Using Value-Based RA Pathway Leads to a Shift to Biosimilars for AHG

Originally published in The Center for Biosimilars

Biosimilars have struggled to gain ground in the United States, with few products launched, relatively low uptake of commercially available products, formulary restrictions that sometimes favor branded biologics over biosimilar options, and exclusionary contracting practices that block biosimilars from formularies altogether.

A variety of policy proposals have been put forward to help spur the US uptake of biosimilars, from legislative solutions to regulatory changes, but some providers are taking the matter into their own hands with concerted efforts to bring biosimilars to the clinic.

In an editorial appearing at the Articularis Health Group’s (AHG) website, Colin C. Edgerton, MD, one of the founding members of the rheumatology practice, explained that AHG has created a value-based rheumatoid arthritis (RA) treatment pathway that has boosted biosimilar use.

Click here to read full article.

Rheumatologists Lead Biosimilar Uptake with Value-Based Pathways

By Colin C. Edgerton, M.D.

Biosimilar Adoption Falters

Rheumatologists hoped that biosimilars would reduce the costs of treating diseases such as rheumatoid arthritis (RA), and thereby increase access to these life altering medications for our patients. The recent Forbes article, “Biosimilars Continue to Exhibit Market Failure” confirms what we as rheumatologists are observing, that biosimilars have failed to adequately penetrate the marketplace, and biologic prices have stubbornly refused to decline (Cohen, 2019).

The article points to the effective maneuvers that originator biologic manufacturers have used to stymy competition from biosimilars, including patent litigation that extends monopolies and incentives offered to payers and pharmacy benefit managers (PBMs) to exclude biosimilars from formularies. As the article mentions, in 2017, “Nearly half the market blocked or step-edited biosimilars,” (Cohen, 2019).

Rheumatologists Take Control

What is a Rheumatologist to do? What can we do to improve access to biosimilars, bend the cost curve of treatment, and improve access for our patients? It may seem that we are relegated to the sidelines as originator biologics block biosimilars with patent litigation, rebates to payers and PBMs, and exclusionary contracts. But this is not the case.

One effective way for Rheumatologists to take control, and get a seat at the biosimilar table, is through value-based contracting. I am a founding member of Articularis Healthcare Group (AHG), the largest rheumatology practice in the country. Three years ago, AHG began developing a value-based RA treatment pathway, using the 2015 ACR treatment guidelines. The pathway goals were reducing the costs of treating RA while improving the quality of care and patient outcomes. Through collaboration with our largest commercial payer, we modeled the performance of the pathway and demonstrated significant savings. We went on to fully integrate the pathway into the EHR in the most user-friendly and “click-free” fashion with our partner, TSI-Nextgen.

After close work with the payer team, establishing relationships based on mutual understanding of costs and outcomes, we were able to negotiate biosimilars as first-line treatment for our RA population, when these drugs had previously been restricted from the payer formulary. Our physicians may now prescribe the infliximab biosimilars Inflectra and Renflexis, or the originator Remicade, as first line biologic therapy without the need for prior authorization. Indeed, the pathway program has eliminated prior authorization for any biologic agent. I believe that our commitment to savings, high quality care, and sophisticated information technology (IT) implementation has solidified our position as a reliable and mature partner with our payers. Our rheumatologists are now in the driver’s seat, eliminating middlemen from the drug selection equation and lowering the cost of healthcare.

Changing Habits

A reasonable question might be, “What about the bottom line?” Studies clearly show that Rheumatologists do not choose biologic agents based on cost of the drug or profit to the practice. Our experience has borne this out, and we have shared this data with our providers. We routinely hold meetings to review benchmarking spreadsheets for each provider. We review the real costs and utilization numbers related to prescribing patterns. One early surprise was finding that Rheumatologists do not realize that the leading subcutaneous biologics are significantly more expensive than their infusion equivalents, even when Centers for Medicare and Medicaid Services (CMS) offers a great public tool allowing drug-to-drug comparison (CMS, 2019). Sitting with trusted professional colleagues to review this data has proven to be an important step in changing habits. The data speaks for itself, adoption of biosimilars is a win-win for the practice, payers, and patient access. Using these methods, we have seen a significant shift to biosimilars in our practice.

