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To say it has been an interesting (the science and the memes), tumultuous (the politics) and heartbreaking (the pandemic and social injustice) year is an understatement. There have been moments of grace and inspiration that we hope have kept everyone going.
As we look to 2021, we take lessons from our experiences in 2020. Washington, D.C., is buzzing, with a new president, new members in the House and Senate, a new Congress (117th) and more COVID-19 legislation negotiations.
The ACR advocacy team in D.C.—Lennie Shewmaker, JD, director of congressional affairs; Amanda Grimm Wiegrefe, MScHSRA, director of regulatory affairs; and Dan Redinger, manager of advocacy and policy affairs—and in our Atlanta office—Adam Cooper, senior director of government affairs, and Joseph Cantrell, JD, senior manager of state affairs—will continue their efforts on behalf of ACR/ARP members, along with Rachel Myslinski, vice president of practice, advocacy and quality, and the rest of her team.
2021 Physician Fee Schedule Final Rule
The win: The Centers for Medicare & Medicaid Services (CMS) finalized the 2021 Physician Fee Schedule Final Rule, with rheumatologists seeing an estimated boost in reimbursement of 14–15%, to start, in 2021. This was the second largest increase among all medical specialties.
Context: Each year, the CMS releases rules on physician reimbursement. It uses recommendations from the American Medical Association’s Relative Value Scale Update Committee to guide decisions on how to pay physicians from a single pot of money. The CMS valued certain Current Procedural Terminology codes higher, including those often used by some subspecialties, and modified documentation requirements to reduce administrative burdens.
The Pediatric Subspecialty Loan Repayment Program (PSLRP) was authorized by the CARES Act legislation; however, it is not yet funded.
In this zero-sum game, other specialties were not so fortunate, with losses in surgery, radiology and physical therapy. Given the pandemic and all practices struggling, recent COVID-19 legislation balanced the cuts some providers may see by adding $3 billion in new money to increase Medicare Fee Schedule payments across the board by 3.75% in calendar year 2021.
Workforce
The win: The Pediatric Subspecialty Loan Repayment Program (PSLRP) was authorized by the CARES Act legislation; however, it is not yet funded. The Resident Physician Shortage Reduction Act (H.R. 1763/S. 348) made progress, with 240 co-sponsors.
Context: Pediatric rheumatology fellowship slots are filled around 50% of the time, while adult rheumatology fellowship slots must turn away applicants. The final COVID-19 package of 2020 repealed the cap on Medicare support for graduate medical education (GME) instituted by the Balanced Budget Act of 1997 and added 1,000 new Medicare-funded GME full-time equivalent residency positions, beginning in fiscal year 2023. The PSLRP legislation addresses the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met.
Telehealth: Parity & Access
The win: The CMS and commercial insurance companies increased reimbursement for telehealth visits to match those of in-person visits during the public health emergency (PHE). Many states followed suit and increased telehealth reimbursement in Medicaid and some state-regulated health plans.
Context: Prior to 2020, telehealth was a novelty practiced by few providers. As in-person visits plummeted during the PHE, providers quickly learned and implemented procedures to treat patients virtually. Prior to the pandemic, reimbursement was quite low for telehealth, despite acuity and providers’ cognitive efforts. The CMS, followed by commercial insurers, increased reimbursement for audio-visual telehealth visits—and, later, audio-only visits—to match in-person visits.
The CMS recognizes that telehealth is here to stay when this PHE is over. It has begun to add additional services to the list of covered services for telehealth for post-pandemic treatment.
Utilization Management & Reimbursement: Step Therapy, Prior Authorization & DXA Scans
The wins: Regarding step therapy, H.R. 2279 has 157 bipartisan co-sponsors and the companion Senate bill, S. 2546, has 18 bipartisan co-sponsors. Regarding prior authorization, H.R. 3107 has 280 bipartisan co-sponsors. Regarding DXA reimbursement, H.R. 2693 and the companion bill S. 283 have bipartisan support.
Context: Step therapy is a burden for providers and patients. This legislation requires Employee Retirement Income Security Act (ERISA) health plans to allow for reasonable overrides for physicians to be able to use certain medications. 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. Funding for DXA reimbursement is at an all-time low. This legislation will set a $98 floor for DXA reimbursement.
