Value of Patient Care Services in Rheumatology Gets Boost

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A bout four-and-a-half years ago, Michael Porter, a professor in the Harvard Business School, posed in the title of his article a question, “What is value in health care?”¹ Porter defined value as the health outcomes achieved per dollar cost, a firmly engrained concept nowadays. According to the ACR’s recent strategic plan (2013–2016), the 10-year vision for the organization is that “everyone will know the essential role and value of the specialty of rheumatology.” Where do these concepts of value intersect?

The main actors in healthcare—the providers, hospitals, insurers, employers, and patients (let’s not forget about the patients)—have a stake in the value equation. However, stakeholders are often at odds with each other because of conflicting goals. Physicians are struggling to preserve their livelihoods in the face of significant changes in clinical practice that have increased administrative burden and documentation requirements, as well as blurred the lines between work and life. They are naturally skeptical about the motivation of insurers that restrict care without paying adequate attention to outcomes.

Hospitals are merging with other hospitals and buying up physician practices to maximize revenues and control costs. Insurers are pushing back against rising medical bills by aggressively marketing new payment models and directing patients to lower cost providers.

Due to rising healthcare costs, employers who provide their employees with healthcare benefits are taking big hits to their bottom lines. As a result, employers are experimenting with new plans that force employees to dig deeper into their own pockets to cover their medical costs. Patients with private insurance are facing higher premiums with higher deductibles, new barriers limiting access to specialists and tiered drug formularies that increase what they pay for medications.

Despite these conflicts, all stakeholders should be united in one goal, namely to improve the value of healthcare.

Reimbursement Changes

Reimbursement is shifting from volume to value-based formulas. In the U.S., the ACR is helping rheumatologists translate value into their practices by focusing its resources on the development of guidelines, guidance documents and quality measures, and creating an infrastructure for gathering and analyzing data related to patient outcomes. The ACR is also increasing the awareness of rheumatology through Simple Tasks, a public relations campaign that has boosted the stock of rheumatology in Congress and among other key decision-makers.

A goal of the current strategic plan is to develop tools that address evolving payment reforms, increase practice efficiency and improve quality of care. To address this goal in part, the ACR formed the Council for Health Care Economics (CHEC), led by former ACR President Dr. Neal Birnbaum. The CHEC has recently completed a white paper that concisely describes evolving payment reforms and payment models from the lens of a rheumatologist and a toolkit to help practices redesign their businesses in response to these changes in healthcare delivery. Another product of the CHEC will be a study of the quality of care delivered by rheumatologists. Not surprisingly, this review illuminates the paucity of research in this area. However, rheumatologists don’t need to stand idle while waiting on further research to build value into their practice.