RheumWATCH Archives


Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.


ACR Leads Effort to Reform Value-Based Modifier; Contact Lawmakers Today in Support of ICD TEN Act

ACR Leads Effort to Reform Value Based Modifier

The ACR has successfully engaged the AMA and other specialty societies in its efforts to address significant problems with the Value-Based Modifier. Because the cost component of the VBM currently includes Part B drug costs, but not Part D drug costs, payments to providers and groups that administer biologics under Part B may be arbitrarily reduced, and there is no adjustment taking into account costs incurred by prescriptions from providers who prescribe biologics primarily through Part D. Read the ACR’s resolution, passed last week by the AMA House of Delegates.

The AMA will now join efforts working with the Centers for Medicare & Medicaid Services to alter Value-Based Modifier cost attribution with regard to all drug costs, to ensure the cost calculation does not unfairly disadvantage providers who administer biologics under Part B. All providers are scheduled to be subject to the Value-Based Payment Modifier (VBM) by 2017, and 2017 payment adjustments under this program will be based on 2015 data. Yet there are significant concerns that the VBM does not accurately portray quality and cost, and physicians continue to have concerns about the VBM, including inaccurate risk adjustment and attribution methodologies, a rushed timeline, confusing feedback reports, and many other problems.

The flaw the ACR has identified in the VBM’s cost component inappropriately penalizes physicians based on the way they prescribe medication, and there is a concern with the potential for adverse selection of patients as well as the potential for skewing practice costs and impacts on treatment decisions. The ACR has voiced its concern about how current VBM policies may force providers to choose between prescribing Part B drugs and increasing their cost measure, resulting in potentially receiving a penalty under the VBM, or prescribing medication under Part D that their patients will not be able to afford and therefore possibly go without crucial treatment. CMS policy should not cause providers to face this dilemma.

To learn more about the ACR’s efforts with CMS and the AMA federation, contact ACR advocacy staff at advocacy@rheumatology. For assistance with reporting for PQRS and minimizing Value-Based Modifier impacts to your payments, contact Maryam Gueye at mgueye@rheumatology.org.

ICD-TEN Act: Contact Lawmakers to Advance ICD 10 Safe Harbor Bill

Recent rollouts of technology-based initiatives at CMS have not been without incident. As the deadline for ICD-10 nears, a reasonable and responsible implementation plan is essential for viability of our practices, continued access to care for our patients, and the integrity of Medicare. Although there are several differing proposals seeking to address ICD-10 implementation, Rep. Diane Black’s ICD-TEN Act (H.R. 2247) is the most reasonable and responsible approach. We need all rheumatologists and health professionals to write to their lawmakers and ask for support of this legislation. Visit the ACR Legislative Action Center to send a message.

Representative Diane Black’s ICD-TEN Act is a common sense and responsible approach that addresses these concerns with ICD-10 implementation. The ICD-TEN Act would provide for an 18-month safe harbor period against errors in subcodes as a basis for rejection of claims. The 18-month period is reasonable time for practices to adjust to new coding, but without losing sight of the expectation that full adherence is imminent.

The provision regarding errors in the subcode is also an important balance to protect against honest errors in the proliferation of codes, but without adding any additional risk of fraud or abuse. For instance, this would protect against an error in coding for RA in the left versus right hand. These codes have the same first three digits, and the subcode after the decimal indicates the specificity. Subcodes most often indicate subtypes or locations of disease that should not be relevant for payment decisions. With 246 new subcodes for RA, the basic assumption is that errors in the subcode are unintentional and that either way, should have no effect on the reimbursement rate from CMS.

What this legislation does not do, is provide blanket immunity for any error. If that were the case, a patient with RA could be billed as a patient with heart failure; these differences are dependent on the main code, not the subcode. These are not errors we expect physicians will make now under ICD-9 or in the future with ICD-10.

Furthermore, this legislation is careful to address claims payment specifically. ICD-10 is important for the advancement of epidemiological data that can help all of our practices and patients in the long term, and we want to make sure these data are accurate. However, the U.S. is one of only a few countries that tie payment with coding in this manner. The bill seeks to protect physicians from errors in coding as it relates to reimbursement, but also recognizes that codes should be corrected for data and quality purposes. In essence, the long-term goal of support of public health and epidemiology should not come at the risk of short-term instability in reimbursement or doctor-patient time.

