Shifting Health Policy Landscape Brings Opportunities, Responsibility to Advocate for Rheumatology

From left: ARHP President Elizabeth A. Schlenk, PhD, RN; ACR/Foundation Treasurer Paula Marchetta, MD, MBA; ACR President Joan M. Von Feldt, MD, MSEd; ACR/Foundation Secretary David I. Daikh, MD, PhD; ACR President-Elect Sharad Lakhanpal, MBBS, MD; Foundation Vice-President Abby G. Abelson, MD; and Foundation President Eric L. Matteson, MD, visited Washington, D.C., in September, where they met with members of Congress to inform them of issues of importance to ACR members.

Heraclitus of Ephesus (c. 500 BC) is credited with the saying, “The only constant is change.” Now, centuries later, change is meteoric, and especially in healthcare and health policy, the pace of change is relentless. Rheumatology and other specialties continue to face challenges that threaten the ability to deliver compassionate, competent care to patients. The Medicare Access and CHIP Reauthorization Act (MACRA), the Part B Drug Payment Demonstration Project, tiered reimbursement, biosimilars, prior authorization and other policy decisions may have large negative impacts on our practice. Policymakers at the national and state levels are making decisions that directly affect our treatment of patients with rheumatic disease.

How will rheumatologists have a voice in the changes that will occur? The answer lies in our own willingness to educate and advocate. Why? Because rheumatologists and rheumatology health professionals are uniquely positioned and qualified to inform policy makers about our own and our patients’ needs, and to educate policymakers about consequences, frequently unintended, that policies may have on our ability to deliver care and our patients’ ability to get care. With this in mind, let’s take a brief look at some of the major issues facing rheumatology and rheumatology practices, and what you can do.

MACRA

MACRA is an entirely new Medicare payment system. It was the result of repealing the flawed Sustainable Growth Rate (SGR) payment formula that called for ever-growing payment cuts to physicians. MACRA shifts reimbursement from fee-for-service to pay-for-performance and will have a greater impact on rheumatologists than the Affordable Care Act.

The MACRA initiative sunsets existing quality reporting and penalty programs and establishes a single new system, the Merit-Based Incentive Payment System (MIPS), as the default fee-for-service track that most rheumatologists will take. For those able to participate in an approved Alternative Payment Model (APM), significant bonuses will be available, as well as exemption from MIPS. Physicians who participate in the ACR’s RISE Registry will have an advantage. RISE usage is expected to generate credit in three of the four MIPS categories. In addition, physician users’ reporting is handled automatically with RISE. Most importantly, what physicians do in 2017, the first performance year, will determine penalties or bonuses coming from MACRA in 2019. The Centers for Medicare & Medicaid Services (CMS) recently announced it has heard the concerns of the ACR and other stakeholders and will give providers more flexibility with regard to MACRA requirements in 2017. Providers will be able to choose among four options within the first year and avoid penalties.

The ACR provides an online resource center that gives members up-to-date MACRA information and guidance. Our MACRA Road Show reviews the ins and outs of MACRA, MIPS and APMs and has been presented in many venues across 22 states. We expect a final MACRA rule by November, and once released, updated guidance will be provided to members. In the meantime, reach out to the College at [email protected] if you want the MACRA Road Show to come to your area. Watch your email for ACR MACRAlerts. If you see one of these messages, review it and forward to your colleagues. The MACRAlerts will contain high-yield information for your practice. Get involved, prepare, and share your experiences, so we can all learn together.

Part B Drug Payment Demonstration Project

As you know, this past March the CMS proposed an initiative to lower the reimbursement rate for Medicare Part B drugs. The policy is intended to test whether alternative drug payment designs will reduce Medicare expenditures while ensuring quality of care. This proposal could further cut payments for Part B drugs. This could have devastating effects on Medicare patients who rely on biologics by making access to these therapies even more difficult. The initial phase of the demonstration would cut payments from Average Sales Price (ASP) plus 6% to ASP plus 2.5% and a flat fee of $16.80 per drug per day (minus cuts resulting from the budget sequester mandated by the Budget Control Act).

As currently proposed, the demonstration project is dangerously broad in scope and fundamentally flawed. The ACR is calling for several exemptions from the demonstration project if it is not withdrawn: for physician practices with 25 or fewer physicians, for rural and medically underserved areas and for therapeutic classes of drugs and biologics that have no equally effective cheaper alternatives.

The ACR is working in collaboration with physician societies and patient groups, such as the American Society of Clinical Oncology (ASCO) and the Arthritis Foundation (AF). The ACR work includes:

1. Authored resolutions in the AMA House of Delegates;
2. Capitol Hill meetings, with more than 200 meetings held so far;
3. Discussions with CMS leaders; and
4. Op-eds with placements inside the beltway and in such publications as The Wall Street Journal.

