A belated Happy New Year to my fellow advocates! Here’s your first update for 2019 on what the rheumatology community should know is going on in Washington, D.C., right now.
Current Climate
On Jan. 3, the 116th Congress gaveled into session with Democrats in control of the House of Representatives and Republicans still the majority in the Senate. Although partisan politics crested again in the longest U.S. government shutdown to date and debate continues over the president’s promise to build a wall, politicians on both sides of the aisle agree the high price of drugs is a problem worth solving. Democratic proposals include addressing problems of price hikes, lack of transparency and rebates to Medicaid—and even consider the government becoming a drug manufacturer. In response, the ACR will reach out to new members of Congress and key committee staff to advocate on your behalf.
The Year Ahead in Advocacy
The main fronts for rheumatology advocacy in 2019 include:
International Pricing Index (IPI) model
This is a big deal. This past fall, the Trump administration released a model to lower drug prices in Medicare Part B and a mandatory demonstration project involving half of Part B drug administration across the country was pending. The model would:
- Use Medicare’s authority to lower drug prices about 30% over five years;
- Remove buy and bill by inserting a vendor between manufacturers and providers; and
- Pay practices a flat fee instead of a percentage of the drug price.
The ACR met with Health and Human Services (HHS) Secretary Alex Azar Jr. in November to convey our concerns about the mandatory nature of any demonstration project. At the end of December, the ACR and many other groups provided detailed comments to the administration. To protect the Part B drug system, which currently offers exceptional access to treatments for many patients, the ACR flatly opposed the mandatory nature of any demonstration project. Because the administration may move forward with a Medicare demonstration project this year, we offered suggestions about how to protect patients’ access to treatments going forward. This kind of constructive feedback was also provided by oncologists, dermatologists and other specialists who will be working together with us. Read the recap of physician responses to the model in a recent article, which states:
“The ACR made a number of recommendations, including make IPI model participation voluntary; allow for an exit for participants if the program is not working for them; provide incentives that could increase gross reimbursement; increase provider reimbursement to cover the expenses associated with dealing with vendors; and make sure the agency is adequately tracking the effect on patient access.”
If the administration proposes a new demonstration project, it will likely happen this spring. My guess is the CMS may move away from the idea of using vendors, but will test a flat-fee reimbursement system.
Medicare E/M proposal modified, postponed
Remember the CMS’ proposal to reduce documentation burdens for doctors while collapsing E/M billing codes so reimbursements for level 2 and level 5 visits would be the same? Well, in November, after a chorus of responses led by the ACR, the administration backed down and finalized a plan to modify and delay the plan for collapsed codes. (Read Medicare’s overview of the final fee schedule.)
Bottom line: Medicare won’t change billing codes until 2021, and plans to keep a level 5 visit code, while collapsing levels 2–4—and for now, as of Jan. 1, 2019, Medicare won’t require repeat documentation of prior historical information. (Read the ACR’s advice on the new documentation rules). The ACR is working with other cognitive specialties on how to make sure the 2021 coding changes work best for rheumatologists and our patients.
Step therapy
No doubt about it: Prior authorization and step therapy are the worst. The ACR opposes step therapy and other utilization management. The Trump administration is allowing more step therapy in Medicare, and Congress is considering helpful reforms. What you need to know right now: Medicare Advantage plans can use step therapy to block coverage for Part B drugs given in the office and at infusion centers in 2019. Although the CMS is promising that plans will cover drugs patients are currently taking—so-called grandfathering and grandmothering—the plans are unfortunately only looking back three to four months to see if a patient is currently taking a drug. So they may not know that a patient is currently receiving a hyaluronic acid injection for knee osteoarthritis every six months or a drug for osteoporosis every six, 12 or 24 months, or a biologic for rheumatoid arthritis is being dosed intermittently.
I met with the No. 2 official at HHS, Deputy Secretary Eric Hargan, in November to express our concerns about this and the lack of other guardrails for our patients going into 2019. I reminded him that utilization management is the worst thing about being a doctor in the U.S. Medicare is currently seeking comments about how to change this in 2020, and the ACR will be weighing in. Send your thoughts, too, before Jan. 25.
Although we’d prefer to remove all step therapy regimes, right now we’re hoping to reform it. Legislation is expected to be reintroduced in the House to regulate step therapy, and we’re hoping for a Senate companion bill this year. The ACR is in a coalition to push this right now. Ask your members of Congress to support commonsense reforms. It only takes a minute on the ACR website, and your message can make a difference.
On another front to try to increase patients’ access to necessary therapies, ACR will also continue its push to stop specialty tiering and excessive cost sharing through the Patients’ Access to Treatments Act. (Read “What the Election Meant for Rheumatology.”)
Arthritis research at the Pentagon
You may know the ACR has been pushing for a new funding stream at the Department of the Defense (DoD) dedicated to rheumatic and musculoskeletal disease research. This could be our year to make it happen. The Pentagon recently told us that it strongly supports this research as a way to promote health readiness for our troops and also prevent and treat arthritis in all Americans. Congress works on this budgeting in early spring, so it’s a hot topic right now. Ask Congress to support DoD arthritis research.
State & local advocacy
Chris Adams, MD, FACP, FACR, and ACR staff Joseph Cantrell continue working on several local fronts through the ACR’s Affiliate Society Council. Check out their plans for 2019 to regulate pharmacy benefit managers, reform step therapy, help solve our workforce shortage and promote safe use of biosimilars. Personal note:My goal for 2019 is to get a biosimilar substitution notification law passed by my city council in the District of Columbia, working through our local medical society. Hold me to it.
ACR health policy statements
Volunteers on the ACR’s Government Affairs Committee (GAC) completed our annual update to the College’s health policy statements recently, and we’ll provide them to the ACR Board of Directors for approval in February. Special thanks to Dr. Chap Sampson for leading his fellow GAC volunteers through this project.
Patient involvement
Lawmakers need to hear from you on all of these issues, but they also need to hear from your patients. No one can tell their stories about how issues are affecting their lives like they can, and policy makers listen when constituents bring to light real-world examples. One way you can help get your patients involved in personal advocacy is to steer them to the ACR’s Simple Tasks website, which includes many resources they’ll find helpful. Start them off at the Simple Tasks website, with an opportunity to reach out to policy makers on these and other issues.
2019 Investment Strategy: Join RheumPAC
Make rheumatology advocacy one of your New Year’s resolutions. Join RheumPAC today. New members of Congress need to hear from the rheumatology community so we can further our progress on all the things I’ve mentioned. Invest now.
Angus Worthing, MD, FACP, FACR, chair, Government Affairs Committee, is a practicing rheumatologist in the Washington, D.C., metro area and a clinical assistant professor of medicine at Georgetown University.
