Given that some degree of competition will exist between primary care physicians and rheumatologists in the ACO environment, how can rheumatologists be successful? “The difference is knowledge,” says Dr. Hochman. “In deference to primary-care physicians, they tend to order more tests up front, like CT scans and MRIs, than rheumatologists do. As a group, I think that rheumatologists are more comfortable with a watch-and-wait approach before starting tests. Intuitively, I think they’re more cost effective,” he says.
Some evidence supports Dr. Hochman’s intuition. In a 2000 study that included nearly 5,000 person-years of follow-up in patients with rheumatoid arthritis, care that included specialists was associated with higher quality.3 Several studies have revealed that primary-care physicians overutilize imaging studies, such as MRIs, in patients with acute back pain, and that rheumatologists are more efficient with these modalities. In one study, care delivered to rheumatoid arthritis patients by rheumatologists was not more expensive than care provided by primary-care specialists, largely because more lab testing was performed in primary care.4 All of the experts interviewed for this article urge rheumatologists to present data showing that the care they provide is both beneficial to the patient and cost effective.
We rheumatologists have always been responsible for the care of our patients. But now, with ACOs, the financial risk is being transferred from health plans and payers to providers….In an ACO, we are fiscally responsible for entire continuum of care for our patients. Not just inpatient or outpatient care, but also extended care, hospice, the whole deal.
It’s likely that ACOs will want to bundle payments around musculoskeletal conditions that rheumatologists manage, including back pain and knee or hip replacement. These are particularly important conditions for study in the ACO debate, because they hit both the commercial insurance populations and medicare populations at high rates, and “they’re one of the biggest spends,” according to Dr. Hochman. “How are you going to leverage your expertise in these conditions? Rheumatologists are uniquely positioned to be the manager of how that bundled healthcare dollar should be split,” Dr. Hochman says. He adds that physicians working in healthcare systems like the Cleveland Clinic, for example, may have an advantage because their organizations already understand the value provided by their rheumatologists when it comes to care for patients with back pain and joint replacement.
According to Dr. Hochman, rheumatologists tend to be modest about their skill sets. “It’s part of the personality,” he says. But he emphasizes that this modesty is misplaced in the current debate over involvement and participation in ACOs. “Rheumatologists are experienced in managing complex disorders that cost the system a lot of money,” he says. He adds that they also have a good feel for evaluating outcomes. Ultimately, Dr. Hochman says, two outcomes matter the most among patients in rheumatology practices. First, how many days are patients out of work, and can they get back there faster? Second, what is the patient’s satisfaction with their outcome? “Rheumatologists take care of patients post-total hip and knee surgery and during back pain episodes. They are very familiar with the outcomes, functionality, and satisfaction,” he says.
