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H.R. 1210 / S. 984

Why is the Arthritis Act so important?

• Nearly one in five adult Americans (46 million) suffer from arthritis.
• Over 300,000 children also live with the pain, disability and emotional trauma caused by juvenile arthritis.
• Nine states do not have a single pediatric rheumatologist.
• Arthritis is the leading cause of disability in the United States.
• According to the CDC, the total costs attributable to arthritis and other rheumatic conditions in the United States in 2003 was approximately $128 billion.
• The burden of arthritis will continue to rise: by the year 2030, an estimated 67 million Americans will suffer from the debilitating pain and limited mobility caused by arthritis.

The "Arthritis Prevention, Control, and Cure Act of 2009" would enhance rheumatic disease research and public awareness of these often-debilitating diseases by:

• Enhancing the National Arthritis Action Plan by providing additional support to federal, state, and private/non-profit efforts to prevent and manage arthritis.
• Providing federal support for initiatives to educate the healthcare profession and the public on successful self-management strategies for controlling arthritis.
• Bolstering federal juvenile arthritis research activities and prioritizing epidemiological activities focused on better understanding the prevalence, incidence, and outcomes associated with juvenile arthritis.
• Providing training grants to universities supporting pediatric rheumatology programs.
• Establishing an education loan repayment program to create incentives for medical students to enter the field of pediatric rheumatology.

Supporting Materials

Printable Issue Brief

Full Text of Legislation H.R. 1210

House Energy & Commerce Committee

Senate Health, Education, Labor & Pensions Committee

Related Bills

Psoriasis and Psoriatic Arthritis Research, Cure, and Care Act of 2009: Full Text of Legislation

Endorsement Letter

• Individuals and families pay premiums for insurance to cover physician visits, hospital stays, surgery, and medications.
• Insurance companies have established small co-pays for physician visits and medications.
• Medication co-pays may fall under a three tier system such as 15/20/30. Fifteen dollars for a generic medication, $20 for a name brand medication and $30 for a medication off formulary.
• Recently, insurance companies are instituting a new copay referred to as Tier IV requiring patients to pay 20 – 30% copays for infusions.
• The 20-30% can cost the patients thousands of dollars.
• The medications, although expensive, allow individuals to lead productive lives. These medications benefit individuals with multiple sclerosis, rheumatoid arthritis, hemophilia, hepatitis C and some cancers.
• If insurance companies are allowed to continue with Tier IV pricing, patients will be forced to go without necessary medication.

Supporting Materials

Printable Issue Brief

Patients Suffer as a Result of Insurance Pricing Scheme Press Release

Co-Payments Soar for Drugs With High Prices

House Ways & Means Committee

Senate Finance Committee

Chronic reductions in Medicare reimbursement for osteoporosis screenings have resulted in reduced access to this important service. The Medicare Fracture Prevention and Osteoporosis Testing Act (H.R. 1894/S. 769), introduced by Representatives Shelley Berkley (D-NV) and Michael Burgess, MD (R-TX) and Senators Blanche Lincoln (D-AR) and Olympia Snowe (R-ME), would restore funding for preventive osteoporosis screening.

Osteoporosis Screening Can Reduce Risk of Fractures

Osteoporosis involves a gradual loss of bone, which causes bones to become thinner, more fragile and more likely to break. Due to the complications of fracture, the disease is associated with significant mortality and morbidity. Osteoporosis and low bone mass affect an estimated 44 million Americans.

In order to reduce the impact of osteoporosis, it is important to diagnose it prior to fracture and initiate treatment for those at high risk. Dual-energy x-ray absorptiometry (DXA) is recognized as the “gold standard” for diagnosing osteoporosis and monitoring the response to therapy. Knowledge of bone density and other risks for fracture allows patients and their health care providers to choose preventative or treatment options to reduce risk of future fracture.

Severe Medicare Reductions Hurt Patient Access

If Congress does not act quickly, DXA reimbursements will be decreased by 62 percent by 2010, greatly reducing access to a crucial preventive screening. Already, from 2006 to 2007, reimbursements were slashed by 40 percent. Numerous physicians and patient groups have indicated that these cuts will make it cost-prohibitive to continue to provide these services in physician offices, where two-thirds of patients are currently tested. In fact, a recent Lewin Report indicates that “No provider will be reimbursed by Medicare at or above their costs in 2010.”

Congress Should Act to Support Preventive Osteoporosis Screenings

Representatives Shelley Berkley (D-NV) and Michael Burgess, MD (R-TX) and Senators Blanche Lincoln(D-AR) and Olympia Snowe (R-ME) introduced the Medicare Fracture Prevention and Osteoporosis Testing Act which would restore and freeze payments for DXA screenings in the physician office at the 2006 rate. This legislation will curb the reduced access to DXA screens, improve patient care, and prevent unnecessary costs to the Medicare program through reduced fracture expenditures.

Supporting Materials

Printable Issue Brief

Full Text of Legislation H.R. 1894/S.769

Thank You Letter to Senators Lincoln and Snowe

Access to Osteoporosis Testing for Americans in Jeopardy

House Ways & Means Committee

Senate Finance Committee

The American College of Rheumatology (ACR) strongly urges Congress to support legislation revising Medicare payment methodology to ensure appropriate reimbursement for specialists treating arthritis, rheumatic, and musculoskeletal diseases.

