Physician payments under Medicare, passing arthritis-related legislation, and increasing governmental sponsorship of research will top the legislative agenda for the American College of Rheumatology this year.
Medicare Physician Pay
Along with many other medical specialty societies, the American College of Rheumatology's top legislative priority this year is to find a fix for the sustainable growth rate (SGR) formula used to calculate physician payments under Medicare, according to Dr. Joseph Flood, chair of ACR's government affairs committee and a member of the clinical faculty at Ohio State University in Columbus. The SGR has led to a 4.4% cut in physician pay under Medicare this year even as physicians face increased costs. But this is especially tough on rheumatologists, who bill mostly for evaluation and management codes and have high overhead costs, Dr. Flood said. “Our margin is so tight,” he said. But Dr. Flood said he is cautiously optimistic about the prospects of reforming the payment system this year because members of Congress are generally more responsive in an election year and because some of the major issues of 2005, like Hurricane Katrina response, will be more settled.
Arthritis Legislation
ACR officials said they also plan to focus on winning passage for the Arthritis Prevention, Control and Cure Act of 2005 (H.R. 583/S. 424). The legislation would create greater access to education and more outreach, and aims to address the shortage of pediatric rheumatologists through loan forgiveness. The bill has a lot of cosponsors, Dr. Flood said, but has yet to make it to the floor for a vote.
Research Funding
Increasing government sponsorship of research is another key ACR priority for 2006, Dr. Flood said. Government sponsorship of research projects, through the National Institutes of Health, is essential to encourage continued research in rheumatology, he said. In the meantime, Dr. Flood said that ACR is developing its own research agenda and funding researchers through its Research and Education Foundation.
Quality Indicators
On the regulatory side, officials at ACR are working with the Centers for Medicare and Medicaid Services to compile appropriate indicators of quality for rheumatic disease care. An ACR committee focused on quality of care has been working on this issue and is already compiling a list of quality indicators for major diseases in rheumatology. Dr. Flood said they would like to work with CMS to develop a possible pilot project to test some of these indicators.
Infusion Therapy
Another important area for rheumatologists in 2006 will be compensation for infusion therapy. Dr. Flood said that officials at ACR are continuing to work with CMS in an effort to gain better compensation for performing infusions. For a year, CMS has been paying physicians the average sales price plus 6% for Part B drugs administered to Medicare patients. Dr. Flood said that ACR is pushing for a continued refinement of the payment methodology to ensure that physicians in smaller practices aren't penalized. For instance, physicians in small practices may not get the best prices because they don't order drugs in bulk. Also, smaller practices have higher overhead because they can't achieve the same economies of scale as larger practices. Continuing to refine the payment system in this area is especially important as new infusion drugs enter the market, Dr. Flood said.
Part D Enrollment Begins
Starting in November, Medicare beneficiaries began enrolling in prescription drug plans as part of the new Medicare Part D benefit that began this month. Beneficiaries who enroll in drug plans by the end of 2005 can begin receiving benefits on Jan. 1, but individuals who haven't made up their minds can continue to enroll until May 15, 2006. As the enrollment period kicked off, the health insurance industry was optimistic. Karen Ignagni, president and CEO of America's Health Insurance Plans, said its members' health plans were seeing higher than expected numbers of calls from Medicare beneficiaries with questions about the plans. And the questions are specific, with beneficiaries asking about drug availability, which pharmacies are participating in plans, and how much their out-of-pocket expenses will be with a plan, Ms. Ignagni said at a press conference. She recommended that Medicare beneficiaries who are evaluating different prescription drug plans consider five issues: Do they have drug coverage now? What drugs do they take? Do they purchase drugs from a particular pharmacy? How much will they pay in out-of-pocket costs for a particular plan? And do they want to stay in traditional Medicare and choose a separate drug plan or switch to a Medicare managed care plan that includes prescription drugs, physician services, and hospital care?