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Explore This IssueJune 2014
The American College of Rheumatology (ACR) is unique because our membership includes both physicians and healthcare professionals. This special relationship allows physician and health professional volunteers to unite in providing resources to help rheumatology move forward with the implementation of healthcare reform.
With the ongoing rollout of the Patient Protection and Affordable Care Act (ACA) we know what happens in government affects us profoundly in how we achieve our mission of Advancing Rheumatology! Made law in March 2010, the ACA represents the largest change to healthcare delivery since the enactment of Medicare and Medicaid in 1965. No aspect of the healthcare system will be left untouched by the ACA. Three core goals of the ACA are to provide access to affordable coverage, improve healthcare quality and reduce the growth in healthcare spending.
The fourth year of a multiyear rollout of these changes, 2014 has seen significant changes in patient access. ACA implementation seeks to expand access for millions of Americans, but so far the basic infrastructure of care delivery has changed little. The expansion of Medicaid and the ability to purchase insurance on healthcare exchanges were the ACA’s two primary ways of expanding coverage and access.
Use of healthcare exchanges to purchase insurance is not a new concept and has been around since the 1970s. However, what’s new is the option for states to operate their own exchanges or to defer to the federal Health Care Exchange, also known as the Marketplace (www.healthcare.gov). Coverage is based on state-level benchmarks. Although the rollout of the Marketplace made the news for its technical glitches, more than 8 million Americans now have insurance obtained through this system.
The Marketplace also provides a method for those who qualify for Medicaid to access the system and enroll. According to the Department of Health and Human Services, new Medicaid enrollments are over 3.5 million. These Medicaid enrollment numbers vary widely by state, and 24 states chose not to expand their programs.
Types of insurance purchased on the exchanges vary by type, cost, state and region. All plans offered by the exchanges have to meet the basic essential benefit criteria defined by the ACA. These must include items and services within each of 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.
As was pointed out on the ACR/Association of Rheumatology Health Professionals (ARHP) Advocacy Listserv, some plans are state specific. So if a patient lives on the border of one state and wants to see his rheumatologist across the state line 10 minutes away, the visit won’t be covered. This is a glaring example of one of the glitches being identified and that must be corrected to provide continuity of care and personal choice of providers. Because state governments affect much of rheumatologic care by creating exchanges, defining Medicaid eligibility and regulating pharmacies (and also by considering legislation to regulate biosimilar products), the ACR has stepped up its presence in state capitals and has recently hired staff to monitor and affect state government activity. Starla Tanner ([email protected]) is a new member of our advocacy crew.
Open enrollment through the Marketplace ended March 31, but there are special circumstances under which people can still apply for insurance. For example, when someone experiences life events, such as marriage, divorce, birth of a child, loss of a spouse or loss of other health coverage, then they would meet the special circumstances criteria. The special enrollment period lasts 60 days following an event. Someone applying for Medicaid or the Children’s Health Insurance Program (CHIP) may apply at any time.
As mentioned earlier, increases in the number of Americans with access to coverage come without the necessary enhancements in infrastructure. The ACR, through its Government Affairs Committee (GAC) and Committee on Rheumatology Training and Workforce Issues (COTW), is working to address infrastructure issues as they relate to rheumatology.
For years, GAC has advocated for more pediatric rheumatologists, using training loan forgiveness as a mechanism to improve access. The COTW monitors and develops curricula for trainees in rheumatology, along with other initiatives designed to encourage selection of rheumatology training among internal medicine residents and medical students. In a recent publication of the Rheumatology Research Foundation’s Pathways, the rheumatology workforce study anticipates the demand for services to increase 46% between 2005 and 2025. Unfortunately, the number of practicing rheumatologists is only expected to increase 1.2% in that same period. In contrast, since 2004, ARHP membership has increased by 30%. Such programming as the Fundamentals of Rheumatology and Advanced Rheumatology Online Courses for health professionals helps train health professionals and aid in meeting this unprecedented growth in demand for rheumatology services. We believe that this is an excellent way to help meet the need as patient demand grows.
Three core goals of the ACA are to provide access to affordable coverage, improve healthcare quality & reduce the growth in healthcare spending.
