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?
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.
Improved Performance
Rheumatologists can begin by measuring and analyzing the care they deliver to patients, especially in the area of outcomes, a necessary step to improve value and inform cost reduction. Patient outcomes are inherently disease-specific and multi-dimensional, encompassing a wide spectrum of subjective and objective measures of disease activity, physical function and quality of life that must be validated for use in the clinical setting.
The ACR Quality of Care Committee is leading the way in developing more meaningful rheumatology performance measures, including concept development for an outcome measure over the next year. At the same time, the ACR has built the RISE Registry, which was launched last summer and enables providers to collect and analyze patient data at the point of care through electronic health records and to create customized dashboards for use in performance improvement.
What are the challenges? There are many logistical and financial barriers that will impede the ability of some practices to rapidly adapt to this new culture of performance improvement. Capturing data about costs is difficult with the complexity of reimbursement—an obfuscation of costs owing to differences between what is billed and what is paid—and the inadequacies of current information systems. Moreover, the delivery of patient care by a rheumatologist typically interfaces with multiple organizational units, such as the primary care provider, other specialists and hospitals.
The reality of this multifaceted structure for healthcare delivery raises the question of accountability—who is responsible for what outcomes—and brings to light the need for team-based care. Many physicians are not used to working in teams and sharing data. However, failure to face these challenges has consequences. If we don’t take creating value in healthcare seriously, it will impede innovation, foster micromanagement of practices (higher costs and less efficiency) and limit value-added services. Nobody wants to end up here.
Make Value a Priority
There is a light at the end of this tunnel. The ACR has created tools to begin measuring and analyzing patient outcomes. Improving the value of rheumatology care has to be a high priority. Waiting years for research to show the value of rheumatology care is not the answer.
Rheumatologists need to make progress on increasing value in their practices now to win the confidence of other stakeholders. We can’t afford to sit on the sidelines and let others define value for us.
E. William St.Clair, MD, is president of the ACR and chief of the Duke Division of Rheumatology and Immunology. Dr. St.Clair, a rheumatologist, has 25 years of experience as a clinical investigator. Contact him at [email protected].
