Conference Coverage

Advocacy 101: ACR efforts, and tips for making your voice heard



– Rheumatologists comprise a “tiny sliver” of the U.S. physician pie chart, but their voices are nevertheless being heard and making a difference regarding policies that affect the specialty, according to Angus B. Worthing, MD.

Dr. Angus B. Worthing is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area

Dr. Angus B. Worthing

However, given the myriad policy issues on the table, more and louder voices are needed, he said at the annual meeting of the Florida Society of Rheumatology, where, as chair of the American College of Rheumatology’s Government Affairs Committee, he provided an “advocacy update” on the committee’s activities.

Recent ACR “wins” as outlined by Dr. Worthing include:

  • The postponement and modification of proposed cuts to Evaluation & Management (E/M) current procedural terminology (CPT) codes.

“Last summer, Medicare proposed that instead of having low-complexity to high-complexity E/M codes, they would condense all of the doctor visits into one code, which would obviously enhance the reimbursement for low complexity, but ding and penalize the reimbursement for high-complexity visits like ours,” said Dr. Worthing, who also is a partner in a private rheumatology practice in the Washington area.

An ACR press release on the proposal led to pivotal coverage of the issue in the New York Times. “It looks like not only did they postpone those cuts, they modified [the proposal], and we’ll find out any day now in the proposal for the next year’s physician fee schedule whether they’ll scrap it entirely and instead try to plus-up E/M code reimbursement for complex patients.”

  • The elimination of proposed Merit-based Incentive Payment System (MIPS) adjustments on Medicare drug reimbursement.

A cut to fee-for-service reimbursement for drug costs as a MIPS penalty could have quickly bankrupted rheumatology practices, Dr. Worthing said.

“[The success] was largely out of rheumatologists and others saying that this could quickly stop access to these treatments, because we wouldn’t be able to provide them,” he noted.

  • The dampening of proposed musculoskeletal ultrasound reimbursement cuts in Medicare.

Ultrasound is a safe, effective, dynamic, and relatively low-cost diagnostic tool, but Medicare has been considering “absurd” cuts to reimbursement, Dr. Worthing said.

“We’ve been able to have good conversations with Medicare ... to bring that argument to Medicare, and we’ll find out – again, when the physician fee schedule comes out – whether they’ll continue the plan to cut diagnostic ultrasound reimbursement or whether they’ll stop cutting it.”

  • The inclusion of more favorable Medicare Advantage regulations for step therapy “grandfathering.”

Medicare Advantage plans were given the chance last summer to use step therapy in Part B medicines for the first time.

“The ACR quickly told the executive branch and officials at [the Department of Health & Human Services (HHS)], that this would not be good for our patients getting medications,” Dr. Worthing said.

Going forward with that plan, and looking back just 108 days to allow people to stay on their medications – as was proposed – wouldn’t work, as some drugs are dosed every 4-6 months, or every year or every 2 years, he said.

“The look of astonishment on the [HHS] deputy secretary’s face when I told him that there was a drug in the U.S. that you give every 2 years was helpful for me to know that these people really need to hear from us before they issue these kinds of regulations,” he said.

The administration listened to the rheumatologists and is going to look back 365 days to keep people on their drugs, he said.

The ACR took the lead on these recent successes, but was also involved in a number of other wins achieved through multisociety efforts, he said.

Examples include securing a $2 billion increase in National Institutes of Health funding, eliminating “gag clauses” that prevent pharmacists from informing patients when it’s cheaper to just buy a drug rather than using their insurance; getting rid of annual caps on physical and other rehabilitation therapy for patients meeting their targets; repealing (before it could take effect) of the Independent Payment Advisory Board established by the Affordable Care Act; and – at least for now – continuing Deferred Action for Childhood Arrivals (DACA) protections that could allow recipients to stay in the country, study, and become doctors, and potentially provide care for up to 100,000 Americans, according to an estimate by the American Medical Association.

Dr. Worthing also noted that the ACR has an Insurance Subcommittee that has been instrumental in many of these and other policy wins, and he encouraged rheumatologists to contact the committee at to report any sort of “canary-in-the-coal-mine” issues, such as refusal of coverage for a new step therapy, service, or item in your clinic that seems “absurd; doesn’t have merit.”

Send a copy of the policy behind the denial (with private health information redacted), or complete a Health Plan Complaint Form, which can be accessed at the website, he advised.

Rheumatologists can make their voices heard in other ways, he said. The ACR has a number of ongoing advocacy efforts addressing things like drug-pricing models, biosimilar agent interchangeability pathways, step therapy reform, workforce issues, and the need for higher dual X-ray absorptiometry (DXA) reimbursement.

The ACR’s Legislative Action Center offers prewritten letters on a number of timely topics, as well as information about legislators and legislation. An app is available that provides alerts about important legislation.

A timely example is DXA-related, bipartisan, bicameral legislation currently on the table that would more than double reimbursement and “improve access to this critical screening tool,” he said.

“Right now is an excellent time to tell your legislators – and there’s a prewritten letter at the [site] – that this is an important topic,” he said. “Right now, as we get into bills that might come out, spending bills or health-related bills coming up to 2020, it would be wonderful to get a lot of support behind this so that it might be added into some kind of package.”

A similar prewritten letter regarding an active bill that addresses paying off student loans for pediatricians going into subspecialties like pediatric rheumatology also is on the table and could help address workforce shortages, he noted.

“The First Amendment protects your right to petition the government for redress of grievances. I don’t have to tell you this is an era of huge tumult ... protecting [democracy and institutions], protecting your organizations, raising your voice is really important right now,” he said, referencing his new Twitter hashtag that encourages doing one #ThingADay. “You could think of advocacy as an extension of the Hippocratic oath to do no harm on a government and social level.”

Quoting Margaret Mead, Dr. Worthing reminded rheumatologists that their voices matter despite (and in fact, because of) their small numbers: “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

Dr. Worthing reported having no disclosures.

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