Breakthrough Rheumatology Therapies, Reimbursement Shifts, and What to Expect in 2025

2024 Treatment Innovations Competitively Position Small Practices

1. New Biologics and Targeted Therapies

In 2024, Bimekizumab-bkzx was approved for treating adults with psoriatic arthritis (PsA), ankylosing spondylitis (AS), and non-radiographic axial spondyloarthritis (nr-axSpA). Additionally, secukinumab was released in IV form for the treatment of adults with PsA, AS, and nr-axSpA.

For private practices, integrating these newer biologic options offers the dual benefit of improving patient outcomes and enhancing your practice’s competitive position. More targeted treatments mean better results with potentially fewer side effects, leading to higher patient satisfaction.

2. Biosimilars Could Improve Affordability if Reimbursed at Cost

In 2024, the growing availability of biosimilars significantly impacted the cost of biologic therapies. Biosimilars to TNF inhibitors (e.g., adalimumab and infliximab) show promise for reducing treatment costs without sacrificing efficacy. However, adequate reimbursement for biosimilars must be addressed to fully realize this potential. Some biosimilars are reimbursed at rates below acquisition cost, limiting patients’ ability to afford these treatments. Collaboration among providers, manufacturers, and payers is crucial to address this issue.

As payers push for greater biosimilar adoption, private practices incorporating these therapies can offer cost-effective treatments while maintaining high clinical standards, ultimately improving patient access to necessary medications.

3. MIPs Value Pathways Pushes Value-Based Care to Forefront

The Merit-Based Incentive Payment System (MIPS) program continued to push for value-based care with changes to Medicare reimbursements that link quality outcomes, cost efficiency, and patient satisfaction. In 2024, the MIPS MVP program incentivized rheumatologists to focus on more relevant quality measures rather than service volume. The program continues to reward practices for achieving high-quality care through categories like Quality, Cost, Improvement Activities, and Promoting Interoperability.

However, there are challenges associated with measuring and reporting these new MVP measures, which require preparation and workflow adjustments. Innovative practices prepared to navigate these changes stand to benefit from the program’s focus on quality care and efficient practice management.

2024 Workforce Trends Drive Operational Change

Several significant milestones in 2024 are shaping the future of rheumatology:

1. Lower Reimbursement Rate for Biologic drugs.

Changes to rheumatology infusion reimbursements are placing financial pressure on private practices. In 2024, Medicare Part B reimbursement rates for infusion drugs decreased further due to adjustments in the Average Sales Price (ASP) calculation and stricter inflation updates.

These tighter margins mean practices must optimize their processes to remain profitable. Common pitfalls such as errors in prior authorization, excess inventory, or failing to meet purchasing tiers can lead to substantial financial losses. Rheumatology practices must carefully evaluate their operations to minimize inefficiencies and protect their bottom line.

2. Increased Reimbursement and Expanded Eligibility for CCM and RPM Services

Advancements in Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) services offer new opportunities for rheumatology providers in 2024.

Key updates include:

Improved Reimbursement: Medicare increased reimbursement rates for CCM services through the Physician Fee Schedule, introduced new billing codes for comprehensive CCM services, and expanded eligibility requirements, allowing more patients with multiple chronic conditions to qualify.
Enhanced Integration: Medicare and private payers have also increased reimbursement for remote monitoring devices that track rheumatology-specific metrics, such as joint pain, inflammation markers, and patient-reported outcomes.
Combined Benefits: Practices now see higher combined reimbursements when utilizing both CCM and RPM services, making it easier to integrate these programs into patient care.

One of the most important updates in 2024 is that non-face-to-face CCM services (such as phone consultations, care coordination, and medication adjustments) will be reimbursed more favorably. Medicare also increased the reimbursement rates for CCM services through the Physician Fee Schedule, introduced new billing codes for comprehensive CCM services, and expanded eligibility requirements for CCM services, allowing more patients with multiple chronic conditions to qualify.