The ACR has also engaged members and patients through newsletters, blast emails and social media; coordinating letters to the editor from members and patients, with more than 40 letters published across the country; and facilitating messages to legislators, with more than 5,000 emails sent.

We continue to leave no stone unturned in opposing this demonstration project as proposed, and will seek Congressional action if the demonstration project moves forward without significant alteration. It’s not too late for you to express your concerns. Go to the ACR’s Legislative Action Center to send a message to your representatives.

Increasing Funding for Research

The College continues to fight for adequate funding to discover the next breakthrough treatments. Focus initiatives include creating a $20 million dedicated arthritis research program at the DOD, supporting $34.5 billion for the NIH and $13 million for the CDC Arthritis Program in FY 2017 and mandatory NIH funding included in 21st Century Cures legislation.

Advancing Rheumatology! on Capitol Hill

Two fly-ins to Washington, D.C., were held this year to educate policy makers on issues of concern to the rheumatology community. The Advocacy Leadership Conference was held May 11–12. The ACR Board of Directors, committee chairs and members of the Government Affairs Committee, RheumPAC Committee and Affiliate Society Council met with legislators and staff. The Advocates for Arthritis conference took place Sept. 12–13, and more than 100 rheumatologists, health professionals and patients went to the Hill. Want to attend this conference next year? Watch for the application in summer 2017.

Rheumatology Issues in the States

The advocacy focus at the state level continues to involve biosimilar substitution, step therapy and prior authorization. Several states have passed requirements to notify the prescriber within five days of substitution of a biosimilar. Step therapy initiatives allowing patients to bypass already failed therapies and providers to shorten the length of a step made progress as well. ACR policy supports care that is patient centric and that allows providers to determine the best course of care.

Prior authorization (PA) legislation has been successful in Ohio this year. SB 129 requires insurers to have a Web-based system to receive PA requests, have shorter timeframes for prior authorization decisions in urgent situations, allow request of retrospective reviews and prohibit retroactive denials regarding coverage or medical necessity as long as the procedure was performed within 60 days of an authorization. Our policy seeks simplification and reduction of administrative burdens of PAs, and the ACR is involved in a PA working group of the AMA to develop additional solutions.

7 Things for Your To-Do List

If you are concerned about these issues, please join in efforts to educate and advocate. It’s easier than you think. Here are seven ways to join your rheumatology colleagues in advocacy.

1. If you’re a U.S.-based member of the ACR or ARHP, invest in advocacy with RheumPAC! RheumPAC is the only advocacy committee that directly represents the interests of rheumatology professionals, working to support and elect pro-rheumatology candidates. RheumPAC is nonpartisan and makes contributions based on policy positions. These dollars give your concerns a seat at the table. Invest at RheumPAC.
2. Attend local events for candidates and lawmakers you support. The RheumPAC Committee may provide a contribution to present from RheumPAC for candidates in election campaigns in the U.S. House or Senate. Make a recommendation for RheumPAC support at RheumPAC.
3. Send messages to Congress. Go to the rheumatology Legislative Action Center. There, you can read more about all of these issues and find pre-written email messages. We also offer tools to easily find your members of Congress and quickly send them your thoughts on these important issues. You can contact our Government Affairs department at [email protected] to assist you in your efforts.
4. Develop a personal relationship with your representatives in Congress and their staff. Visit them while you’re in Washington, D.C., or at their home offices in your district. Invite your Congressional representatives or a member of their staff to spend a day in your office. Allowing members of Congress to witness firsthand a constituent’s rheumatology office gives them perspective on the severity of patients’ conditions, the complexity of care, the reimbursement needs of physicians and the necessity for research.
5. Take a leadership role in your local or state rheumatology society. If there’s not a society for your area, start one. Find your society and other resources.
6. Join the American Medical Association to keep rheumatology at the table to influence AMA advocacy and positions, and to guide reimbursement and coding policy. Go to https://commerce.ama-assn.org/membership to join or renew your membership. This is a critical step. We also need you to vote for the ACR as your specialty organization, which counts your membership toward rheumatology’s seats.
7. Attend the MACRA, Legislative Update and Advocacy Training sessions at the Annual Meeting next month in Washington, D.C. Please put these meetings in your planner:
   • Holy MACRA! How to Survive and Thrive in the New Era of MACRA, MIPS and APMs; Sunday, Nov. 13, 8:30–10 a.m.
   • Legislative Update with Policy Makers; Tuesday, Nov. 15, 7:30–8:30 a.m.
   • Advocacy Training and Workshop; Tuesday, Nov. 15, 10:30–11:30 a.m.

I look forward to seeing you at the ACR Discovery Center in the Exhibit Hall at the Annual Meeting. I want to thank you for devoting some of your time to advocacy for the sake of our patients. I am proud to join you in Advancing Rheumatology!

Joan M. Von Feldt, MD, MSEd, FACR, FACP, is president of the ACR and a professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. She is also staff physician at the Philadelphia VA Medical Center.