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.

FOCUSING ON SPECIFIC DISEASES

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.”

A TRUE MIPS ALTERNATIVE?

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.”