Conference Coverage

VIDEO: Advanced alternative payment model for RA set to undergo testing


AT ACR 2017

An advanced alternative payment model for rheumatoid arthritis will soon be submitted to the Centers for Medicare & Medicaid Services for evaluation, in order to provide rheumatologists with another payment pathway under Medicare’s new Quality Payment Program.

The draft version of the rheumatoid arthritis advanced alternative payment model (APM), prepared by the American College of Rheumatology and unveiled at its annual meeting, aims to give rheumatologists a more focused opportunity to participate in value-based care and potentially earn greater incentive payments. The model is geared not only to private practice rheumatologists, but also to those in academia.

The Quality Payment Program, including its advanced APM track, was established by the Medicare and CHIP Reauthorization Act of 2015 (MACRA).

Dr. Kwas Huston Nick Piegari/Frontline Medical News

Dr. Kwas Huston

A working group from the ACR and the Association of Rheumatology Health Professionals has been developing the model since January 2016 with the hope that it sets the tone for future physician-focused advanced APM efforts in rheumatology.

Other societies are working on or have submitted APMs for approval, Timothy Laing, MD, a member of the RA APM working group and also the ACR representative to the American Medical Association’s Relative Value Scale Update Committee and CPT Advisory Committee, said at the ACR meeting.

After presenting a draft of the RA APM at an AMA workshop in October, Dr. Laing came away encouraged by the attendees’ response to the usefulness and flexibility of the model to pay for services that rheumatologists are currently frustrated by in a fee-for-services system. “It’s a big if, but I think if we can make the money work, this will be a shift and it will have a lot of impact on how we practice, and I think it will be generalizable to more than one condition.”

The cochair of the RA APM working group, Kwas Huston, MD, presented the draft at the meeting. He noted that advanced APMs could be developed just for specific diseases, for all inflammatory arthritis, all types of vasculitis, or for all rheumatic diseases. RA was chosen first because the ACR is new to the development of APMs and “needed to start somewhere.”

“This model allows us to improve our ability to care for patients and is more sustainable over time for rheumatologists from a revenue standpoint,” Dr. Huston, a rheumatologist with Kansas City (Mo.) Physician Partners, said in an interview.

The RA APM helps to reduce barriers to good care by providing adequate reimbursement for cognitive services through monthly payments rather than relying on payment for separate office visits, Dr. Huston said. The model allows for more time spent in shared decision making, educational activities, and improving treatment adherence. It also builds in payment for non–face-to-face communication between rheumatologists, primary care physicians, and other specialists; interaction with patients via phone calls, email, and telemedicine; and using nurses or other staff to help with chronic disease management. It’s meant to be flexible for use in diverse settings by allowing comanagement of patients in rural areas and places where there is a shortage of rheumatologists or travel is difficult.

Why join an advanced APM?

Rheumatologists may want to join an advanced APM because of the potentially unsustainable, “zero-sum” nature of MACRA’s Merit-based Incentive Payment System (MIPS), in which the losers pay for the winners, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a member of the RA APM working group. In MIPS, there are expected over time to be fewer and fewer “losers” in the program, either because participants perform better or the losers drop out. In addition, advanced APM participants will receive a 5% bonus in 2019-2024 and Medicare payment updates will be higher for advanced APMs in 2026 and beyond than for MIPS (0.75% vs. 0.25%).

Beyond the financial practicalities of MACRA, it’s beneficial for rheumatologists to have their own advanced APM because it’s better than being stuck in one that’s “written by the government and doesn’t cater to other specialties; it’s specific to rheumatology, our patients, our work flow, and what we think is valuable,” said Dr. Worthing, a practicing rheumatologist in the Washington area.

Dr. Angus Worthing is chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area

Dr. Angus Worthing

He explained that a good APM reduces avoidable spending that’s part of today’s fee for services payment by reducing unnecessary spending in certain areas and provides flexible, adequate payments for valuable care that is not being paid for in the current fee-for-service system. These valuable services should loop back to save money and control avoidable spending, which is the accountability and risk-taking part of being in an APM. Ideally, this sets up a “win-win-win” scenario in which the total amount spent decreases, patients get better care without unnecessary services, and rheumatologists get adequate payment for high-value services.

To participate in an advanced APM, clinicians will need to have 25% of payments for Part B fall under professional services in the advanced APM or have 20% of their patients receive Part B professional services through the advanced APM. However, Dr. Worthing advised keeping an eye out for new thresholds for participating in the APM track because “it will probably be hard to get 25% of your Medicare reimbursements or 20% of your patients in the first year you’re in it.”


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