The American College of Rheumatology (ACR) is an organization of physicians, health professionals, and scientists that serves its members through programs of education, research, and advocacy that foster excellence in the care of people with arthritis, rheumatic and musculoskeletal diseases. Arthritis means swelling, pain and loss of motion in the joints of the body. There are more than 100 rheumatic diseases that cause this condition that can sometimes be fatal – in both children and adults of all ages. These chronic diseases cause life long pain and disability.
Arthritis is the leading cause of disability in the United States, affecting approximately forty-three million Americans. Arthritis has been found to rank first among the ten leading health problems of individuals age 50 and older. By the year 2020, the prevalence of arthritis will increase to an estimated 60 million Americans. The provision of care to people who are disabled contributes significantly to the financial costs paid by the government, private insurers, and to society as a whole. More than $65 billion are spent yearly due to medical costs and lost productivity associated with arthritis and related diseases each year.
ACR appreciates the opportunity to provide written testimony to the Ways and Means Health Subcommittee, and our organization is available as resource to the Subcommittee as it continues its review of the issues surrounding the current pricing methodology for Medicare Part B covered drugs and the possible downstream effects of reform in this area. The College’s testimony will discuss the potential impact of pricing revisions that are implemented without corresponding adjustments accounting for the costs of administering these services. Within that framework, the focus of our testimony will be the profoundly life-improving infusion therapy services provided by rheumatologists to many Medicare beneficiaries with arthritis and related diseases.
Discussion
The College emphatically believes that physicians should be adequately reimbursed by Medicare and private payers to a degree that covers all costs associated with care and allows for reasonable payment to physicians, in keeping with the underlying philosophy of the resource-based relative value system that is the basis for reimbursement in the Medicare program. However, current reimbursement levels for infusion therapy services are based on pre-1998 data. Therefore, reimbursements for newer therapies often do not reflect the complexity, risks, and true practice expenses associated with their administration. The lack of adequate compensation will only increase as additional biologics complete clinical trials and are approved for use.
In the current payment methodology, the College recognizes that payments to physicians for the purchase and administration of drugs subsidize physician practices in many cases where adequate practice expenses are not being reimbursed. Much of the current debate relates specifically to infusion therapies.
A change to the drug reimbursement policy that does not reflect the needs of practitioners to meet their costs and receive reasonable compensation for their services will force some physicians to stop offering infusion services to Medicare patients, which will limit patients’ access to valuable, life-affecting therapies. If physicians cannot offer these therapies, patients may be referred to hospitals and academic medical centers–institutions that may not be equipped to handle the increased demand and to whom significantly higher reimbursements will be provided through Medicare.
Further, the College is concerned that proposed methodological adjustments intended to address shortfalls in practice expense reimbursement subsequent to the implementation of pricing revisions may be directed toward specific specialties or categories of services. We therefore urge Congress to examine the entire universe of disease groups and specialties that might be affected by such methodological revisions to ensure that broad categories of patient populations and provider groups, such as those with arthritis and related diseases and the rheumatologists who treat them, are not adversely affected by such a change.
Recommendations
In recognition of these facts, and for the overall purpose of assuring that patients will continue to have access to the best available therapies, the College believes that policymakers in Congress within the Ways and Means Health Subcommittee and beyond should:
Aggressively support those payment methodologies that allow physicians to be paid at a reasonable level for their services;
Oppose payment methodologies that rely on outdated or incomplete data to calculate reasonable payment levels;
Advocate for coverage of all competitive treatment methodologies, regardless of their route or frequency of administration;
Ensure that any methodological revisions apply to all affected disease groups and specialties.
Conclusion
The ACR commends the Ways and Means Health Subcommittee for addressing issues surrounding the quality of care delivered to Medicare beneficiaries, with particular emphasis on patients with arthritis and related diseases. We appreciate the opportunity to provide input to your efforts, and look forward to working collaboratively with the Congress to advance the goal of comprehensive health care delivery within the Medicare program and appropriate and fair payment for Medicare providers.