On Call: The Newsletter of the Alliance of Specialty Medicine

Spring 2021

Medicare Sequester Looms Large for Specialty Docs

$36 Billion in Cuts on the Horizon for 2022

The provider community had much to be thankful for in the $1.9 trillion American Rescue Plan, recently signed into law by President Biden.  Among several provisions designed to help keep their practices open and their patients safe, the new law expands tracking and tracing of COVID-19, as well as providing $7.5 billion to the Centers for Disease Control and Prevention’s (CDC) vaccine distribution efforts.

However, the American Rescue Plan price tag also triggered provisions of the Pay As You Go Act of 2010.  This “PAYGO” Act requires that new legislation changing taxes, fees, or mandatory expenditures must not increase projected federal deficits. If any do, automatic across-the-board cuts in selected mandatory programs must be made.  It is due PAYGO, that the passage of the American Rescue Plan triggers automatic across-the-board cuts to the federal budget, including spending reductions in Medicare of an estimated 4% or $36 billion.  These cuts will go into effect at the end of the next fiscal year, September 30, 2022.

Medicare providers are already living with an existing 2% Medicare sequestration, which Congress previously suspended through March 31, 2021.  The Senate recently enacted legislation to extend the moratorium through the rest of the calendar year. Now that legislation moves to the House for a vote and, while it will likely pass in that chamber as well, the House’s next voting day is not until April 13. Thus, the Centers for Medicare and Medicaid Services (CMS) has instructed Medicare Administrative Contractors (MACs) to hold all claims with dates of service on or after April 1, to minimize the volume of claims the MACs must reprocess when Congress extends the suspension. Providers should continue to submit their claims as usual.

Despite the expected 2% Medicare sequestration moratorium, there is still not a clear path ahead to address the larger PAYGO 4% Medicare cut.  With the Alliance’s support, the House passed H.R. 1868 which waives the PAYGO rules triggered by the American Rescue Plan.  The bill passed by a vote of 246-175 with 29 Republicans joining Democrats in support of the legislation.  While other PAYGO waivers and the Medicare sequester freeze have previously been accomplished in a bipartisan manner, some Senate Republicans have indicated that they will not support H.R. 1868.  In 2017, seventeen Democratic Senators joined with the then-Republican majority to waive the PAYGO requirements triggered by then-President Trump’s tax cut package.  That tax cut package would have resulted in $25 billion in Medicare cuts without the bipartisan waiver.

The Alliance of Specialty Medicine has written to Congressional Leadership in support of waiving PAYGO rules which result in cuts to Medicare providers and will continue to advocate to keep specialty practices open and Medicare patients safe.

Alliance Keeps Up the Fight on Step Therapy

In its ongoing advocacy to help patients adversely affected by step therapy, the Alliance of Specialty Medicine sent letters of support to the House and Senate sponsors of H.R. 2163 and S.464, the Safe Step Act.  These bills would provide patients and providers with a clear and transparent appeals process when subject to step therapy protocols instituted by insurers.  The letter endorsing S. 464 was addressed to Senators Murkowski (R-AK), Hassan (D-NH), Cassidy (R-LA), and Rosen (D-NV), and the letter endorsing H.R. 2163 was written to Representatives Ruiz (D-CA) and Wenstrup (R-OH), McBath (D-GA) and Miller-Meeks (R-IA).

Step-therapy protocols may require patients to try and fail an insurer-preferred medication before being covered by the physician-prescribed medication. Many insurers have instituted this practice to help control the costs of expensive medications. However, while this practice may initially reduce insurer costs, it can have devastating health consequences for patients and ultimately lead to more expensive health care costs in the long run.

In an Op-ed posted on Medium, Dr. Aline Charabaty, a gastroenterologist practicing in Washington, DC, provided a first-hand account of the health risks and extra costs associated with the “fail first” protocols related to step therapy.

The Safe Step Act will help patients and physicians by requiring insurers to implement a clear and fair appeals process that is easily accessible on the plan’s website that allows step therapy to be bypassed in medically necessary circumstances such as when a patient is already stable on a therapy. The legislation would also establish a time frame in which insurers must respond to appeals to ensure that patients can receive appropriate treatment in a timely manner.

The Alliance will be advocating for passage of the Safe Step Act during their virtual legislative fly-ins with Members of Congress later this year.

Specialty Spotlight: Dermatologic Surgeons Form Work Group on Diversity, Equity and Inclusion

Dermatology is one of the least diverse specialties. For example, Black or African American and Hispanic dermatologists together comprise 7.2% of all dermatologists while census data show these demographics account for around 32 percent of the U.S. population. Such discrepancies have remained stable or have even widened over the years, despite increasing diversity in the general population.

The formation of the American Society for Dermatologic Surgery (ASDS) Diversity, Equity, and Inclusion (DEI) Work Group represents the Society’s latest effort to uphold its commitment to caring for diverse populations, including Black, Indigenous, and People of Color (BIPOC); and sexual and gender minority (SGM) persons, including lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals.