Patients Access is Threatened by Severe Cuts

Since 2003, Congress has repeatedly passed temporary fixes to prevent severe cuts to the Medicare physician fee schedule. Rheumatologists and other physicians are expected to face Medicare reimbursement cuts of twenty-one (21) percent or more in CY 2010. These cuts will severely threaten seniors’ access to health care and potentially limit access to care for all Americans.

The SGR Contains Factors Over Which Physicians Have Little Control

The Sustainable Growth Rate (SGR) is part of the formula used to calculate physician reimbursement for Medicare. Unfortunately, the basic premise of the formula is flawed. The SGR formula is linked to the performance of the overall economy, yet the medical needs of individual patients do not shrink whenever the economy slows. When overall spending on services in the SGR exceeds the per capita gross domestic product (GDP), cuts to physician reimbursement are triggered. The SGR also includes the costs of drugs covered under Medicare Part B, a cost over which physicians have no control. Notably, spending on these Part B drugs is increasing at a higher rate than spending on actual physician services. This skews the calculation of the SGR and triggers overly harsh reductions in physician reimbursement.

Ensure Patient Access to Care

Congress must repeal the SGR formula and base payments on the growth of the Medicare Economic Index (MEI). The MEI would ensure that the physician reimbursement payments would reflect inflationary pressures on medical practice costs. Congress must replace the flawed payment methodology in order to avoid continually bandaging a broken system.

Supporting Materials

Printable Issue Brief

Arthritis, the nation’s leading cause of disability, costs the U.S. economy $ 128 billion each year.

The American College of Rheumatology (ACR) strongly urges Congress to increase funding to federal programs engaged in vital research to combat arthritis and related diseases. The ACR is very appreciative of the $10 billion investment into NIH from the 2009 Economic Stimulus package. Congress should build on this success by continuing to strengthen NIH funding. The number of people with arthritis and released diseases is projected to be 67 million by 2030. Support for research programs to combat arthritis and related diseases is essential to the development of innovative treatments which decrease costs and improve the quality of life for these patients.

Researchers continue to study arthritis and its effects. Such studies and programs include:

• Osteoarthritis Initiative (OAI)- The OAI is a nationwide research study, sponsored by the National Institutes of Arthritis Musculoskeletal and Skin Disease (NIAMS), that will help us better understand how to prevent and treat knee osteoarthritis, one of the most common causes of disability in adults.
• The Immune Tolerance Network (ITN)- The Immune Tolerance Network (or ITN) is a non-profit, government-funded consortium of researchers working together to establish new treatments for diseases of the immune system, including the ITN conducts clinical trials of specialized immune tolerance therapies used in the treatment of autoimmune diseases (such as type 1 diabetes, multiple sclerosis, lupus and others).
• The National Arthritis Action Plan (NAAP)- NAAP is a public health program developed by CDC and the Arthritis Foundation, which seeks to improve the quality of life for those living with arthritis, including increasing public awareness, prevention, promoting early detection, minimizing pain and disability and ensuring those with arthritis receive community support.
• AHRQ considers arthritis a priority condition based on its relevance to the Medicare population. The Agency is currently engaged in a research project to study the incidence rates and relative risks of important adverse events for commonly used analgesics among patients with osteoarthritis and rheumatoid arthritis.
• A study currently underway by the Harry S. Truman Research Hospital, Missouri Arthritis Rehabilitation Research and Training Center, called the “Coordination of Care for Children with Juvenile Arthritis,” which will facilitate access to applicable public laws, policies, and programs that can help improve coordination of care for children with JA.
  Several agencies assist in these research studies or programs such as:
  • The National Institute of Arthritis and Musculoskeletal and Skin Diseases
  • The National Institute of Allergy and Infectious Diseases
  • The Centers for Disease Control and Prevention
  • The Agency for Healthcare Research and Quality
  • The Veterans Administration’s Medical and Prosthetic Research Program

Supporting Materials

Printable Issue Brief

Physicians who administer in office drugs under Medicare Part B are not receiving the full ASP (Average Sales Price) + 6%% that was mandated in the MMA 2003 legislation, due to a flaw in the formula used to calculate ASP. Included in the formula that calculates ASP are prompt pay discounts and insurance company rebates which reduce the reimbursement for drug acquisition to average private practice physicians.

The prompt pay discount and rebates decrease reimbursement on infusion drugs to an average of only 1-2% above the acquisition cost rather than the intended 6%, insurance companies and wholesale distributors benefit from these discounts, not physicians.

Fortunately Rep. Gene Green (D-TX) and Sen. Arlen Spector (D-PA) have introduced legislation to address this problem. We need you to contact your members of Congress and ask them to support H.R. 1392 and S. 1221 to eliminate the ASP and increase the reimbursement to what was originally intended.

Visit the ACR Legislative Action Center to contact your legislators.

Become an Advocate

The ACR is involved with advocacy efforts related to the rheumatology community. As an ACR and ARHP member, it is your responsibility to advocate for you and your patients.

Visit the Legislative Action Center

capwiz.com/acr

Advocates for Arthritis Conference

» click here to apply

If you have any questions regarding legislation or policy or would like to get involved, please contact:

Aiken Hackett

Director, Government Affairs

404-633-3777 x811

Katie Jones

Senior Specialist, Government Affairs

404-633-3777 x807

RheumPAC

Visit RheumPAC for more information.