The ACR will seek Congressional action if the Medicare Part B demonstration project proposed by the Centers for Medicare & Medicaid Services (CMS) is not significantly altered by the agency. Today, Medicare Part B generally pays physicians and hospital outpatient departments the average sales price of a drug, plus a 6% add-on, minus reductions required by the sequester. The proposed model would test whether changing the add-on payment to 2.5% (minus the sequester) plus a flat fee payment of $16.80 per drug per day changes prescribing incentives and leads to improved quality and value. CMS would update the flat fee at the beginning of each year by the percentage increase in the consumer price index for medical care for the most recent 12-month period. The comment period for the proposal ended in May, and if implemented as proposed, the project will begin in late 2016, run for five years and affect all rheumatology practices.
ACR President Joan Von Feldt, MD, MSEd, describes the demonstration project as “too broad in scope and fundamentally flawed. If [it] is not changed in scope, then our resolution is to go to Congress to legislate a change.”
This resolve is shared by several other medical societies, including the American Academy of Ophthalmology and the American Society of Clinical Oncology, which have joined the ACR in calling on the American Medical Association to “support and actively work to advance Congressional action to block the demonstration project through legislation or restriction of funding,” a resolution that the AMA’s House of Delegates passed in its most recent meeting.
What the ACR Is Doing & Why
Through the College’s Legislative Action Center, ACR members have forwarded more than 4,000 letters to Congress decrying the project, and they have penned more than 40 opinion articles in publications across the country. “Of all the issues I have been involved in with the ACR, this issue has been the most successful in terms of [the] membership standing up and making a difference,” says Will Harvey, MD, chair of the ACR’s Government Affairs Committee.
One of the ACR’s concerns is how the demonstration project would affect payment for infusion therapies that are administered in a rheumatologist’s office and other expensive rheumatology therapies. Because of the size of the reimbursement cut, and the effect of sequester, providing biologics may not be cost effective for rheumatologists – particularly those purchasing medications for prices above the average sales price. Additionally, there are no less-expensive equally-effective alternatives for biologics, in which the small flat fee might offset the reimbursement cuts. Patients will incur increased cost, burden and risk if they seek therapy elsewhere.
What If the Project Is Implemented?
The ACR is calling for several changes if the demonstration project is not withdrawn:
- Implementation in a limited geographic area so the methodology and effect can be evaluated before national implementation;
- Exemption of physician practices with 25 physicians or fewer, as well as exemptions for those in rural and medically underserved areas;
- Adjustment of the flat-fee rate; and
- Exemption for therapeutic classes of drugs and biologics that have no equally-effective cheaper alternatives.
Dr. Harvey says the ACR is in “open communication with Congress on both sides of the aisle to strategize about what we will do if the rule is not changed substantially.” The ACR will ask Congress to defund the proposal through budgetary mechanisms or to otherwise pass a bill to prevent CMS from implementing it. “We don’t want to go that route, but if it’s the only alternative, that’s what we will do,” he adds.
What You Can Do
Dr. Harvey encourages ACR members to send a letter to Congress and to local media outlets by going to the Legislative Action Center on the ACR website. “We are going to need a baseline of education on this issue to the public, so the more we [can] get this message out there, the better.”
Kathy L. Holliman, MEd, is a medical writer based in Beverly, Mass.
