National Military Hospital for emotionally wounded warriors and patients suffering from TBI. She teaches yoga 5 days a week throughout the Washington DC/Montgomery County area. Margaret loves sharing the joy that a regular yoga practice can bring.

Classes will be held for 5 Mondays at 6pm:

Series 3: March 30 and April 6, 13, 20, 27

ADVANCED REGISTRATION IS REQUIRED
Please sign-up at the front desk to reserve your spot or call: 301-929-4125

COST: $105 for series of 5 classes.

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Written By: Ionie Moragahakumbura, PT, DPT

Cooking without pain

Living with chronic pain can be difficult in all stages of life. In order to maintain your independence with regular activities, including cooking and taking care of your house, some modifications may be necessary to minimize exacerbation of symptoms that you may regularly experience.

 

We all must eat at some point in our day for energy. While appetites vary, a certain amount of meal preparation is required prior to eating a meal. Some suggestions related to pain-free cooking include incorporating regular rest breaks and making smaller tasks out of cooking a large meal. For a meal that usually takes one hour to make, divide it up into sections. Initially start with vegetable and meat preparation, including washing, cutting, and seasoning followed by a rest break or a stretching break. Next, partake in the cooking process. Finally, save clean-up for after another break. Many people want to push through, but slow and steady wins the race in this situation.

Other modifications might include performing some pre-preparation in a seated position or with one foot resting on top of a stool to minimize weight on a painful joint. Pulling up a stool next to the stove is also an option for dishes that need more attention like frequent stirring or adjusting heat. The upcoming fall and winter holidays often mean more cooking for those who traditionally host gatherings. Don’t hesitate to ask for help, create a potluckstyle menu or have friends come over earlier to spend time with you as your sous chef. This also applies to requesting a group effort to help clean up dishes, pack away extra food and do other clean-up after dessert is finished.

As a busy mom of a young family, I look to one-pot meals (including crockpot, stovetop, and sheet pan in the oven). This results in decreased clean up and decreased standing time waiting for food to be cooked. While my motives may be different, I save time on cooking to spend time on other things I wish to enjoy. The internet is a huge source of recipes for easy and
simple meals. Cooking shows, bookstores, and even YouTube have insightful tips to simplify cooking as well.

It is important to have an open dialogue with your therapist about the goals you wish to achieve in your course of care. Therapists are a wealth of information to help advise you not only in exercises but also with ideas about how to perform different tasks in different postures or positions to decrease your pain.

Bon appetit, or should I say, Bon a PT!

 

YOGA at Shady Grove!

Yoga is used to maintain or gain muscle tone, balance, strength and an improved frame of mind. Yoga also benefits posture, decreases pain, and increases range of motion and flexibility.

Instructor: Margaret Brozen, RYT 500
Margaret is an experienced gentle yoga teacher and believes anyone can do yoga. In her classes she encourages students to quiet the mind through breathing, flowing through gentle postures and ends the class in deep relaxation. She modifies each and every class to meet her student’s needs.

Her training has included 200 hours teacher training with Yogiraj, Alan Finger (ISHTA), and 300 hours teacher training, Susan Bowen, Thrive Yoga Studio. She has also completed certificates in Reiki 1 and 2 and Mindful Yoga Therapy for Veterans Coping with Trauma. Her gentle classes include techniques from Sarah Meeks and Dr. Loren Fishman and Ellen Saltonstall (Yoga for Osteoporosis and Arthritis). She helped develop yoga classes at Walter Reed National Military Hospital for emotionally wounded warriors and patients suffering from TBI. She teaches yoga 5 days a week throughout the Washington DC/Montgomery County area. Margaret loves sharing the joy that a regular yoga practice can bring.

Classes will be held for 5 Wednesdays at 6pm:

July 31 and August 7, 14, 21, 28

ADVANCED REGISTRATION IS REQUIRED
Please sign-up at the front desk to reserve your spot or call: 301-929-4125

COST: $105 for series of 5 classes.