Medicare and private insurers also have expanded reimbursement for remote monitoring monitoring devices that track various metrics relevant to rheumatology, such as joint pain, inflammation markers, or patient-reported outcomes related to disease activity. And for patients receiving Chronic Care Management (CCM) services, the integration of RPM is now easier, with higher combined reimbursements when both are utilized.

3. Expanded Use of Advanced Practice Providers Insufficient for Covering Specialty Physician Shortage

Federal healthcare workforce projections highlight severe shortages of specialty physicians, including rheumatologists, over the next three decades. While the supply of Advanced Practice Clinicians (APCs), such as nurse practitioners and physician assistants, is rapidly growing, these professionals cannot fully close the gap in specialty care.

The increasing utilization of APPs in rheumatology is seen as a key strategy to tackle the gap in access to care due to a limited number of available rheumatologists. Yet, early projections from a new workforce model by the American Academy of Medical Colleges show that although the rapidly increasing supply of APCs can meet the demand for providing primary care to the U.S. population within the next decade, for nonprimary care physician specialties, the outlook is less optimistic.

The model projects that the nonprimary care physician specialty workforce will experience shortages for the next three decades at least, even when care is provided by advanced practice clinicians. Findings will be discussed in a full report to be published by the AAMC in early 2025.

2025 Promising Trends and Breakthroughs

Looking ahead, 2025 promises even more exciting innovations:

1. AI and Medicine

Artificial intelligence (AI) is poised to revolutionize the way rheumatologists diagnose and treat patients. By analyzing vast amounts of patient data, AI can assist clinicians in predicting disease progression, identifying patterns, and tailoring therapies with greater precision. For example:

Improved Diagnosis: AI-powered tools can analyze imaging, lab results, and patient-reported data to identify conditions earlier and more accurately.
Optimized Treatment Plans: AI algorithms can predict responses to specific therapies, reducing reliance on trial-and-error approaches and improving outcomes faster.

In private practices, AI could streamline administrative workflows by automating tasks like prior authorizations, reducing the burden on staff while allowing providers to focus on patient care.

2. Gene and Cell-Based Therapies

Gene therapies and cell-based interventions are making strides in treating autoimmune diseases such as rheumatoid arthritis (RA) and lupus. These therapies, though still emerging, hold immense promise:

Gene Editing: Techniques like CRISPR could potentially correct genetic mutations linked to autoimmune diseases, offering long-term solutions.
Cell-Based Treatments: Therapies involving modified T-cells or mesenchymal stem cells could reduce inflammation and repair damaged tissues.

While still in early development, these approaches may one day lead to curative treatments, reducing the long-term disease burden for patients and reshaping how rheumatologists approach care.

3. Wearables for Disease Monitoring

Wearable technologies are becoming increasingly relevant in rheumatology for real-time disease monitoring. Devices capable of tracking disease markers, such as joint swelling, inflammation levels, or mobility changes, are on the rise. Key benefits include:

Real-Time Data: Wearables provide continuous patient data, allowing rheumatologists to monitor disease activity and make timely adjustments to treatment plans.
Enhanced Patient Engagement: Patients can actively participate in their care by sharing wearable data during appointments, improving adherence and communication.
Early Intervention: Wearables can alert providers to early signs of disease flares, enabling proactive adjustments to prevent worsening symptoms.

By incorporating wearable technology, practices can improve outcomes, strengthen patient relationships, and differentiate themselves as leaders in innovative care.

Staying Competitive: Rheumatology in 2025 and Beyond

2024 has been a year of significant advancements in rheumatology, with new therapies and technologies enhancing patient care and opening doors for private practices to grow and innovate. From biologic and biosimilar advancements to breakthroughs in value-based care models, private practices have opportunities to stay competitive in an evolving healthcare landscape.

Looking ahead to 2025, emerging innovations like AI, gene therapies, and wearable technologies are poised to reshape how rheumatologists approach diagnosis, treatment, and patient engagement. By staying informed, embracing new tools, and adapting to legislative and reimbursement shifts, private practices can position themselves as leaders in rheumatology care while continuing to improve patient outcomes.