CHICAGO – with hopes to send the fully developed model to the Physician-Focused Payment Model Technical Advisory Committee once financial data gathering and analysis is complete, followed by pilot testing once it is accepted by the Centers for Medicare & Medicaid Services, speakers said at the annual meeting of the ACR.
The “RA Care Team” APM is meant to be versatile and work across various practice settings, from rural Alaska and the Southwest to urban Chicago and Boston, and would consist of a rheumatologist or a nurse practitioner or physician assistant working with a rheumatologist in some areas, while in others a patient would be managed by a primary care physician who has a formal arrangement with a rheumatologist to provide early treatment of RA. Participation in the model would use a standard treatment approach pathway that follows ACR treatment guidelines and saves money by reducing the variability in initiation of expensive medications and would be versatile enough to allow for unique patients by requiring only 75% adherence to the pathway across a practice’s patients, said Kwas Huston, MD, cochair of the ACR’s APM work group and a rheumatologist with Kansas City (Mo.) Physician Partners.
The model covers four phases of care, including diagnosis and treatment planning for patients with potential RA, support for primary care practices in evaluating joint symptoms, the initial treatment of patients with RA, and the continued care of RA. For instance, a rheumatologist could receive payment for an e-consult with a primary care provider to determine if a patient has symptoms requiring an evaluation for RA. A rheumatologist could also receive a one-time payment for treatment and planning services when a diagnosis of RA cannot be established in a patient suspected of having RA, whereas the rheumatologist or a primary care provider with rheumatology support would receive monthly payments for 6 months for the initial treatment of an RA patient and then thereafter would receive monthly payments for continued care of RA. The payments would not be dependent on the number of visits or face-to-face time, would be stratified based on patient characteristics, and would include some lab testing and imaging.
Currently, the RA APM work group is analyzing financial data gathered from two large rheumatology practices for specific CPT codes matched to specific patients based on their clinical characteristics “to get a sense of how much revenue is coming in right now for practices taking care of patients with, let’s say, moderate disease activity and two comorbidities or low disease activity and no comorbidities,” Dr. Huston said. The work group is also surveying practices to estimate additional costs required to participate in the APM and thereby develop a financial model to adequately pay for APM services. They additionally plan to develop a tool kit that is designed to help individual practices determine the economic impact that the APM would have.
Notably, the cost of medications is not included in the APM. “That would be too much of a risk for small practices to take on,” Dr. Huston said.
“This model is a work in progress. We still have a lot of additional work to validate the data,” he added.
Providers who wish to participate in an advanced APM in 2019 need to have at least 25% of their Medicare Part B payments or have at least 20% of Medicare patients in their practice come through the APM in order to avoid having to submit data to comply with the performance criteria requirements of the Merit-Based Incentive Payment System, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.
“The ACR has advocated to reduce these thresholds over the years, but unfortunately that has not happened yet,” Dr. Worthing said.
jevans@mdedge.com