VIEW FLYER

Dr. Angus Worthing
Angus B. Worthing
MD, FACP, FACR
@AngusWorthing

A belated Happy New Year to everyone! Here’s another update about what’s going on in Washington for the rheumatology community, from my perspective as a rheumatologist and volunteer chair of the American College of Rheumatology Government Affairs Committee. Please read, forward freely, and consider doing more advocacy as a New Year’s Resolution — it’s easy, fun, and very important!

On January 3, the 116th Congress gaveled into session as a split Congress with Democrats in control of the House of Representatives and Republicans still the majority in the Senate. Although partisan politics crested again in one of the longest US government shutdowns and a debate over the president’s promise to build the wall, there is some auspicious agreement by politicians on both side of the aisle that the high price and cost of drugs is a problem worth solving. Democratic proposals cover the waterfront including addressing problems of price hikes, lack of transparency, rebates to Medicaid, and even the consideration of government becoming a drug manufacturer. In response to this, and to many issues detailed below, the ACR will be reaching out to new members of Congress and key committee staff to advocate on behalf of our community, including a continued push to stop specialty tiering through the Patients Access to Treatments Act. See ACR’s recap of What the Election Meant for Rheumatology.


Here’s a breakdown of the main fronts for rheumatology advocacy in 2019: 


International Pricing Index (or “IPI”) ModelThis is a big deal. As you may have heard, the Trump administration released a model to lower drug prices in Medicare Part B (drugs given in the clinic or infusion center) last fall — see my overview here — involving 3 main components in a pending mandatory demonstration project involving half of the country:

  • use Medicare’s authority to lower drug prices about 30% over 5 years
  • remove “buy and bill” distribution system by inserting a vendor between manufacturers and providers
  • pay providers a flat fee instead of a percentage of the drug price

The ACR met with HHS Secretary Alex Azar, Jr in November to convey our concerns about the mandatory nature of any demonstration project. At end of December, the ACR and many other groups provided detailed comments to the administration. ACR’s response was crafted by a group of leaders convened to respond to the high price of drugs last summer. In order to protect the Part B drug system which currently offers exceptional access to treatments for many patients, the ACR flatly opposed the mandatory nature of any demonstration project. But since the administration may move forward with a Medicare demo this year, we offered suggestions about how to protect patients’ access to treatments going forward. This kind of constructive feedback was also provided by oncologists, dermatologists, and other specialties who will be working together with us. There’s a good recap of physician responses to the model in a recent article here:”The ACR made a number of recommendations, including making the IPI model participation voluntary; allow for an exit for participants if the program is not working for them; provide incentives that could increase gross reimbursement; increasing provider reimbursement to cover the expenses associated with dealing with vendors; and making sure the agency is adequately tracking the effect on patient access.”If the administration proposes a new demo, it will likely be proposed this spring. My guess is that they may move away from the idea of using third-party vendors, but will test a flat-fee reimbursement system. The ACR will continue to weigh in with in-person meetings as administration officials more forward, possibly with Congressional input, so stay tuned!

Medicare E/M Proposal Modified, Postponed Did you hear about the Medicare proposal last summer to reduce documentation burdens for doctors while also collapsing our billing codes, so that reimbursement for a level 2 and a level 5 visit would be the same? Well in November, after a chorus of responses led by the ACR, the administration backed down and finalized a plan to modify and delay the plan for collapsed codes. See Medicare’s overview of final physician fee schedule here. Bottom line: Medicare won’t change billing codes until 2021, and plans to keep a level 5 visit code (the most complex), while collapsing levels 2-4. This is a bit of a relief in that physicians would be reimbursed for seeing highly complex patients, but a bit concerning about blending codes for moderately complex or low complexity patients. Also, for now, of Jan 1, 2019, Medicare won’t require docs to repeat documentation of prior historical information. The ACR issued advice to doctors on the new documentation rules here. The ACR is working with other cognitive specialties on how to make sure the 2021 coding changes work best for rheumatologists and our patients.


