ARTHRITIS & RHEUMATISMVol. 54, No. 4, April 2006, pp 1029–1033DOI 10.1002/art.21791© 2006, American College of Rheumatology

ACR PRESIDENTIAL ADDRESS

Yesterday, Today, and Tomorrow

Elizabeth A. Tindall

After beginning private practice in rheumatologyin 1982, I began my volunteer career at the AmericanCollege of Rheumatology in 1989. I served on theCommittee for Rheumatologic Care and representedthe ACR on the American Medical Association’s Physi-cian Payment Review Commission’s Advisory Subcom-mittee evaluating “physician work.” In 1992, I wasappointed to the ACR Board of Directors, of which Ihave been a member for 11 of the past 13 years. Fromthese experiences, I would like to share my reflectionson rheumatology and the ACR from 1992 through 2005.

The way we were

In 1992, a membership survey was sent to 4,300US and Canadian ACR members, to which 1,489 re-sponses were received. The breakdown of the respond-ers was as follows: 58.2% rheumatologists in privatepractice, 23.2% in medical school settings, 7.1% inhospital settings, 3.6% in government employment,1.7% in pharmaceutical industry employment, 2.8%employed in HMO settings, and 2.4% in other areas.Only 2.8% of the responders were not performing somepatient care.

The median age of ACR members in 1992 was 46years; 17% were female and 27% were in solo practice.The percentage of ACR members who provided ancil-lary services included 35% with office x-ray, �8% withbone density measurement equipment, 15% with in-

office occupational/physical therapy, and 13% perform-ing or interested in performing office-based needlearthroscopy. In the early 1990s, the ACR providededucational programs on office-based needle arthros-copy and published a position statement supportingperformance of this procedure by rheumatologists andrecommending appropriate reimbursement.

Reimbursement for cognitive medical specialtiessuch as rheumatology declined significantly in the 1990s.Physician reimbursement was still based on “historical,”rather than actual, costs of providing office-based ser-vices. The resource-based relative value scale, orRBRVS, did not come into law until 1992, and not until2002 had those changes in reimbursement completelytransitioned to include physician work, practice expense,and professional liability insurance. Traditionally proce-dural specialties were better compensated than cognitivephysicians, even though much of the overhead costsassociated with procedures were absorbed by hospitals.

In 1992, rheumatologists were profiled as generalinternists by Medicare and other third-party payers. Thespecialty designation UPIN (unique payer identificationnumber) of 66 was not granted to rheumatology until1991. This meant third-party payers, as well as Medicareand Medicaid, considered rheumatologists to be outlierswhen compared with other primary care providers:performing too many joint and trigger point injectionsand billing for higher levels of evaluation and manage-ment services. In a 1994 New England Journal of Medi-cine editorial (1), Kassirer stated: “Specialists are moreexpensive not only because they charge more, but alsobecause they use more health resources in general forcomparable clinical conditions.” . . .“It seems likely thatfuture studies will detect only small differences in qualityof care between generalists and specialists.”

Rheumatology reimbursement was also adverselyimpacted by the institution of the Stark Laws (I and II),

Presented at the 69th Annual Scientific Meeting of theAmerican College of Rheumatology, November 16, 2005.

Elizabeth A. Tindall, MD: Portland Medical Associates andOregon Health and Science University, Portland, Oregon: President,American College of Rheumatology, 2004–2005.

Address correspondence and reprint requests to Elizabeth A.Tindall, MD, 6640 SW Redwood Lane, Suite 301, Portland, OR 97224.E-mail: etindall@msn.com.

Submitted for publication January 24, 2006; accepted January24, 2006.

Arthritis & RheumatismAn Official Journal of the American College of Rheumatology

www.arthritisrheum.org and www.interscience.wiley.com

1029

which became effective in 1992. These laws were de-signed to prevent self-dealing and self-referral by physi-cians with respect to clinical laboratory and other ancil-lary services in which a physician may have ownershipinterest. Essentially, the Stark Laws prohibited physi-cians from providing almost all ancillary services inlaboratory, imaging, and physical and occupational ther-apy. The expansion of managed care in the 1990sseverely discouraged specialty referrals from primarycare providers. Estimated physician manpower needs foran HMO of 450,000 patient lives/900-bed hospital, in-cluded 225 primary care providers, 208 hospital-basedphysicians, and only 91.2 “other” specialists, which in-cluded ophthalmology, otolaryngology, dermatology,pathology, hematology and oncology, neurology, gastro-enterology, allergy and immunology, pulmonary medi-cine, nephrology, rheumatology, endocrinology, infec-tious disease, and plastic and reconstructive surgery (2).