Supporting Community Practices

One key to this success has been size. While community rheumatology practices are the ideal setting for innovative programs like this, Rheumatologists are constrained by relatively small practice sizes. Many practice management teams are not able to take on projects like this. For this reason, AHG has formed the Articularis Rheumatology Network (ARN). This network exists to help community rheumatology practices thrive. ARN offers a Group Purchasing Organization (GPO) with differentiated contracts that are not available through other GPOs, allowing members to purchase medications together at deep discounts. ARN also offers use of the pathway program (including the IT solution) at no cost. ARN is rheumatologist owned and led, existing solely to support community rheumatologists. ARN charges no fees and requires no minimum purchasing. We feel ARN is the future of community rheumatology, putting rheumatologists in the driver’s seat and helping independent community rheumatology practices thrive.

ARN will be holding a community rheumatology practice summit in Dallas, TX August 17, 2019. Contact ARN to inquire about attending at

For more information on the ARN pathway program visit:



Cohen, J. (2019). Biosimilars continue to exhibit market failure. Retrieved from

U.S. Centers for Medicare and Medicaid Services. (2019). Retrieved from

Recipients of Award to Assist with Workforce Expansion in Rheumatology

The field of rheumatology is experiencing a workforce shortage that is expected to worsen in years to come, and many patients living with rheumatic disease already live in medically underserved areas across the nation. Articularis Healthcare is proud to offer care with 12 locations across two states, spanning 11 counties. It’s not uncommon for patients of our practices to travel more than 50 miles to receive necessary care. We applaud our team for actively participating in activities to support the future of rheumatology. Congratulations to the recipients of the Mentored Nurse Practitioner/Physician Assistant Award for Workforce Expansion of 2019, especially our very own Colin Edgerton, M.D. and Kaitlyn Horner, PA-C!

Click here for more information and to view a pdf of the award recipients.

TSI Healthcare Partners with Articularis Rheumatology Network to Develop First Electronic Payer Approved RA Pathway

Originally published in PR Web

TSI Healthcare, a national leader in the sales and support for NextGen Practice Management (PM) and Electronic Health Records (EHR) solutions partnered with Articularis Rheumatology Network to develop the first electronic payer approved Rheumatoid Arthritis (RA) Pathway. Articularis Rheumatology Network, together with TSI Healthcare, developed the clinical decision support pathway to address pressing needs in community rheumatology.

Rheumatologists have lacked an integrated tool that simultaneously provides decision support and allows for value-based contracting. The RA Pathway assists providers in adhering to evidenced-based guidelines, while incorporating value-based features of interest to payers. The pathway significantly reduces the costs of care for RA patients, while maintaining physician autonomy and providing a mechanism to move from fee-for-service to value-based reimbursement. “The fact that the pathway is successfully running with a major payer speaks to its viability, and the benefits to our practice have been enormous,” says Articularis Rheumatology Network Executive Chairman and Chief Medical Officer Colin Edgerton, M.D.

Rather than work with a third party, Articularis Rheumatology Network chose to partner with TSI Healthcare’s development team to embed the pathway algorithm directly into NextGen EHR. Developing the logic in a native way ensured the pathway did not impede the natural workflow of rheumatologists or create any new and unnecessary “clicks.”

TSI Healthcare supports more than 600 independent rheumatologists nationwide and has been a partner of Articularis Rheumatology Network’s founding group, Articularis Healthcare, for nine years. Given the relationship and trust, this direct integration into NextGen EHR was the most logical fit for rheumatologists seeking to join Articularis Rheumatology Network.

“Articularis Rheumatology Network’s mission is supporting the community rheumatologist,” says, Dr. Edgerton. “Articularis Rheumatology Network has grown from the country’s largest community rheumatology practice and therefore understands, in a grassroots way, what a community rheumatologist needs to excel in the current, challenging landscape. We are a collaborative group with a focus on value to members, not organizational profit. Our rapid growth to over 150 rheumatologists within several months has been a testament to this value.”

