RheumWATCH Archives


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


ACR RheumWATCH: May 5, 2016

ACR Urges CMS to Withdraw or Significantly Modify Part B Payment Demo, Citing Devastating Impact

The ACR today submitted detailed comments to the Centers for Medicare & Medicaid Services (CMS) in response to the agency’s controversial Part B payment proposal. The comment letter urged CMS to withdraw or significantly modify the proposal due to the devastating impact it would have on rheumatology patients who rely on Medicare Part B to access needed biologic therapies.

The ACR’s comments go on to state that, “Many rheumatologists have already been forced to stop administering biologic therapies to Medicare patients because the current Part B payment structure does not cover the costs of obtaining and providing these complex therapies in the outpatient setting. Additional cuts will force rheumatologists to send patients elsewhere to get the same drugs, often at increased cost and burden to the patient.” The letter further explains that patients will face more expensive co-pays and facility fees, longer travel, administration of therapies absent the supervision of their rheumatologist, and increased risk of death from infusion reactions under the new proposed payment test.

A Flawed Cost-Savings Premise

The ACR also criticized the “one-size-fits all” approach to the Part B payment proposal, saying it would not achieve the intended effect of lowering Medicare costs for rheumatology care over the long term.

“The underlying proposal relies on reducing Part B drug pricing by encouraging physicians to prescribe lower cost products, but less expensive alternatives do not exist for Part B for rheumatology patients,” the letter states. “We understand and share the concern regarding the rising costs and spending associated with drugs and biologics. However, rather than reducing costs to Medicare, this proposal will likely cause a see-saw effect whereby reimbursement decreases for physicians, physicians then stop offering in-office infusion treatments because Medicare’s reimbursement is insufficient, and patients therefore seek infusion treatment at hospitals where Medicare’s costs are higher. Such a result runs counter to the new innovative payment delivery reforms that CMS has been seeking to promote through the Medicare Access and CHIP Reauthorization Act (MACRA).”

“While we can control for many factors over the course of the treatment, we cannot control how drug manufacturers set their prices,” the letter continues. “Further, unlike the wide array of treatment options available to most specialties, our patients and physicians have a limited number of drug and biologic treatments available.”

Modifications Required to Protect Patients

The comment letter emphasizes withdrawal of the proposal. It continues with a detailed list of significant modifications that would need to be made to the Part B proposal in order to mitigate the access challenges for rheumatology patients.

“If the proposed new methodology is implemented, we request that CMS begin by implementing the methodology in a limited geographic area to evaluate and identify weaknesses of the methodology, including issues of beneficiary access, before implementing the model nationally,” the letter states.

CMS must evaluate changes to the Part B program in a much smaller demonstration project that evaluates the availability of quality and affordable services, availability of alternative therapeutic products with price differentials, and phasing in changes to allow adjustment of operations to ensure that beneficiaries’ access to care is not disrupted, the letter explained.

Second, CMS must align or consider MACRA timeframes and changes, and the impact of these changes.

Finally, CMS must establish key exemptions to protect the most vulnerable Medicare beneficiaries. Suggested exemptions include physician groups of 25 or fewer professionals, physician-owned practices located in rural and medically underserved areas, drugs (including biologics) that have no alternative with more than a 20 percent ASP differential, and drugs (including biologics) where there are three or fewer members of the drug/biologic class available under Part B.

“We share CMS’s goal of providing patients with cost-effective treatment, but effectiveness can be measured in many ways. Further, for chronic illnesses, like rheumatic diseases, effectiveness must be measured over the long term. Medicare must recognize that a proposal that may reduce costs now, but results in longer-term treatment costs for its beneficiaries, has not benefited the beneficiary or Medicare,” the letter concludes.

See the full text of the ACR comment letter >

CMS wants to hear from you, too, regarding its proposed demonstration that would change payments for Part B drugs. The agency especially wants to receive the real-word perspectives of physicians and practices when it comes to the potential effects of its wide-reaching proposal. We urge you to take part in this important action, as feedback from individuals will be vital to the process.

In particular, it would be helpful for the agency to receive data and scenarios illustrating your current experience with buying and billing under ASP+6 minus the sequester, your current situation in providing Part B treatments to patients, and your projections of the effects on patient access if they were to modify the reimbursement formula to ASP+2.5% plus a per-day infusion payment, among the other proposals.

You can read the proposal and a synopsis, and read the ACR’s comments . Remember to submit comments to CMS online by May 9, 2016. You can also weigh in with your members of Congress through the ACR’s Legislative Action Center.

Register for the Mid-Year QRURs Webinar

CMS recently released the 2015 Mid-Year Quality and Resource Use Reports (QRURs) to group and solo practitioners. The Mid-Year QRURs provide interim information about performance on the cost and quality outcomes measures that CMS calculates from Medicare claims, which are some of the measures that will be used to calculate the 2017 value modifier.

Register now for the QRURs webcast, which will discuss the Mid-Year QRURs and explain how to interpret the information. There will be a question and answer session to follow the presentation. The webinar will take place on May 19 from 1:30–3:30 p.m. ET. To register, visit the MLN Connects event registration page.

Visit the CMS website for more information on how to obtain your QRUR. If you have any questions, please contact ACR staff at programs@rheumatology.org.

Important Meaningful Use Legislation Introduced

Following advocacy by the ACR and a coalition of physician organizations, a bipartisan group of Senators and Representatives have introduced S. 2822/H.R. 5001, the Flexibility in Electronic Health Record Reporting Act, which would limit Meaningful Use (MU) reporting periods to 90 days rather than a full year. This bipartisan, bicameral legislation would also allow completion of the reporting for the MU program early in 2016, allowing time to prepare for additional MU changes slated to begin in 2017. Our coalition will be pushing for co-sponsors, and you can help by weighing in with your lawmakers and expressing support. Locate your representatives in Congress at the Legislative Action Center.

In the Senate, Rob Portman (R-OH) and Michael Bennet (D-CO) are leading the bipartisan group of co-sponsors. A significant number of prominent House members are also supporting the bill, including lead sponsor Congresswoman Renee Ellmers (R-NC), who released a statement, as did Dr. Tom Price (R-GA).

Message from the Government Affairs Chair

Will HarveyAdvocates,

Think there is enough going on with the Part B demo? Well, the major proposed rule on MACRA was just released last week. The ACR responded to the release of this much-anticipated proposed rule with a statement from ACR President Joan Von Feldt, MD, MSEd. We will also do our usual digestion and summary, and we will provide the summary to members and begin collecting comments for the formal response letter. We’ve also created a handy infographic to get you started on understanding the big ideas of MACRA.

The rule is actually >950 pages in length, and the details included in the rule could be as or even more impactful to our practices than the Part B demo. In fact, they will be the most sweeping changes to physician payment policy in almost three decades. The ACR will seek to understand how the rule affects all practices and provide whatever guidance we can to prepare for the changes. We will also submit comments in response to any parts of the rule that we feel need to change.

You can view the proposed rule online. We’ll continue to provide you with the most current news and updates surrounding MACRA; you can also check out the MACRA page for more vital information and the ways your practice can prepare. We’re in this together.

Will Harvey, MD, MSc
Chair, Government Affairs Committee