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

Written By: Angus Worthing MD

In case you missed it, a new kind of medicine recently arrived in rheumatology: the biosimilar.

What exactly is a biosimilar? Well, you may know what biologics are – medicines that are given as injections or infusions for rheumatoid arthritis, psoriatic arthritis and other autoimmune diseases that have been in use since the late 1990s. Think of biosimilars as a little like a “generic” version of biologic drugs. The difference between a generic and a biosmilar is that a generic contains the exact same active ingredient as its brand name drug, whereas a biosimilar is proven to be highly similar to its brand name biologic, yet can have slight differences that do not have an effect on the way the drug works. Slight differences are expected due to the large size and complexity of biologic drugs.

Where do biosimilars come from?

Between 1998 – when the Food and Drug Administration (FDA) approved the first biologic drug for rheumatology – until 2010, biologics manufacturers enjoyed patent exclusivity without any chance of market competition.

In 2010, in an effort to reign in the high costs of drugs, Congress granted the FDA new authority to approve biosimilars through an abbreviated pathway. The FDA approval process for biosimilars is much more rigorous than for generics, because biologics are much more complex than previous “small molecule” drugs (such as pills). Regulators review data from advanced analysis in the laboratory and at least one clinical trial in patients to confirm that a biosimilar works as well as the brand name biologic, through the same mechanism of action, and without additional side effects compared to the brand name biologic.

The FDA has approved 9 biosimilars as of this writing (March 2018), but due to patent disputes and manufacturer decisions, only 3 of them are available. Two are biosimilars to Remicade (Inflectra and Renflexis) and the third is an oncology drug (Zarxio).

What can I expect if I start taking a biosimilar?

There are two scenarios in which people can start taking a biosimilar. First, a person currently taking a brand name biologic (such as Remicade), can begin taking the biosimilar (such as Inflectra or Renflexis). Or, a person who is currently not taking a biologic drug can simply start taking a biosimilar. In both instances, patients and doctors can expect that the biosimilar will work equally well – akin to a new “batch” of the biologic from a new source. This expectation comes from the rigorous FDA approval process, numerous clinical studies, and also experiences from other countries where biosimilars have already been used for several years. And biosimilars, like all drugs, are being monitored by the FDA, doctors and electronic registries for any unexpected side effects.

What can I expect if I start taking a biosimilar?

Where can I get more information?

A good way to learn about biosimilars is to ask your doctor. You can also check online resources at the FDA, or my blog at the American College of Rheumatology’s SimpleTasks site here.


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