“With nearly 22 years in the Health IT industry, TSI Healthcare remains committed to providing rheumatology practices of all sizes with the best tools and the best service to ensure their independence and success,” says Alerie Stiles, TSI Healthcare’s Director of Specialties. “Articularis Rheumatology Network’s electronic payer approved RA Pathway is the first of its kind and TSI Healthcare is excited for this seamless integration.”

TSI Healthcare, together with Articularis Rheumatology Network, will demonstrate the RA Pathway workflow at its inaugural Rheumatology User Group Meeting in Chapel Hill, NC, August 2019. A demonstration of the RA Pathway will also be available at the upcoming Articularis Excellence in Community Rheumatology summit in Dallas, TX, August 2019. More information about these summits is available at the Articularis Rheumatology Network’s website This RA Pathway is available exclusively to Articularis Rheumatology Network Group Purchasing Organization Members.

About TSI Healthcare
TSI Healthcare, founded in 1997, is a national leader in the sales and support of customized NextGen Practice Management and Electronic Health Record software. The company’s solutions are designed to meet the unique needs of specialty practices through specialty specific EHR content, top-ranked service, and award-winning software. In addition to core products powered by NextGen, TSI Healthcare also offers Revenue Cycle Management (RCM) Solutions, Patient Portal, Population Health Management, Cloud Hosting, and more. TSI Healthcare’s support and service teams include NextGen Certified Professionals and former practice administrators based in the USA. TSI Healthcare has approximately 200 team members and has provided services to approximately 2,500 providers nationwide since its inception in 1997. For more information, visit, or call 800-354-4205.

About Articularis Rheumatology Network
Articularis Rheumatology Network is a management and group purchasing organization (GPO) committed to advancing community rheumatology while improving the value of care. This is achieved through best-in-class group purchasing, innovative practice performance technology, value-based treatment pathways, clinical and business collaboration platforms, tailored educational activities, and community practice advocacy. Powered by select partnerships, Articularis Rheumatology Network provides member practices with the tools needed to thrive in today’s healthcare environment. For more information, visit, or call 843-329-8831.

Thank you for stopping by ARN’s Exhibit at #NICA2019!

Thank you to everyone that stopped by ARN’s booth at the National Infusion Center Association’s (NICA) conference held in Austin, TX this past week. We’re happy to have connected with so many individuals, and look forward to seeing many of you at #NICA2020!

Additional Arthritis Research Needed Among Veterans

Originally published in Veterans Health Today

Colin C. Edgerton, MD, rheumatologist at Articularis Healthcare in South Carolina and chair of the American College of Rheumatology’s Committee on Rheumatologic Care and former US Army rheumatologist, discusses the prevalence of arthritis among active and former service members as well as the importance of a dedicated arthritis research program at the United States Department of Defense.

I’m Dr. Colin Edgerton. I’m a rheumatologist. I also serve as the chair for the American College of Rheumatology Committee on Rheumatologic Care. I am a former Army rheumatologist.

Arthritis is a large treatment challenge for service members. We know that there is an inability of service members to return to full duty, which is highly impacted by musculoskeletal injuries. This is also the most common reason for medical discharge from the armed services, 78 percent of males and 85 percent of females.

We know that the consistent physical demands placed on the bodies of active duty service members is similar to what you would see with a high level athlete. However, the lifetime of a service member in the military is quite a bit longer than you would see with a professional athlete.

Due to that combination of those activities and a long career, we see a disproportionate impact of musculoskeletal injuries and arthritis affecting service members.

When I was working as Army rheumatologist, I was the primary reviewer for cases where service members were being medically discharged for both arthritis due to injury, as well as arthritis and autoimmune diseases affecting the musculoskeletal system.

I would have to review these cases and see young service members, men and women, who otherwise would have wonderful career opportunities with the military. These were cut short because they couldn’t perform some of the physical services or they couldn’t be deployed to austere environments due to their arthritis or autoimmune diseases.

I saw firsthand the high proportion of soldiers that we were losing due to these medical retirements and medical separations.

I also served overseas with an infantry unit in Iraq and in that role was the first line physician that would see injuries. I saw that these statistics are indeed true, that the majority of injuries that I was seeing in the aid station were related to musculoskeletal injuries.

