Beginning in the late 1800s, Eliza Ruhamah Scidmore, U.S. diplomat and writer, spent 24 years advocating for sakura, or Japanese cherry trees, to be planted in Washington, D.C. After unsuccessfully petitioning every U.S. Army Superintendent of Public Buildings and Grounds for over two decades, she wrote a letter to First Lady Helen Herron Taft about the trees.
First Lady Taft had been to Japan and understood the cherry blossoms’ significance and beauty. Together, they secured a gift from the mayor of Tokyo, Yukio Ozaki. Ms. Scidmore’s persistence had paid off.
In March 1912, 3,020 cherry trees of 12 varieties were shipped to Washington, D.C. The National Cherry Blossom Festival grew from a simple ceremony of planting a tree with First Lady Taft and Viscountess Chinda, wife of the Japanese ambassador.1
Dr. Blair Solow
As the cherry blossoms have come and gone in D.C. this spring, the ACR government affairs team has been hard at work engaging with a new administration and the 117th Congress.2 This diverse group was ready to consider and debate legislation after a challenging year dealing with the pandemic, a major vaccination effort and social injustice.
I hope you’ve had a chance to breathe and can take a break to consider what is happening in Washington, D.C., and around the country. In just five short months, we have had important federal legislation introduced in both houses of Congress.3 States have signed into law legislation on utilization management, copay accumulators and loan repayments. And several large pieces of legislation, such as the COVID-19 relief packages and the infrastructure bill, include attached bills that are important for the practice of medicine.
A midyear review provides an opportunity to assess progress on these fronts and ensure you know how you can help.
Physician Fee Schedule & Sequester
The Centers for Medicare & Medicaid Services (CMS) finalized the 2021 Physician Fee Schedule (PFS) Final Rule, with rheumatologists receiving an estimated average boost in reimbursement of 14–15%. This was the second-largest increase among all medical specialties. However, to maintain budget neutrality, this boost was somewhat offset by a drop in the conversion factor.
This summer, the CMS will release new proposed rules on physician reimbursement. The American Medical Association’s (AMA’s) Relative Value Scale Update Committee (RUC) will provide input to the CMS to guide decisions on how to pay physicians from a single pot of money. In this zero-sum game, other specialties were less fortunate than rheumatology, with losses in procedural practices and physical therapy. With many practices struggling due to the pandemic, COVID-19 legislation helped offset cuts by increasing Physician Fee Schedule payments across the board by 3.75% through Dec. 31.
Sequester is an automatic reduction in federal spending.4 Due to large spending packages by the government for COVID-19, additional sequester cuts—separate from the PFS—will begin Dec. 31 if not addressed. Expiration of a moratorium on a sequester that has been on pause through 2020 and 2021 will result in 2% cuts to reimbursement, and a new sequester, called PAYGO, will add across-the-board 4% cuts.
How you can help: Watch for calls to action on the ACR’s Legislative Action Center in support of suspending or repealing cuts.
Workforce
Workforce initiatives continue to be at the forefront of the ACR’s advocacy efforts. Nationally, pediatric rheumatology fellowship programs fill around 50% of their slots. Meanwhile, adult rheumatology fellowship slots must turn away applicants. The cap on Medicare support for graduate medical education has been in place for more than two decades via the Balanced Budget Act of 1997.
The Resident Physician Shortage Reduction Act (S. 834/H.R. 2256) was re-introduced. This bill adds 14,000 Medicare-funded graduate medical education slots over seven years.
The Pediatric Subspecialty Loan Repayment Program (PSLRP) would address the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met. Although the PSLRP was authorized by the CARES Act in 2020, it has not yet been funded. The ACR is advocating for an initial $50 million appropriation.
At the state level, we are also making progress on our workforce initiatives. The ACR’s model, cognitive care loan forgiveness bill was re-introduced in the Georgia House of Representatives this year. In Washington, pediatric rheumatology loan forgiveness was amended into the state budget. This would be the first state to allow pediatric rheumatologists to apply to state loan forgiveness programs. We are working with our partners to ensure this provision stays in the budget that is sent to the governor.