How You Can Help
All bills will need to be reintroduced in the new 117th Congress in 2021. Watch for calls to action to send letters to Congress or the administration to continue to expand telehealth flexibility and ensure appropriate reimbursement, support complex code add-ons and enact workforce policies. Also, watch for state action alerts to send letters to state legislators if you live in a state that has not passed step therapy reform. Join us for Advocates for Arthritis events; we would love to see you.
Up Next
As we look ahead in 2021, the ACR government affairs team will be tackling several issues:
- Advocating for support for patients and providers during the remainder of the pandemic and monitoring any legislation and regulations that could affect provider and practice solvency;
- Protecting rheumatology evaluation and management payment increases;
- Engaging on policies related to telemedicine;
- Advancing legislation and regulations in the areas of:
- Prior authorization and other utilization management issues;
- Workforce;
- Telemedicine expansion and appropriate reimbursement; and
- NIH/DOD funding for rheumatology research;
- Engaging on drug pricing proposed policies and pilot programs and defending patient access to treatment;
- Addressing issues such as DXA and musculoskeletal ultrasound reimbursement; and
- Monitoring implementation of the new requirements related to surprise billing, including the rollout of the independent dispute resolution program through which payers and providers will negotiate reimbursement.
RheumPAC Update
RheumPAC and ACR advocacy efforts were not spared the pandemic’s impact. However, in mid-March, we made the decision to halt RheumPAC solicitations because of the tremendous financial challenges we were all facing. In addition to worry over our own health and that of our families, providers across the spectrum of care faced grave financial strain, and many were unsure how they would keep their doors open.
Although we halted solicitations, the work of RheumPAC and the ACR advocacy team did not lose steam. Leveraging the existing relationships that your RheumPAC contributions have helped cultivate over the years, we flexed our strength to remind Congress that rheumatology providers needed support for practices to stay open and deliver needed care for our patient population. We were pleased to see COVID-19 relief packages pass through Congress, and we anticipate additional support packages are on the horizon.
We were also able to successfully advocate on behalf of our members who were suddenly thrust into the new world of telemedicine.
Meanwhile, we continued to advocate for many of our pre-COVID-19 legislative and regulatory priorities, including a historic win for an estimated average 14–15% increase in Medicare payments for evaluation and management services, reauthorization of the Pediatric Subspecialty Loan Repayment program, enactment of surprise billing legislation, and accruing more support for step therapy and prior authorization reform bills in the House and Senate.
Recognizing the key role of RheumPAC in facilitating our advocacy successes and the ever-increasing number of important policy discussions taking place in Congress, we decided it was critical to resume fundraising in August. Adequate resources were needed to continue to educate legislators on the serious issues the rheumatology community continues to face.
We thank everyone who, despite the extraordinary circumstances, gave any amount this year to RheumPAC. I’m proud that, in the face of all that 2020 threw at us, we were still able to raise $124,000 from 286 individuals.
With a vaccine now being deployed, 2021 is looking better, but we still have our work cut out for us on Capitol Hill, and RheumPAC will be a key component in getting our legislative priorities across the finish line in a new Congress. As a reminder, our mission is to educate, support and thank our key partners in Congress. Every single dollar raised goes directly to carefully chosen campaigns that maximize our reach. With so many new faces in Congress and different legislators in key leadership positions, it will be especially important that RheumPAC continue to build relationships with the offices of the many healthcare policy stakeholders.
We are a small specialty, but your contributions to RheumPAC have amplified our voice on the Hill. To continue to support and grow that voice, we need your help. In addition to your 2021 contribution, ask your colleagues to join you in supporting the advocacy priorities that will ensure the future of rheumatology.
Visit www.rheumpac.org to help us start the year off strong by making your 2021 donation or setting up a smaller monthly recurring donation to help rheumatology.
Thank you for your time, efforts, enthusiasm and perseverance. We look forward to an ongoing conversation about how advocacy and health policy affect you and your patients.
Blair Solow, MD, is chair of the ACR Government Affairs Committee and an assistant professor of medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center, Dallas.
Zachary Wallace, MD, MSc, is a rheumatologist at Massachusetts General Hospital, Boston, and the chair of RheumPAC, the ACR’s nonpartisan political action committee.