We know that there’s a tenfold higher incidence of ACL, to knee and meniscal injuries in active duty service members. I absolutely saw that. We would see soldiers who were carrying heavy loads, very heavy body armor. They were navigating uneven terrain. They would suffer these injuries.

We know the science behind cartilage and ligament injury is that those sorts of injuries early in life set up an accelerated timeline for traumatic arthritis later on in life.

The service members who are fortunate enough to recover from their injuries, and stay in theater, and continue to do their job unfortunately weren’t really out of the problem zone because that might come back and haunt them when they’re in their 40s and 50s, lead to joint surgeries and joint replacements much earlier than their peers.

Sadly, we saw a lot of service members that we had to return back to the states and lose them as part of the fighting unit because of their injuries. In a deployment setting, you don’t get replacements for injured soldiers. That did affect the readiness of the unit.

We know that there are very consistent physical demands that are placed on the veterans when they were on active duty status. Even if those injuries were such that they were able to complete their career, that sets up a ticking time bomb as far as accelerated damage to the joints down the road.

As adults, we don’t grow new cartilage, the soft cushioning within our knees, so if there is an injury to cartilage, whether it be in a knee, or ankle, or other joint, what’s lost is lost. As life goes on, that joint is more likely to wear out or fail at an early age.

I think what we see in veterans is the results of that, which is damage that was done at an earlier stage of their life which leads them to greater disability earlier than their peers.

I think it’s similar to if you looked at the offensive or defensive line for a football team and compare them to their peers in regular life, you’d see that there are a number of mechanically associated disorders that would occur with a much higher prevalence.

Again, our service members are living like high level athletes for their entire career. We see similar types of problems. I think there’s also a culture in the military, which is necessary to accomplish the mission, which is continuing to drive on despite injury. I definitely saw that in the deployment setting with our young infantry soldiers.

To a degree, injury and pain was part of the job. That was accepted. I think we could do a better job of focusing on preventing and treating those problems when they’re occurring so that we don’t lose those assets as time goes on.

There’s a unique opportunity in the Department of Defense to focus on research related to arthritis and rheumatic conditions, autoimmune conditions.

First of all, there’s a single electronic medical record and an element of control over aspects of individuals’ lives that make it a very rich resource for studying and comparing populations, and their outcomes, and what people have been exposed to, and what sort of interventions are effective.

From the active duty perspective, looking at our service members, when research is performed within the Department of Defense, it’s far more likely to be accepted by the people who need to accept it, which is unit commanders and the individuals who are in charge of soldiers, and sailors, and airmen, and Marines in their day to day lives.

There is an example of this. When I deployed with the infantry unit to Iraq, that unit was the 101st Airborne out of Fort Campbell, Kentucky.

They had an ongoing research project called the Disease Prevention and Disease Injury Prevention Laboratory, where research was occurring on the actual base, looking at ways to modify physical fitness training to reduce injuries when soldiers were deployed.

If that research had been performed in a non‑DoD setting, in an academic medical center, even if it looked great and the results were great, you would never have seen unit commanders actually start to implement the findings of that research with their units.

They’re not really interested and, perhaps, don’t trust what people from outside are telling them they should be doing with their soldiers. Because that research occurred on base, and it incorporated the units, and the commanders could see what the training looked like, and how it could be incorporated into the normal physical fitness training for the soldiers, it was accepted.

That made a big difference in reducing injures. Again, research done within the walls of DoD tends to have a more direct impact on soldiers and, by extension, on those soldiers when they become veterans than things that are done outside.

Again, the veteran population, when it comes to arthritis and autoimmune conditions, occupy part of the spectrum of what happens younger in life. The benefits that are seen in the active duty population very easily translate into benefits seen down the road.

Another example of the opportunities within DoD include, again, having a large pool of combined resources. The DoD runs a program called the Serum Bank, where Serum samples are frozen in warehouses when labs are done periodically on service members.

That serves as a wonderful resource for researchers if they need to look back in time for things like serologic biomarkers for diseases.

