One Member’s Personal Story Illustrates How RheumPAC Can Help Underserved Children

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Almost one year into my term on the ACR’s Political Action Committee, RheumPAC, I’m looking back and reflecting on what led me here. My early career was focused on learning the basics of clinical practice and building relationships with healthcare providers. Shortly after I completed my fellowship, I established goals to improve access to care for children and adults in East Tennessee, join the conversation on the Merit-Based Incentive Payment System (MIPS) and reimbursement changes, and play a role in state-level education and legislation. The only way to accomplish these goals was to establish relationships with legislators: I chose to do that through RheumPAC.

Pediatric Access in East Tennessee
My goal of improving pediatric access began in North Carolina, where I had additional training in pediatric rheumatology. East Tennessee had never before had a formally trained pediatric rheumatologist, and opening the pediatric clinic proved to be an eye-opening experience: Within the first 60 days of opening, our practice had a 10-week waiting period. Children with juvenile arthritis, dermatomyositis, macrophage activation syndrome, lupus, chronic relapsing multifocal osteomyelitis, uveitis and juvenile ankylosing spondylitis have now established care in our clinic.

These children need a physician, but they also need a legislative advocate, which is one reason I am active in RheumPAC. State and federal legislators have the ability to improve or derail our goals. In Tennessee, 50% of births occur under the state’s Medicaid program, TennCare, and over 50% of children receive their healthcare through the TennCare program until the age of 18. Under the Affordable Care Act, 31 states expanded their Medicaid programs, allowing 11 million individuals to receive additional medical coverage. Recently, the Congressional Budget Office found the proposed House version of the American Health Care Act would leave 23 million individuals without health insurance over the next decade, partially through cuts to the Medicaid program. RheumPAC has been actively working to ensure our legislators are aware of the damage the proposed bill would do to our patients.

In the state of Tennessee, children living with rheumatic disease are in constant uncertainty of access due to these legislative swings.

Nationwide
This situation of limited pediatric access is not isolated to East Tennessee. An estimated 300,000 children are living with juvenile arthritis, but eight states do not have a board-certified pediatric rheumatologist and five states have only one. That said, states with limited pediatric access do have the ability to expand access through the Pediatric Specialty Loan Repayment Program (PSLRP), which offers up to $50,000 of loan repayment in return for two years of clinical practice. Such programs as the PSLRP provide the opportunity to promote improved access nationally, but the program needs more advocates to accomplish that goal.

Cost Control & MIPS
Although access is critical, cost control remains a priority for insurers and legislators. Recently, I received an in-depth look at MIPS, and although it sounds good in theory, the system will eventually grade physicians based on a formula that includes cost per capita. What about those physicians at academic medical centers who routinely care for high-acuity patients? What about rheumatologists who work in underserved areas, caring for more complex cases than the average rheumatologist? Due to higher cost per capita, these physicians may not be Tier 1 for many insurers, resulting in higher co-pays for their patients.

In my situation, I provide a significant proportion of the pediatric rheumatology access in East Tennessee, so children with refractory or severe presentations, such as anti-TNF resistant JIA, refractory juvenile dermatomyositis, pediatric microscopic polyangiitis and macrophage activation syndrome associated with juvenile SLE, are all cared for in our clinic. Access has improved, but it appears we have a new problem because we have a higher cost per capita, which may not sit well with the insurers.

Providing feedback on legislation is crucial in situations like this, because the result may be financial penalties for physicians who are willing to step up and help those who need it most. That’s what RheumPAC does for us. It provides a means for us as individuals to amplify our voices as we provide our feedback.

One Small Movement
Our small movement in East Tennessee is just one piece of this huge movement for improved access and quality care. Writer/journalist Malcolm Gladwell said in The Tipping Point, “That is the paradox of the epidemic: that in order to create one contagious movement, you often have to create many small movements first.” In this small movement, I invest my resources into my community and into RheumPAC. I encourage you to pursue your own small movement and consider investing your time or financial resources into RheumPAC to help us all accomplish our goals in this epidemic.

Brett Smith, DO, is a rheumatologist at East Tennessee Medical Group in Alcoa, Tenn., and at East Tennessee Children’s Hospital in Knoxville, Tenn. He also serves on RheumPAC and on the Board of Directors for the Tennessee Rheumatology Society.