Rheumatology Patients & Providers Push for Step Therapy, Workforce Changes

Attendees met with 117 legislators during the event.

Editor’s note: Read a first-person account of the event from Angus Worthing, MD, FACR, FACP, below.

On Sept. 9 and 10, 2019, 112 rheumatology advocates visited 117 of the nation’s top lawmakers and their staffs on Capitol Hill during the ACR’s annual Advocates for Arthritis event, bringing rheumatology professionals and patients together to make their voices heard in the halls of Congress. The meetings this year focused on workforce shortages in rheumatology and on limiting the effects of step therapy, whereby insurers may not approve a doctor-prescribed therapy until the patient has tried a drug preferred by the insurance company, even if the doctor believes the insurer-preferred treatment will not be effective for the patient.

Twenty-two rheumatology fellows also took part in the ACR’s Advocacy 101 program. The course is designed to educate trainees about legislative and regulatory healthcare policies impacting rheumatology and about the challenges of the changing healthcare system that they will face in their careers and practices. The program also engages fellows in health policy and advocacy endeavors.

“I think the issues struck a chord for all of our advocates,” says Angus Worthing, MD, FACR, FACP, a D.C.-based rheumatologist and chair of the ACR’s Government Affairs Committee (GAC). “We are essentially trying to reduce wait times for people to get into a doctor’s office and to get on the medications they need by bolstering the workforce and working on step therapy.”

Advocates also pressed legislators on drug costs. Dr. Worthing says, “Congress and the Trump administration are facing well-deserved pressure from the American public to reduce drug prices and the cost to patients, so the timing was great for us to tell them what the rheumatology community cares about.”

“Meeting with representatives is a great way to exercise our First Amendment rights and feel like we are doing something,” says Ethan Craig, MD, MHS, a rheumatologist at Penn Medicine and GAC member.

Congressional Education
Laura Ballenger, MD, a third-year pediatric rheumatology fellow at Nationwide Children’s Hospital in Columbus, Ohio, returned to Advocates for Arthritis after taking part in Advocacy 101 last year.

“The biggest thing that brought me back is advocacy is really based on educating people and that’s one part of the medical world I really enjoy,” Dr. Ballenger says. “I met with some people again who I met with last year, and it’s exciting to continue the conversation.”

Among the discussions, she says, was a bill introduced this year in the House, the Safe Step Act (H.R.2279), which if passed would provide step therapy exemptions for qualifying patients.

“We are trying to put guardrails on step therapy so there are ways to get our patients the medications they need without have to fail multiple medications first,” Dr. Craig explains.

Boosting the Workforce
Advocates also discussed the factors that underlie workforce shortages in both pediatric and adult rheumatology. A recent analysis projected a deficit of more than 4,000 rheumatologists by 2030 in the U.S.¹

For adult rheumatology, there are simply not enough slots to accommodate the number of interested trainees, Dr. Craig explained. On the pediatric side, about half of the available training slots go unfilled each year because of financial disincentives that keep providers from entering the field.

“We have nine states with zero pediatric rheumatologists and five states with just one; there are wide geographic areas lacking pediatric rheumatologists,” Dr. Craig says. “Doing general pediatrics sets you up better as far as lifetime earnings compared with pediatric rheumatologists, despite the extra training.”

Advocates discussed with legislators two current House bills aimed at incentivizing trainees to enter pediatric rheumatology. The EMPOWER Act (H.R.2781) would provide loan forgiveness for pediatric subspecialties in economically underserved areas. The Resident Education Deferred Interest (REDI) Act (H.R.1554) would defer student loan interest while physicians are in residency to reduce the financial barriers to entering subspecialty training.

“I am a pediatric rheumatology fellow, so I feel especially invested in recruiting people into my very small field,” says Dr. Ballenger.

Seeing Results
As a rheumatology health professional, Philadelphia-based Donah Zach Crawford, MA, also feels particularly invested. She is also a rheumatology patient and regular participant in Advocates for Arthritis.

“There have been specific asks through the years, and I really do believe it makes a difference. When we do look back, we’ve had gains over the years,” she says.

“The ACR has really been able to log significant victories despite our small numbers,” says Dr. Worthing. “We led an effort that ultimately resulted in CMS proposing to boost rheumatology reimbursement by 15% instead of reducing it. … Another [win] was preventing MIPS cuts applied to Part B drug costs in clinics.”

Dr. Worthing encourages all rheumatology providers and patients to get involved in advocacy efforts, whether through national events, such as Advocates for Arthritis in D.C., at their local level or “in a minute or two through the ACR website for providers and the Simple Tasks website for patients and families.” The ACR also encourages all rheumatology fellows in the U.S. to participate in Advocacy 101.

“You really do build up a relationship with some of these [government] staffs, and with a lot of them, you feel like they’re on your side,” says Ms. Crawford. “My last words to Rep. Perry [Warren, D-PA] were: ‘Whatever disability costs, it’s more than the medicine. The three of us standing here—me, a teacher, a medical student, who would not be here if we couldn’t get the medications we need in a timely manner—we’re contributing members. We pay a lot in taxes that otherwise would have been spent on us for disability.’ [Rep. Warren] looked at his aide and said: ‘Write that down.’”

Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.

Reference

1. Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology Workforce Study: Supply and demand projections of adult rheumatology workforce (2015–2030). Arthritis Care Res (Hoboken). 2018 Apr;70(4):617–626.