Prashker and Meenan published a 1991 article inthe Annals of Internal Medicine entitled “SubspecialtyTraining: Is It Financially Worthwhile?” (3). The au-thors analyzed average before-tax net incomes in 3specialties in 1988, which included gastroenterology,internal medicine, and rheumatology. Their analysisshowed that, despite 2–3 years of additional subspecialtytraining beyond that of general internal medicine physi-cians, the average rheumatologist was not adequatelycompensated to recoup short-term or long-term earn-ings. The average before-tax net annual income for aninternal medicine specialist was $115,825, with totalcareer earnings being �$512,952. Gastroenterologistsearned an average of $210,875, with career earnings of�$1,101,863. Rheumatologists earned an averagebefore-tax income of $118,056, with total negative careerearnings of �$92,467. The authors concluded that,“When considered exclusively as a financial decision,

fellowship training in a cognitive-oriented medical sub-specialty such as rheumatology is a poor investment.”

The average debt carried by 1984 medical schoolgraduates was $22,000 for public school and $26,500 forprivate school. By 2004, the debt had increased to$105,000 for public school and $140,000 for privateschool, and only about 20% of medical students gradu-ated with no debt (4). Students with high medical schooldebt are less likely to pursue family practice and cogni-tive specialties, and instead seek specialties with higherincomes.

A Graduate Medical Education National Advi-sory Committee (GMENAC) study projected that by1990, only 1,900 rheumatologists would be needed in theUS workforce. The GMENAC model indicated that only22.5% of patients with rheumatoid arthritis should betreated by a rheumatologist and underestimated thevolume of patients with osteoporosis and fibromyalgia.This study directly led to a decrease in AccreditationCouncil for Graduate Medical Education–accreditedrheumatology training programs. The actual number ofUS rheumatologists practicing in 1990 was 3,200. TheACR conducted a detailed needs assessment study ofrealistically projected rheumatology manpower numbersbased on 19 diagnoses, and estimated that the idealnumber of rheumatologists needed for optimal care in1990 was 3,619 (5).

The cumulative effects of these variables pro-duced significant declines in the number of adult andpediatric training programs and the number of trainees.These numbers reached a low point in the mid-1990sand increased thereafter, but only very slightly, as shownin Tables 1 and 2. The actual number of rheumatologistsentering the US workforce was less than depicted in thetwo tables, as many of the international medical gradu-ates returned to their countries of origin.

Table 1. Trends from 1996 through 2000 in adult rheumatology training programs and number offellows*

Academic year

1996–1997 1997–1998 1998–1999 1999–2000 2000–2001

ACGME accredited programs 114 107 106 105 107Total positions available† 329 357 351 358 368No. completing program‡ 116 113 120 105 122% IMGs§ 52 58 63 59 45

* Refs. 8–11, 16, and 17. ACGME � Accreditation Council for Graduate Medical Education; IMGs �international medical graduates.† Total positions available, projected for the next academic year.‡ Completed training in previous academic year.§ Total positions filled as of current academic year.

1030 TINDALL

In addition, the ACR projected a dramatic de-cline in membership due to retirement of the “babyboomers,” peaking in 2016 (Figure 1). With the largenumbers of rheumatology practitioners retiring alongwith the declining numbers of trainees, rheumatologyappeared to be a specialty headed for extinction.

From 1998 to the future: saving rheumatology

There is no single action credited with “turningaround” the subspecialty of rheumatology. Rather, aseries of positive steps culminated in improved therapiesfor inflammatory arthritis, improved reimbursement for

rheumatologists, increased fellowship support and post-doctoral training, and reorganization within the Ameri-can College of Rheumatology.

The most important changes in the specialty ofrheumatology in the past 10 years are due to neweffective therapies for arthritis. The first wave of inno-vative nonsteroidal antiinflammatory drugs (NSAIDs)was launched by the discovery of 2 distinctive cyclooxy-genase enzymes, COX-1 and COX-2, and the release of3 COX-2 inhibitor drugs, celecoxib, rofecoxib, andvaldecoxib. A large influx of pharmaceutical funding forrheumatology was suddenly available for researchers,

Figure 1. Projected decline in American College of Rheumatology membership via retirement. Heavy line shows the projectednumber of new trainees entering the US rheumatology workforce (�100 per year).