Step TherapyNo doubt about it: prior authorization and step therapy are just the worstThe ACR opposes step therapies and other utilization management. There’s a lot going on in this arena as the Trump administration allows more step therapy in Medicare, and Congress considers helpful reforms to it. What you need to know right now: Medicare Advantage plans can use step therapy to block coverage for Part B drugs given in the office and infusion centers in 2019. Although Medicare is promising that plans will cover drugs patients are currently taking — so-called grandfathering and grandmothering — the plans are unfortunately only looking back 3-4 months to see if a patient is currently taking a drug. So they may not know that a patient is currently receiving a hyaluronic acid injection for knee osteoarthritis every 6 months, or a drug for osteoporosis every 6, 12, or 24 months, or a biologic for RA being dosed intermittently. I met with the #2 official at HHS, Deputy Secretary Eric Hargan in November to express our concerns about this and the lack of other guardrails for our patients going into 2019, and I reminded him that utilization management is pretty much the #1 worst thing about being a doctor in the US, because of all the delays and barriers to patient access to treatment, and administrative burdens for doctors. Medicare is currently seeking comments about how to change this in 2020, and ACR will be weighing in. Send your thoughts too! You can comment here before Jan 25; click on “Comment now”.


Although I’d prefer to remove all step therapy regimes, right now we’re also hoping to reform it. Legislation is expected to be reintroduced in the House to regulate step therapy, and we’re hoping for a Senate companion bill this year. ACR is in a coalition to push this right now. Tell your members of Congress to support commonsense reforms — it makes a difference! Rheumatologists can send a note through the ACR website.


Arthritis Research at the PentagonYou may know that the ACR has been pushing in recent years for a new funding stream at the Dept of Defense dedicated to rheumatic and musculoskeletal disease research. This could be our year to make it happen! The Pentagon recently told us that they strongly support this research, as a way to promote health readiness for our troops and also prevent and treat arthritis in all Americans. Congress works on this budgeting in early spring, so it’s a hot topic right now. Tell your member of Congress to support DOD arthritis research — rheums can send a note with a few clicks hereState and Local AdvocacyDr. Chris Adams and ACR staff Joseph Cantrell continue working on several local fronts through the ACR’s Affiliate Society Council. Check out their plans for 2019 here to regulate PBMs, reform step therapy, help solve our workforce shortage, and promote safe use of biosimilars. I recommend rheumatologists get involved in your state society! Personal note: my goal for 2019 is to help get a biosimilar substitution notification law passed by my City Council in the District of Columbia, working through our local medical society.


ACR Health Policy StatementsVolunteers on the ACR’s Government Affairs Committee completed our annual update to the College’s health policy statements this week, and we’ll  provide them to the ACR Board of Directors for approval soon. Shout out to the GAC and lead volunteer Dr. Chap Sampson for doing a great job representing our members and patients! Stay tuned – these will be published soon.


Thanks for reading and forwarding this. Remember: with the new calendar year, it’s a new opportunity to reaffirm your civic engagement and tell lawmakers about how to make your community a healthier place to live! A hundred new members of Congress need to hear from the rheumatology community so we can build on our progress about all the things I’ve mentioned. 

Dr. Angus Worthing

Dr. Angus Worthing

Angus Worthing MD

 
Greetings, Advocates!
 
Great news for the rheumatology community came on February 9, 2018 as the Bipartisan Budget Act of 2018 was enacted. It contained several critical health care fixes. First, after hundreds of emails, meetings, letters to the editor, an op-ed and a forceful 109-member coalition letter led by the American College of Rheumatology (ACR) to House and Senate leaders, the new law dropped plans for Medicare’s new quality payment program to threaten large cuts to medical practices for providing Part B drugs to patients, which would have threatened to close infusion centers across the country. Now, Medicare’s MIPS payment adjustments will not be applied to the costs of Medicare drugs people receive in their doctor’s office, and patients’ access to these treatments will be protected. Also, in a just-in-time victory, the law permanently repealed Medicare’s annual hard cap on rehabilitation therapy services like physical therapy, occupational therapy and speech therapy, so that our seniors can now avail themselves of the care they need and stop self-rationing. Other provisions extended CHIP to 2027; repealed IPAB (the unelected board which could have cut Medicare services without Congressional approval); made plans to close the Medicare Part D “donut hole” a year early, in 2019; increased NIH research funding $2 Billion; and oh yeah, reopened the US Government until March 23. One downside: the law reduced doctors’ promised 2019 pay raise from 0.5% to 0.25%.
 
