Value-Based Care Continues to Evolve in Rheumatology

Editor’s note: ACR on Air, the official podcast of the ACR, dives into topics important to the rheumatology community, such as the latest research, solutions for practice management issues, legislative policies, patient care and more. Twice a month, host Jonathan Hausmann, MD, a pediatric and adult rheumatologist in Boston, interviews healthcare professionals and clinicians on the rheumatology front lines. In a series for The Rheumatologist, we provide highlights from these relevant conversations. The following article focuses on an episode about value-based care and how it impacts the rheumatology profession. Listen to the podcast online at https://acronair.org, or download and subscribe to ACR on Air wherever you get your podcasts. Here we highlight episode 3, “Value-Based Care in Rheumatology,” which aired Sept. 17, 2019.

Is today’s healthcare system broken? That’s a question that Colin C. Edgerton, MD, Articularis Healthcare Group, Charleston, S.C., and Angus B. Worthing, MD, FACP, FACR, a partner with Arthritis & Rheumatism Associates, Washington, D.C. pondered during an episode of the ACR on Air podcast with host Jonathan Hausmann, MD. Dr. Edgerton is a former chair of the ACR Committee in Rheumatologic Care, and Dr. Worthing is a former chair of the ACR Government Affairs Committee.

Healthcare priorities are not aligned well, and the current focus on volume-based payments clashes with a rheumatologist’s preferred focus on quality care. “It’s the way we’re trained almost to a fault—being somewhat blind to the cost and reimbursement environment,” Dr. Edgerton says.

Often, rheumatologists struggle with the cost of treatments for patients, including biologic agents, which can cost thousands of dollars per month. “We’ve got to figure out some solutions,” he says.

Dr. Worthing noted the U.S. health system usually does what it needs to do to help patients get better, but it can feel broken when he prescribes a patient a breakthrough drug for autoimmune inflammatory diseases and sees them back for their next appointment. He gears up for a positive report from patients only to have them occasionally say they didn’t get the drug because they were in the Medicare Part D donut hole or similar cost concerns. He describes this experience as heartbreaking.

Another broken part of the healthcare system is the paperwork, with physicians and their staff drowning in prior authorization forms that slow patients’ access to treatment.

Dr. Hausmann shared his experience with a drug that may be beneficial for a patient but was not FDA approved for the requested indication. As a result, insurance companies refused to pay for the treatments even though it may be cheaper in the long run for them to cover the treatment and help the patient avoid side effects from other treatments or the long-term damage of the disease.