Efforts by the ACR to develop a rheumatology-specific alternative payment model (APM) are well under way. The first draft proposal was approved by the ACR Board of Directors in November and presented to the rheumatology community during the 2017 ACR/ARHP Annual Meeting in San Diego.
The ACR is pursuing the development of a rheumatology-specific APM to offer rheumatologists a specialty-driven, value-based reimbursement option for Medicare patients enrolled in their practices. Under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, physicians and practices can choose an APM as one of two avenues for reimbursement of Medicare patients. The other avenue is through the Merit-Based Incentive Payment System (MIPS).
A Focus on RA
The current APM is focused on the treatment of rheumatoid arthritis (RA), with emphasis on the importance of recognizing RA as a lifelong condition that requires different levels and types of treatment, depending on the stage of the disease. Such recognition is key to ensuring that reimbursement for these different levels and types of RA treatment is appropriate.
“The model was created to reduce burdens to good care, pay for high-value services and provide flexibility for various practice environments,” says Kwas Huston, MD, who works at the Center for Rheumatic Disease in Kansas City, Mo., and serves as co-chair of the ACR working group that is developing the APM.
In addition, he says, providing rheumatologists with an APM also “provides a mechanism to avoid MIPS penalties and reduce documentation burdens, and gives physicians more control over their destiny in the era of value-based payments.”
How the Model Works & Why
The APM model breaks down rheumatology care into four distinct phases:
- Diagnosis and treatment planning for patients with potential RA;
- Support for primary care practices in evaluating joint symptoms;
- Initial treatment of patients with RA; and
- Continued care for RA.
In a letter submitted to the Centers for Medicare and Medicaid Services (CMS), the ACR emphasized the importance of aligning reimbursement of RA treatment to the different stages of the disease, saying, “The APM reflects the varied involvement of the rheumatologists during these distinct stages, splitting payment into an initial stage for diagnosis (including, for example, communication with primary care physicians), followed by ongoing care stratified by disease severity and recognizing other illnesses that complicate treatment.”
Additionally, Colin Edgerton, MD, FACP, RhMSUS, chair of the ACR’s Committee on Rheumatologic Care, testified at a Congressional hearing in November about the ACR’s APM and called on Congress to minimize the financial risks and practical barriers that practicing rheumatologists could face in order to qualify for MACRA’s APM track. His testimony starts at 2:35:08 of the video.