There were some pivotal studies done in lupus using that Serum Bank where researchers were able to go back in time, once a service member was diagnosed with lupus, and identify markers in the blood that existed years before the onset of the disease that would predict that disease.

Now, those markers are used in the commercial and the civilian setting as a mainstay of diagnosing lupus. That sort of differences that exist within the DoD system can be leveraged well with research programs that are aimed at the DoD funding stream.

We know that the congressionally mandated research programs, there are specific disease states that are funded by name. Because arthritis has such a high level impact on the military, it makes sense to us that that should be an area of research that’s funded by name.

Currently, it’s not. And so, if someone wants to perform arthritis research using that DoD funding stream, it’s a competitive process whereby their research has to compete with other disease states on a yearly basis.

That process leads to a research funding stream that can be interrupted very frequently. That leads to a degradation in the quality of research. For a really good quality research program or laboratory to consistently perform on a topic like this, there has to be a consistency and dedication in the research funding stream.

Given the outsize impact that arthritis has on DoD, it certainly makes sense that it’s a disease state that would be funded by name.

Articularis Rheumatology Network GPO will Exhibit at Inaugural NICA Meeting

ARN’s CEO Ray Waldrup is looking forward to exhibiting at the NICA conference in a couple of weeks! Stop by Booth 52 for more information about how ARN GPO works with independent rheumatology practices to increase revenue and reduce expenses, while improving the value of care.

Key Elements of a Successful Medical Practice

by Ray Waldrup, CEO

Medical practices from all over the country visit Articularis Healthcare Group’s (AHG) Charleston, South Carolina locations and are taken back by the efficiency and caliber of AHG employees. Many are also puzzled by the lack of managers and supervisors we employ. Inevitably, someone always asks, “How do you develop and recruit employees?”

The cornerstones of a successful business are its People, Processes, and Culture (PPC).  Take Chik-fil-A, for example; it’s a fast-food restaurant chain specializing in chicken sandwiches, and it’s wildly successful. It’s rare to pull into a Chik-fil-A lot without a line of cars wrapped around the building and even more customers filing through the doorway. On these busy days you can still expect to receive your order in a timely manner, without error.  If you’ve been to Chik-fil-A, you know this is true. So, how is it that Chik-fil-A can consistently perform, but another fast-food restaurant falters under the same circumstances?

It’s simple: PPC. Chik-fil-A hires intelligent employees, implements efficient processes, and fosters a culture that appeals to its employees. It seems like a straightforward concept, and it’s certainly not original, yet many tend to over-think and over-complicate it.


I can walk into an office and tell you within 30 seconds the competency level of the staff. From how patients are being greeted to the staff’s personal appearance, the culture of the office can be identified quickly.

Early on in my career my mentors instilled in me a sense of personal responsibility and talent philosophy regarding the hiring process. Rather than let personal ego get in the way, I was taught to hire people that are smarter than me. Smarter employees bring innovative ideas and fresh perspectives to the table, and they’re a direct reflection of their supervisor’s leadership.

My recruitment perspective truly differs from others in that I not only seek intelligent candidates, I frequently seek recent college graduates. The market is full of recent graduates uncertain of their career paths and in need of a place to land while they figure it out. These individuals are often smart, teachable, and motivated. I’ve found individuals with experience lack initiative or intelligence needed to take the next step in their career, and I’d rather invest my time as a mentor to individuals that seek growth and success.

A colleague once questioned how AHG could afford to hire college graduates, “Don’t they all expect $50,000+ upon graduating?” The reality for many college graduates is that degrees do not frequently translate to instant jobs, and the type of degree they have may not align with their definition of success. Young adults are often told to follow their passions and pursue degrees that make them “happy.” However, jobs in many of these fields tend to be low-paying and hold them back from the life they imagine. All too soon these young adults, now young professionals, realize a financially supportive job may be a better option than following their passion. These are the individuals I’m seeking to recruit.

Although recent graduates are motivated and ready to learn, they’re all missing one thing: experience.  Most, however, realize the value of experience working with a reputable organization and are willing to put in the time to acquire and apply new skills. These employees require little supervision, and flourish when given some autonomy.

