The RA APM’s treatment pathway
Undergirding the whole model is a treatment pathway that takes a standardized approach to RA care, based on ACR 2015 guidelines, and will be updated regularly by the ACR, Dr. Huston said. Following the guidelines gives an opportunity to lower spending but increase the percentage that’s going to rheumatologists by reducing the variability in initiation of expensive medications. “Currently, we get about 2.5 cents on the dollar for every dollar that’s spent on rheumatoid arthritis care, and we want to increase the part that’s going to the rheumatologist to provide more services but decrease total spending,” he said.
The pathway requires the use of methotrexate and/or another disease-modifying antirheumatic drug (DMARD) before targeted therapy. However, the model also allows for treating unique patients by requiring only 75% adherence to the guidelines. Deviation from the guidelines is allowed if a patient has a contraindication, intolerance, or inadequate response to a DMARD, or if there are barriers outside of the rheumatologist’s control, such as insurance coverage. The ACR guidelines also specify the frequency and type of monitoring that’s needed for treatment.
Because the ACR guidelines will be followed, the model asks that payers make patients eligible for lower out-of-pocket costs for medications. Following the guidelines should also reduce the need for prior authorizations. Providers in the advanced APM would attest to 75% adherence to the pathway, which would be subject to audit. “We want to reduce the reporting burden. In MIPS, it’s very complicated. It’s hard to know how to report all of this. In the APM pathway, we’re trying to simplify reporting. You only have to report two things; one of them is following the treatment pathway 75% of the time” and the other is an outcome measure, he said.
The payments made under this RA treatment pathway are divided into four areas: diagnosis and treatment planning, support for primary care physicians in diagnosing joint symptoms, the initial treatment of RA patients, and continued care for RA.
Diagnosis and treatment planning
This step offers a one-time payment to support all the costs of evaluation, testing, diagnosis, and treatment planning for a patient who has symptoms that potentially indicate RA, has not been previously treated or diagnosed with RA, or has been treated unsuccessfully for RA by other physicians. It is not dependent on the number of visits.
This phase also covers basic lab testing and imaging, which if not done by the rheumatology practice, would then have a standardized amount deducted from the payment and be paid separately. Lab tests and imaging performed for other conditions would be paid separately as well.
The payment covers communication with other physicians, spending more time with patients in a shared decision-making process regarding treatment options, and developing a RA treatment plan.
“If you don’t end up diagnosing RA, you still get the payment. But there will be two different payments; one is a little lower if they don’t have RA. If they do have RA, then you spend more time with them developing this treatment plan, so that would be a higher payment,” Dr. Huston said.
Support for primary care physicians in diagnosing joint symptoms
This payment goes to a rheumatologist or a nurse practitioner or physician assistant who is working under the supervision of a rheumatologist for a patient who is under the care of a primary care physician who has an agreement to work collaboratively with the rheumatology practice. The payment, which is limited to one bill for one patient in a 1-year period, is for communication between the rheumatologist and the primary care physician about patients with symptoms that might indicate RA to determine the need for referral.
“This communication could be a phone call, an email, face-to-face, or some other form of communication ... to discuss how fast the patient may need to be seen or if there are other tests that need to be done before expediting referrals for patients who are higher risk,” Dr. Huston explained.
The payment would still be made if the patient does not require referral to a rheumatologist.
Initial treatment of RA patients
Payment for initial treatment can be made to a rheumatologist, a nurse practitioner or physician assistant under the supervision of a rheumatologist, or a team comprising the rheumatologist and a primary care physician who have a formal arrangement to support the early treatment of RA.
The latter scenario is intended for rural areas and other areas where there is a shortage of rheumatologists. The formal arrangement would specify how payments are shared and who is responsible for each of the accountability requirements and for treatment pathway, “but there is a lot of flexibility, and this can vary quite a bit, so what happens in rural Alaska where the primary care doctors might be more involved is not going to be the same as in a big city where the primary care doctors may not want to be involved at all. So there is no requirement for primary care doctors to be involved, but it just provides the resources in areas where that might make sense,” Dr. Huston noted.
The initial treatment payment would be made monthly for 6 months, replacing evaluation and management billing for office visits related to RA. It pays for typical lab tests and imaging and allows flexibility for non–face-to-face communications, and enhanced services to patients who need them. This payment is also stratified to adjust for sicker patients who have more comorbidities, he said.