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Committee on Rheumatologic Care Update

March 2017
Doug White, MD, Chair

The Uncomfortable Move from Fee-for-Service to Value

ACR members are spread out across the U.S., but we all work in the same place: the land of fee-for-service. FFS, as it’s known to policy nerds, poses certain problems for cognitive subspecialists like rheumatologists. For instance, much of the work we do – calling providers and patients, coordinating care after hours – often isn’t compensated. And some of the tasks we perform, prior authorizations being at the top of the list, take up ever-increasing amounts of time and energy but seem far removed from patient care.

The result? It feels like our day-to-day activities are more and more about money – getting an expensive medicine paid for or justifying our bill – and less and less about taking care of patients. In fact, it has been observed that administrative burdens may actually impede our ability to provide high-quality care.

Rheumatologists are not the only ones who think FFS has problems. But those who pay for healthcare see the cost of FFS as the burden. Indeed, CMS has determined that FFS is so expensive that it poses an existential threat to Medicare and Medicaid. Importantly, in their estimation, these programs are not simply strained by the baby boomer bulge working its way through the system. Rather, CMS has decided that the very structure by which physicians and hospitals are reimbursed drives up the cost of care.

So the powers that be have decided that we are going to move. We are moving from the land of FFS to a place called “value-based care.” And even though we know that FFS has problems, we resist. In particular, we question whether value-based care as promoted by CMS will truly encourage the delivery of high-quality care to our patients.

Individual rheumatologists have had a range of responses to being moved from FFS to value. Some retire. Some lobby Congress. Some join a larger group in hopes that a dedicated infrastructure will provide shelter. Most of us focus on our patients and grumble about how it’s difficult to practice amid the tumult. But a few rheumatologists have done something different: a few have engaged CMS in a conversation.

And this is where things get interesting. It turns out that CMS knows where it wants rheumatologists to go, but doesn’t know how they should get there.

The ACR would like to provide a map. A group of ACR members, under the auspices of CORC* and with the invaluable support of other ACR committees, including Government Affairs, Quality of Care, and the RISE Registry, are currently engaged in a conversation about how rheumatologists can inform the definitions of quality and cost such that a value-based payment system would be better than FFS for patients and physicians. We started this conversation with the understanding that we can either influence the path we take, or the path will be selected for us by people who have never practiced rheumatology, much less run a rheumatology practice.

Some more details for those who have read this far: If you run a practice, then you know that MACRA is the law that repealed SGR and, as of January 1, 2017, dictates your reimbursement for seeing Medicare and Medicaid patients. It’s been widely reported that there are two pathways under MACRA: MIPS and APMs.

What that over-simplified explanation does not convey is that (1) both CMS and Congress are strongly incentivizing physicians to join APMs; (2) all accepted APMs to date have been created by payers; and (3) the MACRA legislation explicitly encourages the creation of “physician-focused” APMs. Indeed, Dr. Tom Price, recently confirmed as Secretary of HHS (which oversees Medicare and Medicaid), has expressed his support for physician-focused solutions.

Therefore, the APM group at the ACR, with the expert guidance of Harold Miller from the Center for Healthcare Quality and Payment Reform, and in coordination with similar efforts by other cognitive subspecialty societies, is constructing a rheumatology-focused APM. This physician-focused APM is being designed to serve as a model that can be modified, adapted, and adopted on a completely voluntary basis by practices around the country that wish to pursue such a path – and for whom MIPS and conventional APMs hold little attraction.

A rheumatology-focused APM won’t solve all our problems. But if done properly, it does offer a genuine opportunity to align reimbursement with cognitive work, reduce the cost of care, and reward high-value care. The alternative is a pathway designed by and for non-rheumatologists. The APM group at the ACR thinks there is a better way.

[*Sidebar: CORC (Committee on Rheumatologic Care), a committee with a memorable but uninformative name, was created years ago to enhance the voice of ACR members in practice. One of our most important duties, working alongside the Insurance Subcommittee and the Affiliate Society Council, is to help practicing rheumatologists navigate payment reform.]