What will it take? We will first need to be able to identify and evaluate the population.
Currently, our populations are those patients who come into the clinic. Possible populations around which data might be collected and evaluated are: all PCP office populations in your referral network; all employees of a single or several businesses; all enrollees in a closed-model ACO or HMO; and all people in a geographic community.
From a community perspective, Lawrence et al reported in 2008 that an estimated 27 million Americans had osteoarthritis, 3 million had gout, 5 million had fibromyalgia, 59 million and 30 million had back pain and neck pain, respectively, in the prior three months.13
From a business perspective, musculoskeletal disorders are associated with high absenteeism, lost productivity and increased healthcare, disability and worker’s compensation costs.14 Worker’s compensation care management has led to the development of physician medical and treatment guidelines, which are specific about objective parameters that must be met to proceed with MRI diagnostics, spine injections and a variety of surgeries.15 One usual criterion to be met before authorizing a procedure or surgery is “failure of conservative care,” but there is little specificity as to what that means other than duration of care. This population invites new innovations in patient-centered, comprehensive, conservative care services.
A Premera medical director recently stated that there are three areas for Triple Aim focus: oncology care, cardiovascular care and musculoskeletal care. Richard A. Deyo, MD, MPH, reported that spine-related expenditures increased substantially from 1997 to 2005, without corresponding improvement in self-assessed health status.16 The cost of total knee arthroplasty and spine fusion surgery each tripled during these years. Musculoskeletal complaints account for over 30% of primary care visits.17
Costs of arthritis care have skyrocketed with dramatic increases in some generic drugs and the pervasive high costs of biologic disease-modifying anti-rheumatic drugs (DMARDs). Many factors affect a patient’s financial bottom line, including basic coverage, deductibles, donut holes, co-pays and pharmaceutical support programs. The updated Arthritis Foundation website offers in-depth support for patients regarding healthcare costs and pharmaceutical support programs.18 The Rheumatologist has reviewed these issues.19 Drug pricing is outside the control of our practices, but therapy selection is not. Our choices are being scrutinized not only from the perspective of the public good and the cost to health plans, but more commonly by our patients with large deductibles.20
Why Rheumatology?
This brings me back to my last day. The stories of Alice, Sue, Grant, Stormy, Claudia, Drs. Carkin, Peterson and Kenney, and all the patients who need us to be their champions of yes prime me to give you the 10 reasons why I think rheumatologists are best suited to lead the changes needed to meet the challenges of attaining the three aims for a population with musculoskeletal illness risks and care needs.
Our nurses are the champions of yes. ‘Yes, I care; yes, I will get your refills; yes, I understand how stressed you are; yes, I will get you the answers; yes, I will get you worked in; yes, we will appeal the denial; & yes, I am here for you.’
How many times have you heard, “I saw a dozen doctors and multiple therapists before getting in to see you”? How frequently have you seen individuals who have run the gauntlet of spine injections and surgery before getting their spondyloarthritis syndrome diagnosed? How many arthroscopies and MRIs are still done before anyone considers inflammatory synovitis? How many X-ray reports state “degenerative joint or disc disease,” suggesting this is an aging or wear-and-tear process, rather than an arthritic condition?
