MACRA’s near and potential long-term future outlined for rheumatology
EXPERT ANALYSIS FROM THE ACR ANNUAL MEETING
Creating rheumatology-focused APMs
MACRA designated the development of the Physician-Focused Payment Model Technical Advisory Committee, of which Mr. Miller is a member, to solicit and review physician-focused payment models and make recommendations to CMS about which ones to implement.
Physician-focused payment models got their start through pioneering work by physicians who obtained data from insurers to find ways to reach out proactively to patients to address problems before patients are hospitalized. Through these efforts, they have reduced cost and increased patient satisfaction while also increasing payment to physicians by supporting “medical home” services, according to Dr. Miller.
These efforts to create APMs that support high-quality, physician-directed care begin by identifying avoidable spending that varies from specialty to specialty and from condition to condition. Then they address barriers in the current fee-for-service system – such as no payment for many high-value services and insufficient revenue to cover costs when using fewer or low-cost services – by providing flexible, adequate payment while requiring physicians to take responsibility for the things they said could be avoidable when paid in that way. However, this responsibility must be focused on what a particular physician can influence, Mr. Miller noted.
Rheumatologists could be helped by these physician-focused payment models because they receive less than 10% of the total Medicare health care spending per patient whose care was directed by a rheumatologist. In that case, finding ways to drop total spending per patient by 5% could at the same time give rheumatologists a 25% increase in payment while also saving Medicare 3% overall, he said.
Rheumatologists are best set up to take condition-based payments that are geared to keep patients out of the hospital, rather than the hospital episode–based payments that have dominated APMs in existence so far. Central to this condition-based model is getting the right diagnosis at the start, so payment for getting the correct diagnosis would be critical.
APMs designed for rheumatologists could take into account the diseases often seen by a rheumatologist, such as RA, and then identify opportunities to improve care and reduce costs while identifying barriers in the current payment system for achieving those goals, Mr. Miller said. These opportunities and barriers would vary from condition to condition. In some cases, particularly for low-frequency conditions, there may not need to be a new payment model established and it could be done through fee-for-service.
Ideally, these condition-based payment models for specialists such as rheumatologists would exist within the “medical neighborhood” of primary care physicians who could refer to them when necessary. Specialists would be accountable for the aspects of care that they can control, such as avoiding unnecessary tests and procedures and avoiding infections and complications.
“That’s building the ACO from the bottom up, rather than what Medicare is trying to do, which is to create it from the top down,” Mr. Miller said.
Mr. Miller noted that it will be important for specialties such as rheumatology to define the cost data it needs in order to develop condition-based payment models.
Dr. Harvey had no relevant disclosures. Mr. Miller has no financial relationships with any commercial interests.
