United Rheumatology: How History Was Made

By Max Hamburger, MD
Founder, Executive Chairman and Chief Medical Officer of United Rheumatology

Today, United Rheumatology is currently the leading Network and Management Services Organization in Rheumatology. But to get to this position of strength we started from humble beginnings, looking for ways to enable practicing rheumatologists to work together on major issues. Let’s take a look at how UR started, and where we’re headed.
Why isn’t there a rheumatology supergroup?
In 2013, in many areas around the country, particularly in LA, DC, NYC metro, and Florida, practicing rheumatologists started to explore ways to work together and to best take accountable and responsible positions about major issues facing our practices and the patients we serve. I as well as others considered the idea of supergroups. Why? Other specialties had them, they seemed to bring value, but no rheumatology supergroup existed. Why not? Current UR membership reflects rheumatology practices across the US, with two-thirds of our members in groups of three or less. So, while everyone says we are a happy, smart, and friendly group, we still tend to go it on our own. As a Founding President of the NY State Rheumatology Society, I tried to encourage supergroup formation, and everyone told me “Max, this is another one of your great ideas. Go do it and tell us how it works out.”
The pressure builds to get a supergroup started
Early in 2014, an insurance company reduced the imaging benefit for rheumatologists by declining to compensate for musculoskeletal ultrasound. This galvanized me to launch a movement to further invigorate seeking a way for us to have a voice at the table. My wife Fran and I organized two meetings, bringing more than 70 of my closest friends together in Florida and NY to consider moving forward with supergroup formation. I brought in physicians from pediatrics and OB/GYN who had formed successful supergroups. I brought in a lawyer who built them, and a population health expert. What we came to realize is there aren’t enough rheumatologists in any single community to make forming a supergroup worthwhile. Why not?
A supergroup is a partnership. Physicians joining a supergroup become employees of the practice and give over their practice assets to the supergroup. They become partners with many other physicians that they do not know. A central business office is required, and centralized compliance programs are needed. All of this administrative infrastructure comes at a cost. Physicians may likely need to adapt to a new EMR.  Even if the formation agreement provides terms of separation should the parties agree, it is currently not possible to extract patient records from an EMR and transplant them. Physicians joining a supergroup need to understand the complexities of a possible exit strategy.  What makes a supergroup worth all this? The essential unique value of a supergroup is its ability to perform fee for service negotiations with health plan payers. A group needs to be able to move the cost of care dial if a payer is going to work with them. This means that the supergroup has to see a sufficient number of members of a given insurance plan to be able to impact the plan’s financials.
Dangers of the supergroup model
If you can form a group large enough to make a fee for service discussion effective, then the sacrifices may be worth it. But with a rare exception, there are very few communities in the US where there are enough community-based rheumatologists in practice willing to combine to make a supergroup effective. Fee for service negotiations are local, not national. A supergroup with 200 members nationally still will not have the local clout necessary to impact reimbursement negotiations on behalf of all of their members. Additionally, to make the investment in the necessary supergroup infrastructure most experts suggest at least 60 participants. The essential ingredients for a successful regional supergroup are a very limited number of payers with high membership concentrations and a group of rheumatologists willing to surrender autonomy. After a comprehensive review of the country with a major healthcare consulting firm, I determined the risk-reward scenario to build one or a series of supergroups would not benefit the rheumatology community as a whole.  So, I moved on.
Building something unique to Rheumatology
Knowing the dynamics of rheumatology, and most states having fewer than 50 independent practice rheumatologists, I decided to build a Management Services Organization (MSO) instead. The very word supergroup has strong connotations: not just a group, but a supergroup.  An MSO doesn’t sound very exciting. But the reality is very different. The founding 70 who joined me in 2014 committed their time and money, and we built the infrastructure of a network and a GPO that launched in early 2015. Within 4 months, we were over 100 members. We negotiated for value with distributors, helping practices find essential financial stability for their ancillary services.
The next major innovation was the signing of the specialty’s first direct to manufacturer (DTM) agreement in the summer of 2015.  UR followed that early in 2016 with another DTM and has continued to be the innovator when it comes to DTM’s, whether with pharma, or other vendors. We developed a most favored national pricing agreement with the pre-eminent EMR vendor, TSI, and together led the field in introducing key data fields needed for assessing outcomes in patient care.
At the same time, we launched our Medical Policy Committee (MPC). Our MPC set forward to draft copyrighted pathways that face payers and physicians alike. Usable pathways that have already been the basis of important initiatives.
Growth and helping smaller practices
While our core mission has always been to establish the framework for collaboration with payers and policymakers on our members’ behalf, I knew we needed to also offer near-term solutions to stabilize and solidify practices to keep them viable.  We recognized the need to help smaller practices when they encounter crises.  If a small practice has one biller and that biller leaves, then claims aren’t submitted, error reports are not addressed, and payments aren’t posted or reviewed. If a practice administrator leaves, the practice now is a rudderless ship. To answer this need UR brought on practice administrators and billers as full-time staffers. We parachute these staff into a practice that issues a distress signal, and we can restore order until the hiring of new staff. No other group has taken its funds and invested as UR has.
I cannot stand by idly when a physician feels they must sell to a hospital to survive. It’s just who I am. I also believe we can create a launchpad for Fellows leaving training with the goal of setting up a practice. To go solo these days takes a lot of courage and determination. If a Fellow makes that choice, UR has developed programs and allocated resources to see them through to personal and professional success. If a rheumatologist wants to leave an institution and go out on their own, UR has developed programs to help them.  We are a physician-driven organization, and it is the physicians and administrators that drive our offerings. Our independence gives us success in implementing these programs and allows us to have a voice at the table with all other major stakeholders in the healthcare system.
It’s important to have that voice because it can be daunting dealing with the “800 lb. gorilla in the room” when Rheumatology is so small by comparison. Next post, I will talk about how this journey continues and why it is so personal for me.

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