In contrast, employees that don’t understand the value of experience tend to move to the next job that will pay fifty cents more per hour. These employees frequently end up with many years of experience in a specific role without advancing their skills. They reach their peak in career growth early-on and plateau financially.

Over the years, we’ve had many employees leave to return to school in pursuit of nursing and professional degrees, often in healthcare, and many that have developed their careers through internal promotions.  We may serve as a launch-pad for some, but we’ll always be known as the place that gave them a foot in the door, so to speak.


People are an important aspect of a business, however, without a balanced approach to PPC the business will never reach its full potential. Processes are integral to every business. They are most effective when everyone knows about them and when they increase efficiency and reduce the workload.

The primary method of communicating processes should be through a policy and procedure manual. Each department should have a manual that is accessible by all employees, both new and veteran, for training purposes and as a reference. Additionally, all manuals should be updated to reflect any changes made to existing processes.

At AHG, issues with current policy and procedure are discussed at bi-weekly executive committee meetings for which all department managers are present. During this time, we address any issues and devise a solution that works across departments. I’ve been a witness to many practice managers, and even physicians, resolving process issues without consulting department managers first.  The fix may seem quick and uncomplicated, although often results in other unexpected issues that could have been avoided. Take advantage of the intelligent employees that you’ve hired, you might find yourself surprised by their creative ideas.


A medical practice’s culture extends beyond its staff; it’s conveyed to a patient from the moment they walk in until the moment they walk out. Workplace culture dipped for AHG and many other medical offices across the nation shortly after implementation of the electronic medical record (EMR).  Employee and physician burnout became a top concern for our organization. Doctors extended their hours in an attempt to maintain pre-EMR schedules, and many were taking work home to complete after a 12-hour day. Employees’ schedules reflected physicians’ schedules, resulting in overtime for many employees. Morale and quality of life plummeted and it was clear this was not a sustainable schedule. So, we developed one that is.

About five years ago we shifted to a four-day work week. With that change came other significant changes: physicians reduced the number of patient appointments on their daily schedules, patients no longer wait in the lobby past their scheduled appointment times, utilization of ancillary services increased, patient satisfaction increased, and physician and employee morale increased. We reviewed the impact of the four-day work week and upon doing so realized that we had effectively debunked the myth that a physician must see a greater number of patients per day to increase practice revenue.

At AHG we offer employees top-notch benefits, the ability to grow as professionals, and above all a team-oriented atmosphere. Our staff thrives in the culture we’ve developed and the efficiency in which they operate is a testimony. Over the years, employee tenure and development has increased, and recruitment has become easier.

AHG owes its success to its people, processes, and culture. Intelligent employees, efficient processes and a positive culture create a work environment that high-functioning employees gravitate to. If your practice is struggling, these are key elements to consider. I firmly believe community-based rheumatology practices need to stick together and welcome you to reach out to me with any thoughts or questions.

About Articularis Healthcare Group
Articularis Healthcare Group (AHG) is the nation’s largest rheumatology specialty group with 27 board certified rheumatologists, in 12 locations, spanning 11 counties.  For more information, visit, or call 843-793-6980.

Is An Alternative Payment Model Just For Rheumatology Possible?

Originally published in March edition of News On Rheumatology Matters (NORM)

The healthcare industry has been trying to shift away from the fee-for-service models that can incentivize overutilization towards payment models that reward quality – but these so-called “Alternative Payment Models” have been slow to catch on. However, some practices have embraced the core elements of APMs by customizing them to their specialty and patient population, producing cost savings that have won over private payers.

Articularis Healthcare in Charleston, S.C., a large rheumatology group practice with locations throughout Georgia and South Carolina, is moving toward adoption of a rheumatology-specific APM by implementing a value-based rheumatoid arthritis (RA) treatment pathway, and the results so far have been eye-opening, says Ray Waldrup, CEO. The project launched on Jan. 1 and has attracted commercial payer attention, with the state Blue Cross Blue Shield signing on to share 50% of the projected savings, which are expected to be “significant,” Waldrup says, though he is unable to disclose any specific figures.


