MACRA: More Points, Smarter Future

Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.

To create an APM that works well for rheumatologists and their patients, the ACR has engaged Mr. Miller as a consultant. APMs are needed because existing reimbursement models don’t pay physicians for the types of services that provide better outcomes and lower-cost care, said Mr. Miller.

“If you answer an emergency phone call that could keep a patient out of the hospital, there’s no payment for that,” he said. “There’s no payment for the time a physician spends on the phone trying to communicate with other providers to figure out what’s wrong with a patient. There’s no payment for hiring a nurse to provide patient education that will help patients manage their disease more effectively.”

Although many APMs to date have been designed as “shared-savings models,” they provide only temporary bonuses to physicians who can lower spending and no up-front resources to improve care, said Mr. Miller. This model doesn’t benefit providers who are currently efficient in how many procedures or tests they order, and it doesn’t provide sustainable support for new approaches to care delivery.

“Rather than forcing physicians to change patient care so it aligns with payment systems created by payers, physicians need to decide how to redesign care to get better results and then ask payers to pay them that way,” he said.

DIY Physician-Focused Payment Models
Rheumatology could potentially create its own physician-focused payment model that supports care for chronically ill patients who benefit from interventions that prevent long-term damage and costly complications, Mr. Miller said. One model is SonarMD, a payment and care delivery system created by an Illinois gastroenterologist who based the system on data he obtained from a commercial payer about the complications his patients were experiencing and the costs of treating them. This payment model reimburses practices for interventions specifically designed to improve care for patients with inflammatory bowel disease, such as using nurse care managers to guide patients’ self-management.

“A good APM provides flexibility and resources physicians [can use] to deliver better services. But physicians can’t just say ‘pay us more and trust us.’ An APM requires physicians to take accountability for achieving the improvements in cost and quality that better care can deliver,” Mr. Miller said.

To that end, APMs should be designed to focus accountability on the things that physicians can control, without putting physicians at risk for aspects of cost and quality they can’t control, Mr. Miller said. For example, rheumatologists can’t prevent autoimmune diseases, but they can treat them in less costly ways that achieve better outcomes. Rheumatologists excel at diagnosing complex illnesses so patients can get appropriate care sooner, he said. A good payment model will support their ability to work with primary care physicians and others to identify the most appropriate rheumatology-specific interventions.