The breakdown of the main rheumatology advocacy in 2019

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”) Model This 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 Therapy No 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 Advocacy Dr. 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 Statements Volunteers 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. 

© 2024 All Rights Reserved.