 

 

Meanwhile, in other legislative news: Congress is still debating whether to continue DACA — which could provide legal status for immigrants, many of whom will train as doctors that would eventually care for 100,000 American patients — and whether to authorize Obamacare insurance market stabilization payments. The ACR supports these initiatives.
 
 

 

New Medicare Threats 

 
Right after we heard the great news that MIPS will no longer apply payment adjustments to Part B drug costs, the Trump Administration announced new possible proposals to that could again threaten patients’ access to some of the same critical drugs. Details appear vague, but here are the 4 main ideas:
 
 
  • allow Part D plans to restrict drug formularies more
  • move Part B drugs into Part D (read: prior-authorization delays, high copays, donut hole)
  • reduce clinics’ reimbursement margin for Medicare Part B drugs from 6% (actually 4.3% with sequester) to 3%
  • changing reimbursement from being tied to drug prices
The ACR is reaching out to CMS and our coalition partners to gather more information about these possible proposals and stands ready to work with Congress and HHS Secretary Azar’s office to protect all the different therapy options that our patients depend on, including access to Part B drugs. The good news is that the administration has signaled plans to:
  • pass drug rebate payments along to patients
  • reduce Part D out of pocket costs
  • reduce pharmacy benefits manager consolidation

Too-High Drug Costs

Most of these policy ideas relate to the too-high cost of rheumatology treatments and the effects of costs on individual patients and society. As I’ve said before, there is wide agreement that drug prices are too high. ACR’s strategy to address this is a two-pronged approach regarding the drug pricing system on one hand, and biosimilars on the other. Regarding the drug pricing system: ACR encourages lawmakers and regulators to address the problems of the PBM-pharma relationship, in which rebate payments encourage higher prices, not lower prices. Good news: lawmakers are acting! Congress continues to look into PBMS, 17 state bills have been introduced and on February 23, Virginia passed the country’s first PBM legislation of 2018. Regarding biosimilars: ACR advocates with state and federal lawmakers for a smooth transition to an era of less expensive biologics that provide safe, effective treatments accessible to more people. Also, in order to provide useful educational content the ACR released a biosimilars white paper on February 7. It was an honor to participate in this project to provide information on the scientific, clinical, and economic issues surrounding biosimilars. The ACR biosimilars white paper is open access for those who are interested.
 
 

Regulatory Advocacy

 
Aside from the ACR’s advocacy efforts on Capitol Hill, I’m glad to report that the ACR has expanded its efforts to influence federal agencies like HHS, CMS and the FDA on behalf of our profession and our patients. In 2017, the ACR more than doubled the number of letters submitted to federal agencies. Topics vary. For example, as Congress appears to be backing off from overarching efforts to repeal and replace Obamacare, the Trump Administration continues to propose regulatory reforms which will affect our patients’ access to continuous health insurance, and coverage for important services and treatments. The ACR has written several letters to federal policymakers thus far in 2018 about promoting health care choice and competition, and reducing out of pocket costs for prescriptions. We also supported the FDA’s plan to close a loophole in drug development for pediatric orphan diseases. You can check out the ACR letters to the US Government, compiled here.
 
 
 
 
Check out rheumatologist Dr. Will Harvey’s Senate testimony at a Feb 7 hearing, “From Joint Pain to Pocket Pain: Cost and Competition Among Rheumatoid Arthritis Therapies.” (His remarks start at 35:30 into the video)

 


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