The second major focus of the ACA is to address healthcare quality. Reporting of quality data is becoming standard across the entire healthcare delivery system. Just as data collection and system quality improvement changed the automotive and airline industry years ago the hope is this will be the case with healthcare. Realizing that healthcare delivery is complicated, quality measurement in healthcare is not a new concept. The National Quality Forum (NQF) is celebrating its 15th year. Such groups as the Hospital Quality Alliance, Ambulatory Care Quality Alliance, Pharmacy Quality Alliance and the ACR are engaged in the development, testing and dissemination of quality measures related to the respective areas. We have submitted new rheumatoid arthritis quality measures that are currently being vetted through the NQF process.
The Physician Quality Reporting System (PQRS) uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. Examples of eligible professionals include physicians, physicians assistants, nurse practitioners, physical therapists, occupational therapists and clinical psychologists. The ACR is actively communicating with its membership on requirements, methodologies and documentation. The ACR is actively engaged in developing a registry that will aid the membership in meeting the requirements of PQRS. Our members have been reporting these measures through the initial iteration of our registry (RCR). We are seeking participation in our new RISE (Registry Informatics Supporting Effectiveness) registry as a substitute for individual quality measure reporting.
The current fee-for-service system of healthcare payment and reimbursement is projected to be phased out and replaced by different models. The Accountable Care Organization (ACO) is one well-publicized model created by the ACA. The definition of ACOs varies widely, but is an organization that is held accountable for the health of a defined population. To date, relatively few ACOs have been created, and participation by physicians remains relatively low.
Healthcare reform has placed much emphasis on population health and population health management. Data, registries, ACOs and patient-centered medical homes are means to potentially provide a better understanding of the nation’s public health or population health and produce improved health outcomes. What does the data say? Who is responsible? Who is accountable? What are the outcomes? These are questions that have not previously been answered.
Where is the patient in the equation? The ACA uses patient centeredness, patient satisfaction, shared decision-making and patient engagement to reinforce one of the Institute of Medicine’s goals for a 21st century healthcare system. A recent report by Millenson and Macri for the Robert Wood Johnson Foundation describe this as an “unsung transformation.” The ACR is studying means to incorporate patients into quality measure development, classification criteria and treatment guidelines in line with modern practice. We also seek ways to effectively and efficiently collect patient-derived data so our practices can know and report this important information.
Advocacy is a core strength of ACR and its members. The Government Affairs Committee, our passionate volunteers and arthritis advocates have led the way on the issue of the Sustainable Growth Rate and also on efforts to make treatments more accessible to patients. The Simple Tasks campaign bridges our patients’ needs with the value of rheumatology professionals to satisfy those needs. Communicating the value of rheumatology to external stakeholders and decision-makers is critical to our specialty’s future. Indeed, the vision of the ACR is that everyone will know the value and role of rheumatology.
The ACR continues to monitor the evolving healthcare environment and to provide education about how rheumatologists and rheumatology health professionals can be included in new models of care, changes in reimbursement and issues related to these changes. A successful healthcare organization is one that is engaged, innovative, willing to change and keeps the patient at the heart of decision-making. As this period of change in healthcare continues, the ACR will continue to be at the table, helping determine what healthcare and healthcare delivery systems should look like for the patients served by our members.
Healthcare reform has put everyone on notice: patients, caregivers, physicians, nurses, physicians assistants, pharmacists, insurers, employers and many more. The system has changed and continues to change. It is our intention to help influence those changes in ways that Advance Rheumatology!
Joseph Flood, MD, is a rheumatologist at the Columbus Arthritis Center and adjunct associate professor at The Ohio State University College of Medicine and Public Health, both in Columbus. Contact him at [email protected].
Kam Nola, PharmD, MS, serves as president elect for ARHP, 2014. Dr. Nola is the vice chair, Department of Pharmacy Practice at Lipscomb University College of Pharmacy in Nashville, Tenn. As associate professor, she teaches in the areas of healthcare policy and delivery, communications skills, caring for vulnerable and underserved patients, and rheumatology pharmacotherapy. She has been involved in rheumatology for more than 15 years.