Table 2. Trends in the number of pediatric rheumatology training programs and trainees*

Academic year

1997–1998 1998–1999 1999–2000 2000–2001

ACGME accredited programs 16 18 20 20Total positions available 25 38 39 44No. completing program 0 4 5 4% IMGs 33 55 50 57

* Refs. 8–11, 16, and 17. ACGME � Accreditation Council for Graduate Medical Education; IMGs �international medical graduates.† Total positions available, projected for the next academic year.‡ Completed training in previous academic year.§ Total positions filled as of current academic year.

ACR PRESIDENTIAL ADDRESS 1031

educators, the ACR, and the Research and EducationFoundation (REF). Two of the agents have been re-moved from the market due to adverse side effects, andnow all NSAIDs carry a black-box warning about poten-tial adverse cardiovascular, cerebrovascular, and gastro-intestinal events. Despite the huge continuing contro-versy and litigation, the COX-2 NSAIDs brought anincreased public awareness of arthritis.

Since 1998, 5 new disease-modifying antirheu-matic drugs (DMARDS) have been released in the US,including 3 anti–tumor necrosis factor � (anti-TNF�)antagonists (etanercept, infliximab, and adalimumab),an interleukin-1 receptor antagonist (anakinra), and apyrimidine inhibitor (leflunomide). Rheumatoid arthri-tis and other inflammatory arthropathies were con-trolled better and more safely than with any previoustreatments. Early, aggressive treatment of RA is now theaccepted standard of care. Economists estimate that“approximately 30% of the moderate to severe RApatient population will be receiving anti-TNF therapy,with increasing penetration in mild to moderate pa-tients. Over the next seven years, approximately 19DMARDs are expected to be launched, and will bepositioned in different areas of the RA market, de-pended on efficacy, mechanism of action, side effectsand costs” (6). Over half of these 19 DMARDs will beinfused medication. The ACR worked diligently toachieve parity with oncology in infusion reimbursement.The discussion needs to shift from discrediting rheuma-tologists who infuse to what is the best therapy for agiven patient. In 2006, 2 new biologic therapies (abata-cept, rituximab) will be available for treating rheumatoidarthritis and bringing therapeutic options to those pa-tients who either don’t respond to other agents or cannottolerate other therapies.

With the introduction of COX-2 inhibitors andbiologic response modifiers, the ACR REF formed theIndustry Roundtable, allowing pharmaceutical compa-nies to provide financial support for awards and grantsspecific to rheumatologists and related health profes-sionals. For 2006, the REF awards and grants total $4.2million.

Using randomized controlled prospective trialsand evidence-based medicine, rheumatologists musttake the lead in evaluating the appropriateness of newerimaging techniques such as use of office-based portableMRI scanners and ultrasound machines. If portableMRI and ultrasound imaging is proven to be the “stan-dard” for diagnosing joint damage and monitoring ther-apy, then the ACR will recommend to third-party payers

that reimbursement for rheumatologists be equivalent toradiologists’ services.

In the fall of 2001 and spring of 2002, �300 ACRpractices received a membership survey questionnaire.Of these, 48 practices representing 119 physicians pro-vided data for various 12-month periods in 2000 and2001. Each responding practice was provided with anindividualized analysis of its practice results and com-parison with external benchmarks on 21 discrete indica-tors. Those responders may be self-selected to representthe best practices of rheumatology. The responses fromthe survey showed that 75% of practices were 3 peopleor less. The mean annual income in the group was$261,674, ranging from a low of $103,556 to a high of$789,243. Providing office-based ancillary services pre-dicted the difference between the highest and lowest netincomes. Ancillary services included infusion services(76%), bone densitometry (51%), laboratory (69%),x-ray (51%), physical therapy (4%), and ultrasound(4%) (7). The additive effects of increased reimburse-ment, effective therapies, and improved financial sup-port of trainees and programs by the REF resulted in anincreased number of rheumatology fellows in 2004–2005, to the highest-ever number of 333 (8–15).

The demographics of the ACR have changed inthe past 13 years, such that by 2005, the US rheumatol-ogy membership totaled 5,164, of whom 30.2% werefemale. In 1992, the 20 members of the Board andcommittee chairs included 1 woman and 4 private prac-titioners. By 2005, both the President and President-Elect were women, 7 out of 18 Board members werewomen, 3 out of 10 committee chairs were women, and7 Board members were in private practice.

