Demonstrating value in concrete, specific terms may be difficult. One goal of ACOs is to standardize medical practice in many areas, reducing variability in practice. But is that realistic?
“There are a number of situations in which variation in performance is due to a lack of precise standards, such as how often a patient with rheumatoid arthritis should be seen in the office and how frequently lab tests should be done. With financial incentives, care would be optimal, but there is also concern that it would be minimal,” says Ron Kaufman, MD, former president of the ACR and chief medical officer of Tenet California.
Dr. Kaufman explains that, ideally, quality metrics developed by specialty medical organizations would help diminish much of the variability in rheumatology practice. “But the reason there is so much variability in rheumatology practice is that the patients exhibit a lot of variability,” he says. “This will be difficult for rheumatologists. And any physician who treats patients with chronic diseases with exacerbations, like diabetes, inflammatory bowel disease, or diabetes, will be in the same boat. The course of these diseases is not steady,” he says.
The difficulties associated with working in one of the cognitive specialties were highlighted in written testimony from the ACR on reforming medicare physician payments, which was submitted to the House Ways and Means Committee in May 2011. Timothy Laing, MD, a rheumatologist and associate professor of medicine at the University of Michigan in Ann Arbor, wrote: “Rheumatologists are uniquely trained to perform intense evaluation and management services to ensure proper diagnosis, determine the best treatment option, and provide expert care. Rheumatology services require lengthy discussions and review of a patient’s history … The current system devalues spending time with patients.”
Dr. Dwyer, who has been co-chair of the National Committee for Quality Health Care (NCQHC) Performance Measurement Tools Task Force since 2004, says that “rheumatologists are very efficient in the way that they care for patients with complex rheumatic disease. To the extent that efficiency is an important part of an ACO, then partnerships between primary-care physicians and rheumatologists is beneficial to both specialties. There are many opportunities for rheumatologists to be involved in the care of their patients and to partner with primary-care physicians to improve efficiency and coordination of care.” One study, for example, revealed that pre-appointment screening by a rheumatologist of patients referred to a rheumatology clinic found that only 60% of patients actually needed to see the specialist, highlighting another way that care by rheumatologists can be cost effective and efficient.2
Advance the Cause: What Rheumatologists Can Do
Depending on the region in which rheumatologists practice, says Dr. Hochman, they need to become familiar with the involvement that their major health systems have with ACOs. Then they have to present their potential value to the healthcare system and the ACO. “Make sure you’re playing a significant role,” he says.