Led by Dr. Mona Gohara, Chair, and Dr. Omer Ibrahim, Co-chair, this Work Group will help ensure diversity within the subspecialty and within the patient population is acknowledged, valued, and embraced. One of the Work Group’s first milestones was this YouTube video introducing the Work Group, with an accompanying expert panel on DEI, at the ASDS Annual Meeting in October 2020. Since then, DEI Work Group members have presented at other ASDS Work Group and committee meetings to emphasize achieving the Society’s position statement on DEI is the responsibility of all members and not just that of a single Work Group. In February 2021, the Work Group hosted its landmark inaugural webinar, “DEI and What It Means for Dermatologic Surgery and Cosmetic Dermatology,” featuring expert panelists in a town-hall format watched live by more than 100 ASDS members. Six future webinars in this series will tackle topics such as addressing macro- and micro-aggressions in clinical practice; LGBT considerations in cosmetic dermatology; procedural dermatology in patients with skin of color; the state of skin of color clinical research; diversifying your practice and inner circle; and women in dermatologic surgery.

The DEI Work Group will strive to ensure diversity of speaker panels and topics at Society meetings, as well as emphasize the need for educational content on dermatologic issues affecting BIPOC and SGM people on the Society’s website and on its social media platforms. Other Work Group initiatives include a celebration on social media of Black History Month; creating a dashboard of priority metrics to measure DEI success across the Society; creating new networking events for dermatologists with underrepresented backgrounds, as well as mentorship programs for residents and fellows looking for career support; and educating residency and fellowship program directors on the equitable selection of candidates with the goal of cultivating a next-generation workforce that more closely mirrors the diversity of our general population.

We hope that the ASDS DEI Work Group will inspire those in other specialties, as there are unfortunately many other areas in medicine with a similar lack of diversity within their ranks.

Learn how you can get involved at asds.net/diversity

Eye Care Executive Partners with Retina Specialist to Overcome Retinal Detachments


David Bragg was giving a company-wide presentation when it started “snowing” in his right eye. That morning, before boarding a flight to St. Louis, David noticed a faint, arching light in his vision, but chalked it up to not sleeping well. Hours later he was three minutes into his presentation when he noticed what seemed like snow or grey matter filling his eye from the bottom up, causing him to lose vision. He quickly finished up, and called an ophthalmologist friend who recommended that he see a retina specialist right away.

David had experienced a retinal detachment, in which the retina detaches from the back wall of the eye, separates from its blood supply and no longer functions properly.


“Be proactive about managing your eyesight. I told my siblings to go get their retina exam and all of my children have had theirs … I’m not sure if I could have prevented my retinal detachments, but now I pay very close attention to what’s happening with my eyes, everyone should.”


Since then, he has experienced several more retinal detachments and tears due to the development of scar tissue on his retina (a condition known as proliferative vitreoretinopathy) requiring multiple surgeries and numerous laser treatments. Through it all, his retina specialist ASRS member Dr. Jay Stallman, has helped David proactively manage his condition to preserve his sight.

“Dr. Stallman is amazing. He was honest and prepared me mentally for the fact that I might experience additional tears and detachments throughout my life,” David said. “He reassured me, though, that he could help me manage my condition and that I was getting the best treatment available, which gave me real comfort.”

Now David pays very close attention to his vision and calls Dr. Stallman immediately if he experiences symptoms such as flashes of light or floaters. He is able to get in for evaluation and treatment quickly, which has helped him preserve a significant amount of vision. This has allowed David to continue working, playing golf, gardening and enjoying his family including his wife, five daughters and three grandchildren.

Ironically, despite working in the vision industry for decades, David wasn’t always on top of taking care of his eyes before his retinal detachments, only getting a dilated retina exam every 2-3 years. Today he encourages his family and friends to prioritize their sight.

“Be proactive about managing your eyesight. I told my siblings to go get their retina exam and all of my children have had theirs,” David said. “I’m not sure if I could have prevented my retinal detachments, but now I pay very close attention to what’s happening with my eyes, everyone should.”

Rheumatologists Gather Virtually for Fellows Conference

The Coalition of State Rheumatology Organizations (CSRO) held its 15th Annual Fellows Conference last month. Its first (and hopefully only) year as a virtual event, this was the first time that it was open to both fellows and practicing rheumatologists, and attendance was at an all-time high.

Each year, the Conference provides a forum to introduce fellows to a network of experienced physicians that provide valuable perspectives on how to navigate the next phase of their professional careers.

More importantly, it provides insight into the importance of the advocacy efforts of the CSRO. Through a detailed look at the insurance landscape and how to navigate the differences in providers, fellows and practitioners alike learned about some of the specific barriers created by payers, pharmacy benefit managers, and even legislation.

This more nuanced understanding emphasizes the importance of being informed, and ideally being an advocate, to affect policy in order to ensure better access to consistent, quality care for our patients – the mission of the CSRO.

Other presentations highlighted best practices in personal financial management, especially for those early in their career as a physician; successful tactics for negotiating an employment contract in the medical field; an overview of the anatomy of a malpractice lawsuit, including suggestions for how to avoid one; significant updates in coding that went into effect in 2021; and essential considerations when transitioning from life as a fellow to a career in private practice.

A full outline of the program, including speaker bios, presentation slides, and session videos, is available on the CSRO website at www.csro.info/fellows.

CSRO looks forward to coming together, in person, for the 2022 Fellows Conference! Save the date for Saturday, March 19, 2022, at the Intercontinental Mark Hopkins in downtown San Francisco.