How you can help: Visit the Legislative Action Center to find a pre-populated letter to legislators you can send showing your support for these workforce actions.
Arthritis Research
The U.S. Department of Defense allocates research funding to certain diseases, as well as a general fund. To date, researchers seeking grants related to rheumatic disease have had to apply via the general fund. The ACR is working toward having a line item dedicated to arthritis research, given that arthritis is the second-leading cause of medical discharge from the military. This slow-moving effort has gained serious traction, and I am hopeful we may be successful in this Congress.
How you can help: Visit the Legislative Action Center to find a pre-populated letter to legislators you can send showing your support for this funding.
Telehealth—Parity & Access
Prior to 2020, telehealth was practiced only by a few providers. Following the extreme drop in patient visits during the public health emergency (PHE), providers quickly learned and implemented telehealth practices to treat patients virtually. The CMS, followed by commercial payers, increased the reimbursement for telehealth to match in-person visits for audio-visual and, later, audio-only visits during the PHE. Several active pieces of legislation moving through Congress and in various states would expand access to telehealth beyond the PHE.
How you can help: Watch for a call to action to send letters to Congress, the administration and state legislators to continue to expand telehealth flexibility and ensure appropriate reimbursement.
Utilization Management & Reimbursement
Step therapy bills have been re-introduced in both the House (H.R. 2163) and the Senate (S. 464). This legislation requires Employee Retirement Income Security Act (ERISA) health plans to allow for reasonable overrides so physicians can use certain medications, helping relieve the burden placed on providers and patients.
We are awaiting re-introduction of bills on prior authorization and dual-energy X-ray absorptiometry (DXA) reimbursement, which had strong bipartisan support in the past Congress. The prior authorization legislation will protect patients in Medicare Advantage plans that delay or deny access to care. It also supports reporting back to the CMS how often Medicare Advantage plans approve or deny medications and services.
Additionally, we have seen some wins early in the state legislative year. Arkansas has passed step therapy reform, and Georgia has sent prior authorization reform to the governor. Utilization management reform legislation is on the move in California, Arizona, Oregon and Texas, while several other states have introduced bills that we are supporting. We expect additional wins as the year progresses.
How you can help: The Legislative Action Center contains pre-written letters urging utilization management reform.
Up Next
This May, we (virtually) visited Washington, D.C., to advocate for workforce expansion, step therapy legislation and provider solvency as we continue to practice during a pandemic. We are tracking a number of issues and would love to hear from you. Check out the ACR’s advocacy priorities and join us for a Hill Day in September. I look forward to having conversations with you about how advocacy and health policy affect your patients and your practice.
We need a seat at the table. Investing in RheumPAC allows for nonpartisan meetings with lawmakers working on issues that impact rheumatology.
A colossal thank you to the ACR’s Government Affairs Committee members, patient advocates and physician and interprofessional team member advocates for continuing to embrace virtual advocacy and ensuring another year of success. I am also very grateful to the ACR staff in D.C., Lennie McDaniel, JD, director of congressional affairs; Amanda Grimm Wiegrefe, MScHSRA, director of regulatory affairs; and Dan Redinger, manager of advocacy and policy affairs, who work in tandem with our Atlanta office, Adam Cooper, senior director of government affairs; Joseph Cantrell, JD, senior manager of state affairs; and Rachel Myslinski, vice president of practice, advocacy and quality.
I hope you will enjoy some version of hanami (cherry blossom viewing) this spring.5
Elizabeth (Blair) Solow, MD, chairs the ACR’s Government Affairs Committee and is an assistant professor of medicine, Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas.
References
- History of the cherry trees. National Park Service. [no date] https://www.nps.gov/subjects/cherryblossom/history-of-the-cherry-trees.htm.
- The American College of Rheumatology. https://www.rheumatology.org/Advocacy/Advocates-for-Arthritis.
- Congress.gov. https://www.congress.gov.
- FAQs on sequester: An update for 2020. House Committee on the Budget. 2020 Mar 27. https://budget.house.gov/publications/report/FAQs-on-Sequester-An-Update-for-2020.
- National Park Service. 2017 Feb 3. https://www.nps.gov/subjects/cherryblossom/hanami.htm.
