Surviving ACA: A Guide for Rheumatologists

Implementation of the Affordable Care Act is underway for rheumatologists as for everyone else. Is your New Year's resolution to avoid being collateral damage? Here's expert opinion on how to survive, and perhaps even thrive.

First of a two-part series.

Healthcare reform implementation is in full swing. How will it affect rheumatologists? Questions remain, but industry experts say that much of the impact lies with rheumatologists themselves.

The specialty has already faced one healthcare delivery re-design: In the 1990s, health maintenance organizations (HMOs) proved disastrous for providers and facilities. Now, in similarly-designed accountable care organizations (ACO) touted under the Affordable Care Act, providers are assigned to share responsibility and payments for patient care.

For some, ACOs may conjure the ghosts of failed collaborative-care efforts under HMOs. But experts say that rheumatology’s response has been largely positive.

“Rheumatologists are more hopeful now,” said Rod Hochman MD, president and CEO of Providence Health & Services in Seattle. “There are lessons learned from the HMO experience. We know rheumatologists must ensure the healthcare system knows what they do and how they affect change.”

In fact, according to the 2013 Medscape Rheumatologist Compensation Report, [] 23%  of rheumatologists have participated in ACOs.

Preparing For Success

While positive attitudes will help during this transition, Hochman’s biggest concern is whether rheumatologists can educate their physician-colleagues about the impact of rheumatology services. Succeeding, he said, means demonstrating how rheumatology simultaneously improves patient care and controls costs.

“Rheumatologists must position themselves as musculoskeletal managers,” he said. “They’re uniquely situated to understand what’s needed or not and what therapies are possible, particularly with joint and back pain, before going for surgery.”

It’s crucial for rheumatologists to assume this role because musculoskeletal services often rank among a facility’s top five service lines, accounting for significant expenditures.

For example, rheumatologists can increase collaborations with orthopedists and neurosurgeons to determine whether a patient needs surgery. Or they can partner with primary clinicians to diagnose many causes of joint pain without extensive and expensive imaging studies.

Job Security

With cost control as a bedrock ACO principle, concerns exist within rheumatology that hospital-provider relationships could shrink. Instead of partnering with practices, some providers fear, facilities will opt for a single part-time rheumatologist to treat patients. Some evidence supports this concern – more than 80% rheumatologist providers spend fewer than four hours weekly treating inpatients, according to the Medscape report.

But Hochman believes relatively low numbers and skill-set specificity will protect rheumatologists.

“There will be few rheumatologists nationwide, so there shouldn’t be a big worry about being out of work. The focus should be maximizing abilities and relevance,” he said. “Understanding inflammatory disease is invaluable, so it isn’t a question of not working. It’s of getting reimbursed for work they do.”

Gathering Reimbursement

Recouping adequate payment in ACOs could prove difficult because rheumatologist-managed conditions, including joint pain or knee and hip replacements, face bundling.

“It’s going to be tricky as we go to bundled-episode payments from fee-for-service,” Hochman said. “Under fee-for-service, rheumatology has been predominantly outpatient, so things can’t get worse. They can only get better.”

He recommended that providers closely monitor reimbursement for biologic agents used to treat rheumatoid arthritis and other autoimmune conditions, as well as infusion therapy payments.

The American College of Rheumatology (ACR) is more wary of bundled payments, however. In a Nov. 12 letter to the U.S. Senate Finance Ways & Means Committee, the ACR expressed concern over the potential long-term impact.

“Bundled payments under one label or another will drive providers to identify patients with the best margins,” the ACR wrote. “This will result overall in less value and even worse access for the patients.”

Consequently, Hochman said, providers should discuss with payers how they’ll handle reimbursement and care management in ACOs. Based on Medscape report data, nearly 40% of rheumatologists would drop poorly-reimbursing payers.

Healthcare attorney Stephen M. Harris, a member of the Knapp, Petersen, Clarke firm in Glendale CA,  advised rheumatologists to determine whether participating in a Medicare ACO – which often uses primary services for patient assignment – prevents them from participating in others.

There are two ways to avoid this problem, he said:

  • Bill under a separate federal tax ID number (TIN): Provide some services under professional services or employee leasing agreements with facilities billing under their TIN. Or form a separate group that retains and bills for physicians or lets providers work part-time elsewhere. Physicians could also bill under their Social Security numbers.
  • Code differently: Select codes not categorized with primary care services. For example, code office visits as part of a global procedure fee. Beware, though: This method could limit reimbursement.

Ultimately, Hochman said, rheumatologists must integrate into care management in a way that avoids being seen as part of primary care.

“Rheumatologists will be teachers and managers of patient populations in ACOs,” Hochman said. “If I formed an ACO, I would ensure leadership had a couple of rheumatologists to manage the system and work with primary doctors.”


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