Finally, and of equal importance, the legislation requires end-to-end testing to ensure that it really works! As we have seen before, this is not always the case on rollouts of any technology, and when small business viability and patient access to care are on the line, assurance to this end is necessary.

Members of Congress need to hear from you about Rep. Diane Black’s reasonable and responsible approach to these issues. We need all rheumatologists and health professionals to write to their members of Congress and ask them to support this legislation. Visit the ACR Legislative Action Center today to send a message.

IPAB Repeal Legislation Moves Forward

Earlier in June, the U.S. House Ways and Means Committee approved ACR-supported legislation to repeal the Independent Payment Advisory Board (IPAB), with a substantial bipartisan majority (31–8). H.R. 1190, the Protecting Seniors’ Access to Medicare Act, introduced by Reps. Phil Roe, MD (R-TN), and Linda Sanchez (D-CA), would repeal sections of the Affordable Care Act related to the IPAB. The bill will likely move to the House floor for a vote before the end of June, and it is expected to pass with another significant bipartisan vote.

“This legislation would prevent unaccountable bureaucrats from making health care decisions for seniors and their physicians,” said Will Harvey, MD, chair of the ACR’s Government Affairs Committee. “Physicians should not be subjected to the risk of even more payment cuts through this independent commission. Containing health care cost is important, but not when risking patient access to care.”

A similar bill, S. 141 by Senator John Cornyn (R-TX), is also backed by the ACR and is awaiting action in the Senate. Contact ACR staff at advocacy@rheumatology.org if you would like to get involved in advancing these bills.

Message from the States June 2015

Pennsylvania Rheumatology SocietyPennsylvania Rheumatologists a Model for Successful Advocacy Collaboration

The Pennsylvania Rheumatology Society (PRS) has been in existence since the 1980s. The mission of the organization is to serve as a voice for the 539 Pennsylvania rheumatologists in practice and advocacy activities. The PRS governing structure has clinical practice and academic representatives from across the state, drawing from individuals who are also involved in local rheumatology organizations, including the Philadelphia Rheumatology Society, the Western Pennsylvania Rheumatology Society, and others.

The PRS partners with the Pennsylvania Medical Society, located in Harrisburg, which provides administrative coordination especially in advocacy matters and in our statewide fall education symposium, attended by more than 100 individuals in 2014. In addition, the PRS works closely with the ACR, including actively participating on the Affiliate Society Council and with the local and regional Arthritis Foundation offices in patient and advocacy programs. We have been working hard to impact legislative initiatives, and traveled to Harrisburg on June 10 for the Great Lakes Region Arthritis Foundation Advocacy Day to demonstrate to our legislators the combined voice of the ACR and the Arthritis Foundation.

Issues that we addressed include:

(1) Making arthritis a priority: stressing that accessing appropriate specialty care and affordable, effective therapeutic options are key components of managing the inflammatory and autoimmune forms of arthritis. Also a priority is explaining the importance of early diagnosis of arthritis and providing an effective treatment plan, including exercise, education, and affordable medical and pharmacologic therapies, to reduce the burden of arthritis.

(2) Biosimilar substitution: including communication to the patient upon substitution, communication to the prescriber within 48 hours of the substitution, retention of substitution records for a minimum of five years, permitting a physician to override the substitution where patients are stable on a prescribed biologic, requiring that biosimilar medications must be approved by the FDA as therapeutically equivalent and interchangeable to the original biologic, and ensuring that naming of the biosimilar medications is individualized and unique and noticeably different from the reference biologic.

(3) Out of pocket medication costs: including limiting the cost of a 30-day supply of any single prescription medication to no more than $150 a month, capping the total aggregate monthly out of pocket cost for all prescription medications, and defining the total annual out of pocket expenditures for all prescription medications at a maximum of 50% of the ACA total out of pocket limits for an individual or family plan.

As rheumatologists we must be well informed about the issues, raise awareness about arthritis, and be strong advocates in order to help improve the lives of people living with arthritis. By working together and having effective partnerships with other organizations in these challenging and changing times in medicine, we as rheumatologists can have our voices heard and can positively represent and impact our patients and our profession.

Terence W. Starz, MD, past president, Pennsylvania Rheumatology Society
Paul Killian, MD, president, Pennsylvania Rheumatology Society