November 10-15

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ACR Convergence 2023

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Clinicians must know how to prove rheumatology’s value


3 minutes

Rheumatologists require no convincing that their care has great value, but payers are increasingly demanding evidence that rheumatologists add value.

In the world of health care reform, practices that can’t prove they provide quality care may not get paid.

Janet Coffman, MPP, PhD

“There is a growing emphasis on demonstrating the value of what you are doing, showing that you are providing the highest quality care, demonstrating that you are providing a return on the investment in yourself, your practice, and your patients,” said Janet Coffman, MPP, PhD, Associate Professor of Health Policy at the University of California, San Francisco School of Medicine’s Phillip R. Lee Institute for Health Policy Studies.

Dr. Coffman will explore the changing world of health care during a special seminar on Demonstrating the Value of Rheumatology Within Various Payment Models for Practice, taking place on Monday. While health care reform has been moving forward for many years, the Affordable Care Act kicked change into high gear.

“We are helping rheumatologists navigate the changing landscape of health care,” said co-presenter Andrew Snyder, MD, Executive Vice President & Chief Clinical Integration Officer, Mount Sinai Health System, New York. “Health reform and the ACA require a brain shift, a mental frame shift on how you deliver care from your basic workflows all the way through oversight of your panel of patients.”

New payment models are based on shared risk and measurable improvement in patient outcomes.

Andrew Snyder, MD

“The biggest mental change is realizing that you can do better by doing fewer inappropriate services and more appropriate services for your patients,” Dr. Snyder said. “You have better outcomes and you make more money. We have enough experience to know that it is possible. But it’s not easy.”

Rheumatologists, like most other clinicians, seldom had to pay strict attention to the business side of practice, Dr. Coffman said. That realm belonged to practice managers, but business is now a vital component on the clinical side.

“The clinical side and the business side have to work together so rheumatologists know the value of what they are doing, how they can show that they are providing the best quality care, and how they can document outcomes,” she said. “You have to know your local marketplace, whether there is a dominant health plan or a competitive atmosphere that lets you play one payer against another. Are hospitals in your area gobbling up practices, or is there still room for independent practices? And you absolutely have to invest in electronic systems.”

Electronic health records make up only part of the solution, she said. Just as practices must be able to track patients, treatments, and outcomes and demonstrate positive changes, they must also track business operations and expenses. Value is simply the ratio of costs to benefits, but demonstrating value cannot happen without tracking all of the costs and all of the benefits involved in practice.

“Some rheumatology practices are very sophisticated,” Dr. Coffman said. “Not only do they have functional EHRs and electronic business systems, they are already doing things like providing electronic consults to primary care providers. That can be very valuable in helping sort out which patients actually need to be seen by a rheumatologist vs. those who have something like osteoarthritis, which, with appropriate consultation, primary care can manage appropriately.”

At the other end of the spectrum are practices that are largely manual, working with paper charts and voice recorders.

“Providing care and managing the utilization of care under value-based care is very different than it was under fee-for-service,” Dr. Snyder said. “So are the management of coding and the absolute importance of coding and documentation for reimbursement. We will be providing rheumatology-specific information on the mindset and the changes needed to be a part of risk-bearing, value-based health care.”