The ACR’s delegation to the American Medical Association (AMA) House of Delegates (HOD) will have a busy agenda at the AMA’s annual HOD meeting, June 7–12 in Chicago.
At the meeting, the ACR delegation will lead a resolution that supports efforts to shore up the pediatric specialist workforce, including pediatric rheumatologists, and improve access to timely care. They will also co-lead four resolutions addressing issues impacting rheumatology practices and patient access, along with representing the rheumatology community in many other impactful debates slated for the meeting.
The AMA holds annual and interim meetings in June and November of each year, respectively, at which delegates from medical specialty societies and state medical associations set policy and direction for the nation’s largest physician organization.
A Critical Shortage of Pediatric Specialists
Much like adult rheumatology, pediatric rheumatology faces critical workforce shortages. There are far too few pediatric rheumatologists to meet the needs of children who need care for rheumatic conditions, and this coverage gap continues to grow.
Pediatric rheumatology, like other cognitive pediatric specialties, faces several challenging issues: a lower income than general pediatrics, despite three required years of fellowship training; high burnout rates due to higher workloads with lower numbers of colleagues; high student debt; and maldistribution of available care across regions. Lower income is a primary factor in the low recruiting rates for pediatric specialists and is mostly due to Medicaid reimbursement rates. Medicaid reimbursement rates for pediatric subspecialists are often significantly lower than private insurance and Medicare reimbursement rates, leading to financial challenges for healthcare providers and limited access to care for Medicaid-enrolled children.
The ACR’s related resolution, Pediatric Specialty Medicaid Reimbursement, seeks to address these issues. It has been filed for the HOD meeting and already has the support of the American Academy of Allergy, Asthma and Immunology; American Academy of Neurology; American Academy of Ophthalmology; American Urological Association; and Association for Clinical Oncology. If passed by the HOD, it would have the AMA:
- Make increasing Medicaid reimbursement for pediatric specialists a significant part of its plan for continued progress toward health equity;
- Work with pediatric specialty societies to develop a value-based payment model that makes pediatric specialist practices sustainable and promotes access to care and health equity among the pediatric patients; and
- Work with state stakeholders to support the implementation of the value-based payment model for pediatric specialists in state Medicaid programs.
The resolution would also take into account budget neutrality requirements and call for associated improvements to modernize Medicaid payments to be exempt from budget neutrality, in particular with regard to Medicaid demonstration projects. There will also be a push to have the AMA advocate for payment parity with Medicare for the same or similar services provided to pediatric patients under Medicaid.
The ACR’s pediatric reimbursement resolution builds on work at last year’s Interim HOD Meeting on Resolution 817, Expanding AMA Payment Reform Work and Advocacy to Medicaid and Other Non-Medicare Payment Models for Pediatric Health Care and Specialty Populations. That resolution, supported by the ACR and passed by the HOD, has the AMA prioritizing improving Medicaid payment rates due to their critical impact on patient care and patient access to care. Additionally, it:
- Added to AMA policy new support for demonstration projects, carve outs and adjustments for pediatric patients and services provided to pediatric patients within the payment reform arena;
- Called for the AMA to work with societies on payment models and to call for related payment models to be developed by the Center for Medicare & Medicaid Innovation (CMMI);
- Will have the AMA support appropriate demonstration projects, carve outs and adjustments for pediatric patients and services provided to pediatric patients within the payment reform arena; and
- Will have the AMA support and collaborate with state and national medical specialty societies and other interested parties on the development and adoption of physician-developed alternative payment models for pediatric healthcare that address the distinct prevention and health needs of children.
Rheumatology Practice & Access to Care
The ACR’s delegation is also co-leading, with the American Society of Clinical Oncology (ASCO), four resolutions addressing issues that impact rheumatology practices and patient access to care:
- Resolution 232, Medicare Advantage Part B Drug Coverage, would have the AMA advocate with Congress, through the appropriate oversight committees, and with the Centers for Medicare & Medicaid Services (CMS) to require that Medicare Advantage (MA) plans cover physician-administered drugs and biologics in such a way that the patient out-of-pocket cost is the same as or less than the amount that a patient with traditional Medicare plus a Medigap plan would pay;
- Resolution 233, Prohibiting Mandatory White Bagging, would have the AMA urge state and federal policymakers to enact legislation to prohibit the mandatory use of white bagging;
- Resolution 234, State Prescription Drug Affordability Boards—Study, would have the AMA conduct a study to determine how upper payment limits (UPLs) established by state prescription drug affordability boards (PDABs) will impact reimbursement for physician-administered drugs and what impact state UPLs will have on patient access to care, and to report the results of this study to the AMA HOD in 2025; and
- Resolution 707, Alternative Funding Programs, would have the AMA educate employers, benefits administrators and patients on alternative funding programs (AFPs) and their negative impacts on patient access to treatment and advocate for legislative and regulatory policies that would address negative impacts of AFPs.
Additionally, with nearly 250 resolutions and reports filed for consideration at the AMA’s June HOD meeting, several topics that impact rheumatology will see extensive debate and related action by the AMA HOD. Some topics slated to be addressed include:
- The use of artificial intelligence by third-party payers to deny insurance claims, as well as broader development and use of augmented intelligence in healthcare;
- Addressing sustainable payment for community practices;
- Research handling of de-identified patient data;
- Ramifications and further steps in addressing the Change Healthcare cyberattack and outage and impact on practices;
- Biosimilar use rates and addressing related pharmacy benefit manager abuses;
- FDA regulation of biosimilars;
- Extension of Medicare reimbursement for certain telemedicine services;
- Accountability and transparency in graduate medical education funding;
- Insurer accountability when prior authorization harms patients; and
- Efforts to reform Medicare Part B drug reimbursement to promote affordability and practice sustainability.
Resolutions are introduced and considered by the ACR based on its positions and policies, and the work of ACR committees and the Board of Directors. The ACR’s delegation to the AMA House of Delegates consists of Gary Bryant, MD (Delegate and Delegation Chair), Eileen Moynihan, MD (Delegate), Cristina Arriens, MD (Alternate Delegate), Colin Edgerton, MD (Alternate Delegate), Luke Barre, MD (Young Physician Section representative), Christina Downey, MD (Young Physician Section representative), and Rami Diab, MD (Resident and Fellows Section representative).
The ACR encourages rheumatologists to join or renew membership in the AMA so this work may continue. Input on the AMA delegation’s work on behalf of the rheumatology community—along with questions or suggestions for this House of Delegates meeting—can be directed to [email protected]. The ACR offers individualized assistance to ACR and ARP members. If you are experiencing specific issues with payers or have other insurance, coding, billing or practice concerns, write to [email protected].
