APMs & Refining Your Practice

Excerpt from The Rheumatologist, April 2019

Karen Ferguson, practice administrator for Arthritis Northwest, Spokane, Wash., offered lessons from her experience in helping refine a seven-rheumatologist, 60-employee practice’s habits of documentation, patient communication and handling referrals. The idea has been to link rheumatologists, primary care physicians and patients throughout the care process, putting the foundation to succeed under new payment models—a key element of success in any practice’s strategic plan.

Arthritis Northwest was recognized with Patient-Centered Specialty Program Certification, and it recently marked a milestone when it entered into a value-based contract with Premera Blue Cross.

The practice developed a platform that provides a total care management system for patients, with real-time treatment decision support to help direct the course of care for the physician. It also handles necessary documentation and pre-authorization process support, which greatly simplifies the administrative burden for staff, said Ms. Ferguson. This arms the practice with the data it needs to show that it’s meeting the requirements of value-based agreements and federal programs.

To reduce the administrative burden of reporting under MIPS (the Merit-Based Incentive Payment System used by the Centers for Medicare and Medicaid Services, the practice uses its platform to submit MIPS quality measures directly to Medicare’s Quality Payment Program website.

Ms. Ferguson said alternative payment models (APMs) will likely become more prevalent under MIPS. Although still in their infancy, she said, APMs hold promise to show reduced costs with a higher quality of care.

Arthritis Northwest’s planned transition to an APM is based on three main principles:

First is to improve the patient experience—and that means embracing technology. “We’re going to need a technology platform to increase efficiency and information sharing so we can have a better experience for our patients,” including patient access to their records wherever they happen to be, Ms. Ferguson said.

The analytics of your rheumatology practice are more than just financial numbers, Owen Dahl said. Consider the time spent with patients, the percentage of cancellations recovered, your number of no-shows.

Second is to improve the quality of care by assessing patient performance on measurable health outcomes. “Is this patient,” for example, “doing better on this treatment, and do you have the documentation to support the decision to use this medication?” she asked.

Third is to move toward transparency on the total cost of healthcare. “Most of us talk about the total cost of care, but [most practices] don’t have that kind of transparency in our office,” she said. For example, practices don’t even receive the cost of medications from payers.

As it went about assessing what needed to be changed, the practice found that primary care providers were not adequately recognizing RA; they were making inappropriate referrals to rheumatologists; there was a lack of necessary records transferred after referral; there was no good system for e-referral; and there was poor communication between the primary care physician, the patient and the specialist to “close the referral loop,” Ms. Ferguson said.

Arthritis Northwest’s improvements involved measuring and eliminating the backlog of referrals by 76%, an increase of 43% in scheduled appointments involving inflammatory conditions and a decrease of 64 days—about an 80% change—in the number of days patients and providers have to wait before hearing from their office once a referral is received.

It has also begun offering expedited referrals through an e-referral system, which includes a screening questionnaire, and has developed protocols and tools for handling non-rheumatic disease diagnoses.

“Now, we’re seeing a lot more of the right patients at our practice,” Ms. Ferguson said.

Documentation has also been dramatically revamped, she said. Everything doctors decide is documented and aligned with guidelines. The clinical and financial picture is analyzed to give a total cost of care for the patient.

“This is really eye-opening for both the payer and our practice,” she said, and it allows them to try to reduce the cost of care together.

She offered these seven steps for defensive documentation:

  1. Tracking and monitoring the health status of specific patient groups;
  2. Documenting adherence to ACR guidelines;
  3. Documenting and reconciling medications;
  4. Documenting appropriate prevention screenings;
  5. Doing regular function and disease activity assessments;
  6. Documenting medical necessity; and
  7. Coding to the highest level of specificity.