Many issues impact a large number of ACRmembers and do not fit into the traditional standingcommittee structure. Two new committees that cutacross all ACR membership are the newly formedACR/FDA Committee and the Quality Measures Com-mittee.

The COX-2 debate led the ACR to reevaluate itsrelationship with the FDA. At a recent Board meeting,Dr. Janet Woodcock of the FDA invited the ACR tomeet with her on a regular basis. This ACR/FDACommittee will 1) assist the FDA in designing mecha-nisms for monitoring and reporting adverse events; 2)communicate directly to ACR members, the public, andhealth care providers new information on drug safetyand monitoring; 3) influence future safety monitoringand clinical trial design; 4) monitor post-marketingsurveillance of adverse events in all populations, ratherthan relying on ad hoc anecdotes.

1032 TINDALL

The ACR has revitalized its approach to profes-sional standards by forming the Quality Measures Com-mittee. This committee has under its charge 1) develop-ing guidelines, response criteria, and professionalstandards; 2) enhancing rheumatologists’ practices andpromoting quality care; 3) proactively responding to“pay for performance”; 4) working toward increasedrecognition for rheumatologists’ expertise and qualitycare; and 5) addressing “hassle factors”—justificationfor reimbursement, documentation overload, approvalfor treatment, and diagnostic tests.

The ACR Task Force on International Relationshas recommended changes in our approach to interna-tional members, leagues, and other organizations. In1992, the ACR had �400 international members (out-side the US, Canada, and Mexico), and in 2005, therewere over 1,000 international members. Although inter-national members are not concerned about US advocacyefforts, they do care when what happens in the USaffects the rest of the world. The ACR is increasing itsnational advocacy and lobbying with a firm based inWashington, DC, Patton Boggs. The ACR is expandingits educational programs and international advocacy forarthritis through EULAR, PANLAR, APLAR, andAFLAR. As ILAR continues to be the “umbrella”league which reports to WHO, the ACR will continue towork with its leadership as well. The ACR will expand itscollaboration and advocacy with other organizationsincluding OMERACT, US Bone and Joint Decade, andthe Arthritis Foundation.

In conclusion, I wish to thank my husband, Dr.Charles Colip and children, Leslie and Chuck Colip. Iwant to thank Mark Andrejeski and his exceptionalACR staff, as well as the outstanding ACR volunteerswith whom I’ve worked with for many years.

REFERENCES

1. Kassirer JP. Access to specialty care [published erratum appears inN Engl J Med 1994;331:1535]. N Engl J Med 1994;331:1151–3.

2. Kronick R, Goodman DC, Wennberg J, Wagner E. The market-place in health care reform: the demographic limitations ofmanaged competition. N Engl J Med 1993;328:148–52.

3. Prashker MJ, Meenan RF. Subspecialty training: is it financiallyworthwhile? Ann Intern Med 1991;115:715–9.

4. Morrison G. Mortgaging our future: the cost of medical education.N Engl J Med 2005;352:117–9.

5. Marder WD, Meenan RF, Felson DT, Reichlin M, Birnbaum NS,Croft JD, et al. The present and future adequacy of rheumatologymanpower: a study of health care needs and physician supply.Arthritis Rheum 1991;34:1209–17.

6. Mount C, Featherstone J. From the analyst’s couch: rheumatoidarthritis market. URL: http://www.nature.com/news/2004/041220/pf/nrd1611_pf.html.

7. URL: http://www.rheumatology.org/practice/benchmarking/bench2003.asp?aud�mem.

8. Graduate medical education. JAMA 1998;280:836–41.9. Graduate medical education. JAMA 1999;282:893–906.

10. Graduate medical education. JAMA 2000;284:1159–72.11. Graduate medical education. JAMA 2001;286:1095–107.12. Graduate medical education. JAMA 2002;288:1151–64.13. Graduate medical education. JAMA 2003;290:1234–48.14. Graduate medical education. JAMA 2004;292:1099–113.15. Graduate medical education. JAMA 2005;294:1129–43.16. Graduate medical education. JAMA 1996;276:739–48.17. Graduate medical education. JAMA 1997;278:775–84.

ACR PRESIDENTIAL ADDRESS 1033