California Rheumatologists Explore Managed Care, Treatment Options

Questions about healthcare reform, including how to improve recognition and reimbursement for the medical contributions of cognitive specialists such as rheumatologists, were firmly in the background of the 8th Annual Medical and Scientific Meeting of the California Rheumatology Alliance (CRA), held May 19–20, 2012, in San Francisco. The 750-member CRA, founded in 2004, with most of its membership drawn from the Northern California, Southern California, and San Diego Rheumatology Societies, devoted two of eight sessions to reform and payment issues at state and national levels.

One of the outstanding questions involves the Supreme Court’s anticipated ruling on legal challenges to the Affordable Care Act (ACA), with a decision expected in June. “Since we don’t know what will happen, we will proceed in accordance with what we are trying to accomplish in health care reform,” observed Brent Barnhart, director of the California Department of Managed Care.

“California has embraced reform and all of the components of ACA,” added Jane Ogle, deputy director of the state Department of Health Care Services. Even if the national law were overturned, the state likely would continue down the path of reform in such areas as encouraging the emergence of accountable care organizations and medical homes; improving integration and coordination of health services (such as through a new demonstration project to combine Medicare, Medicaid, long-term care, and other in-home supportive services1); finding more robust ways to measure quality of care; and pursuing pay-for-performance and value-based purchasing.

Value-based payment modifiers for Medicare will apply to all physicians between 2015 and 2017, said Betsy Thompson, MD, DrPH, chief medical officer for Region IX of the Centers for Medicare and Medicaid Services. Implementation of electronic health records is a necessary but not sufficient condition for value-based payment for physicians, “some of which will be very good for people in your specialty, although any big change is likely to be painful,” she said.

Pathways to Care Delivery

Opening speaker David G. Borenstein, MD, immediate past president of the ACR, described a rheumatoid arthritis (RA) clinical pathways program to streamline care delivered by rheumatologists in Maryland, Virginia, and the District of Columbia, including his own rheumatology practice at George Washington University Medical Center in Washington, D.C.

The pathway was negotiated with CareFirst BlueCross BlueShield, working with Cardinal Health Specialty Solutions, a Dublin, Ohio-based healthcare services company. Based on evidence-based best practice, outcomes measurement, and a “treat-to-target” approach, it allows for RA treatment with methotrexate for 12 weeks, followed by an additional disease-modifying antirheumatic drug if that is not working, and a second-line agent after a further 12 weeks. “For the provider, we have access to biologics, and there are fewer preauthorizations or denials,” Dr. Borenstein said. “So it’s more predictable.”

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