Notably, their pathway model is entirely private and not recognized in any way by CMS. Their model is based on the 2015 Rheumatoid Arthritis Treatment Guidelines, created by the American College of Rheumatology (ACR), which applies evidenced-based care to RA therapies. However, where the ACR treatment guidelines do not specifically address costs, the Articularis pathway codifies mechanisms to reduce the cost of RA treatment while trying to maintain high quality care and positive patient outcomes.

The ACR has published a draft proposal for a Rheumatoid Arthritis APM, dividing rheumatology care into several distinct phases:

  • Diagnosis and creating plan oftreatment for patients who may haveRA, including supporting primary carephysicians in evaluating joint symptoms;
  • Providing ongoing care for RApatients, with therapies stratified by disease severity; and,
  • Identifying and treating other illnessesthat complicate RA treatment.

Close adherence to a treatment pathway is integral to value-based treatment in the ACR’s APM to ensure quality and cost outcomes. The Articularis pathway produces savings in part by ensuring patients receive adequate trials of less expensive therapies and requiring providers to use accepted disease activity measurements to follow the effects of therapies. The pathway also identifies patients who would benefit from infusion services, which can be significantly cheaper than drugs managed by pharmacy benefit managers (PBMs). “For years, we’ve had PBMs taking a big part of the healthcare pie, and now we’re reducing their share and getting to payers and providers,” Waldrup says.

Their deal with Blue Cross Blue Shield allows them to skip prior authorizations for services that typically require them, from MRIs to various RA treatments so long as they maintain a high rate of compliance – 75% or higher – with the RA pathway. “You’ve got to be able to get creative and do things differently,” Waldrup says. “What we were able to show our payers was that if physicians could stay on their formulary, we could significantly reduce their spending.”


CMS established an APM “advanced track” that would allow participating providers to avoid reporting data under its Merit-based Incentive Payment System (MIPS). If providers where part of an APM that CMS officially recognized, they could skip MIPS and still receive a 5% positive update to their Part B Medicare payments every year. Unfortunately, the CMS-designed APMs haven’t done well because the agency is trying to make onesize-fits-all models that don’t work well when applied to specific specialties and the diseases and patients they manage, Waldrup says. Only by doubling down on specificity can an APM produce savings, he believes, and that means moving ahead with APM initiatives in the private sector without CMS recognition.

The RA pathway that Articularis developed hasn’t been recognized by CMS, but the goal is to get there one day, says Colin Edgerton, MD, FACP, founding partner at Articularis Healthcare and medical director for the Articularis Rheumatology Network. “CMS is interested in physician-driven, specialty-specific APMs that are aimed at managing patients based on their specific disease states,” Dr. Edgerton says. “The long-term plan is for the rheumatology community to work through the ACR to develop an RA-specific payment model and have that designated by CMS as an advanced APM.”

The fact that Articularis’ current treatment pathway is not yet recognized by CMS means that their physicians have had to work on MIPS reporting at the same time, Waldrup says. Thus far, they’ve done well on MIPS reporting, earning the maximum 2019 performance bonus based on 2017 performance, though the bar for a meaningful Medicare payment bonus in terms of a MIPS score goes up every year. But for Articularis, treatment pathways and alternatives to fee for service are the future, and if everything continues to go well, they will approach other local payers to expand their program, Waldrup says. “We want to reduce the cost of healthcare, that’s our number one goal.”

ACR Calls For Abolishing Step Therapy In Letter To Congress, CMS

Originally published in Healio Rheumatology

The American College of Rheumatology has called for the removal of step therapy, ranked medications and fail-first policies that are based solely on cost.

The call to abolish step therapy is one of several recommendations issued by the ACR regarding drug pricing and access. The recommendations were included in two position papers recently sent to members of Congress, CMS, pharmacy benefit management companies and others.

“Step therapy is an enormous barrier between patients and the prescription medicines they and their doctor decide on — and a very frequent problem for people with rheumatologic diseases,” Angus B. Worthing, MD, FACP, FACR, chairman of the ACR government affairs committee, told Healio Rheumatology. “It erodes patient and physician autonomy by covering preferred drugs that benefit the insurer and pharmacy benefit manager most instead of what is best for the patient.”

Click here to read full article