Also, proposed musculoskeletal ultrasound reimbursement cuts were significantly eased after the ACR argued that it is useful and safe—and often more effective than more expensive imaging.
Another success, Dr. Worthing said, was the start of unique coding for biosimilars, which he said creates a “more providerfriendly environment” in which to prescribe these drugs. Under the new coding, biosimilar reimbursements will no longer be pooled—lumping less and more expensive drugs together—but will be individualized.
E/M Coding Changes
The changes to the E/M codes are ostensibly meant to simplify documentation by blending E/M levels 2 through 5 into a single payment, requiring documentation only at level 2, which is less onerous. But the ACR and other medical organizations say the changes will lower reimbursement for more complex cases.
“What it ends up meaning—and may be an unintended consequence—is reducing access to care for our patients to see us, because it reduces reimbursement pretty severely for rheumatologists,” said Dr. Worthing. “Medicare anticipates a 3% reduction in reimbursement, which translates into a 10% pay cut.” That calculation assumes 70% overhead and 30% take-home, he said.
Several health plans have introduced policies to cut reimbursement for E/M services when billed with Modifier 25—involving distinct services on the same day—by up to 50%, in the belief they’re paying twice for certain fixed costs built into the coding. The counterargument, according to Sean Fahey, MD, chair of the ACR’s Insurance Subcommittee, is that the American Medical Association’s Relative Value Scale’s Update Committee has already addressed this overlap by reducing the value of the codes that are frequently billed with Modifier 25. The ACR and other medical societies have opposed the policy.
The ACR has led the national response to this proposal in partnership with other specialty societies, such as the American Academy of Neurology, including facilitating meetings on Capitol Hill and, with the agency, writing and coordinating a stakeholder letter from more than 130 physician and patient organizations to the Centers for Medicare and Medicaid Services (CMS), and letters from members of the U.S. House of Representatives and the U.S. Senate expressing concerns.
So far, the large national payer Anthem has rescinded its policy, but UnitedHealthcare recently announced a policy to reduce the reimbursements, Dr. Fahey said.
Step Therapy & Other Threats
Another threat, Dr. Worthing said, is the proposal to allow step therapy policies—requiring physicians first try therapies they believed are doomed to fail—in Medicare Advantage Part B.
Dr. Fahey said three trends—the reimbursement reduction for E/M, biologic drug infusion site access and coverage for viscosupplementation—are the top insurance issues threatening rheumatology.
Some payers have initiated policies with the goal of moving infusions from hospital outpatient facilities to other, less costly sites, such as a patient’s home or physician’s office.
Since 2015, Dr. Fahey said, the Insurance Subcommittee has talked to 10 different health plans about this change, advocating for patients’ access to a monitored healthcare setting for their infusions.
Dr. Fahey also said a growing number of commercial plans—mostly Blue Cross Blue Shield companies—have started to limit or eliminate coverage for viscosupplementation. The ACR has advocated continuing coverage, saying it’s a good option for patients who don’t respond well to other therapies.
Dr. Fahey reminded ACR members they can report insurance-related complaints to the subcommittee using a form on the ACR website.
State-Level Advocacy
Sen. Hutchinson
At the state level, the ACR has been busy on issues regarding biologics, step therapy and pharmacy benefit managers, said Zachary Wallace, MD, MSc, instructor in medicine at Harvard and a member of the Government Affairs Committee.
Forty-five states have laws on biosimilar switching—nine were enacted in 2018—with most requiring notification to patients of the switch within five days and allowing providers to prevent substitutions by, for example, writing “dispense as written” on prescriptions.
The ACR’s policy is that if a switch happens, the patient should be notified within 24 hours. This year, Dr. Wallace said, the ACR helped prevent two states from creating substitution rules that require no notice at all.
On step therapy, seven states considered bills—and New Mexico passed reform—to bring policies closer in line with the ACR’s goal. Its hope is that step therapy rules will be eliminated. When they are in effect, the aim is to allow physicians to override step therapy, based on a patient’s history, according to a reasonable timeline and in a way that’s easily accessible, Dr. Wallace said.
Among legislative victories on pharmacy benefit managers, Arkansas brought PBMs under the authority of the insurance commissioner. In Rhode Island, the ACR helped defeat legislation that would have codified copay accumulators, which prohibit manufacturer coupons from counting toward deductibles, making drugs less affordable.
Also this year, the ACR introduced state rheumatic disease report cards, in which each state is graded based on access, affordability, and activity and lifestyle, Dr. Wallace said. Those are available on the Simple Tasks website.
Dr. Wallace said advocating at the state level can include meetings at state capitals and in the community, along with phone, emails, letters and using social media. He put in a special word about RheumPAC, the ACR’s political action committee.
“A lot of what GAC (Government Affairs Committee) does and a lot of what the ACR does for providers and patients really wouldn’t be possible if we didn’t put our foot in the door,” Dr. Wallace said. “And the way to do that with a lot of these issues is through donations and showing these [representatives of Congress] that we support them, and we need them to advocate on our behalf.”
Political Outlook
In a look at the upcoming elections, former Senator Tim Hutchinson, now a lobbyist who works on behalf of the ACR, said the midterms have been described as “the healthcare elections,” with voters ranking healthcare higher than the economy as a motivating factor in how they’ll vote.
History, he said, might be on the side of Democrats to reclaim the House of Representatives.
“If Democrats perform only at the average—since World War II on the mid-term elections in the first term of a president—though narrowly, they will gain control of the House of Representatives,” he said.
The outcome of the midterms could have effects on everything from the fate of the Affordable Care Act to Medicaid expansion and Medicare accessibility, and the coverage and marketing of opioids, he said.
Get Involved
In a video message, U.S. Rep. Michael Burgess, MD (R-Texas), chair of the House Energy and Commerce Subcommittee on Health and an obstetrician by training, told rheumatologists they have his ear.
“It is critical for doctors and specialists to be involved in policy as it is developed. Your voice is important. Your input matters,” he said. “I’ve been in your seat before, and together, I believe we can work to reduce burdens on rheumatologists, bring reforms that are necessary and improve patient care.”
Dr. Worthing urged rheumatologists to join the American Medical Association to strengthen the field’s representation within that group, to submit comments to proposed regulations through www.regulations.gov, and to send emails and make phone calls to elected officials about important issues. “Getting your voice heard” makes a difference, he said. He asked all rheumatologists and interprofessional team members to go online to the ACR’s Legislative Action Center to communicate directly with members of Congress using prefilled messages they can personalize.
He said that although Congress and the administration have been “absorbed” in partisan battles, government shutdowns and other distractions, “the same strategies that we’ve had in the past continue to work, which are proposing common-sense approaches, fixes that maintain our patients’ access to treatments, diagnostic testing, therapies.
“Usually when those kinds of initiatives get through Congress, and passed into law, they have wide bipartisan support, and these times are no different.”
Thomas R. Collins is a freelance writer living in South Florida.
