Taming the 800 lb. gorillas in the room
Inflammation drugs are at the top of the specialty pharmacy spend list. Spending on rheumatology drugs is larger than any other specialty (oncology, HIV, etc.) And when practices move from one drug distributor or Group Purchasing Organization (GPO) to another, significant dollars move as well. The result is a very competitive marketplace. With UR having stepped into the void that existed before, it didn’t take long for others to see the need to compete with us. I would urge you to ask when presented with temptations from a GPO other than UR, where were you before UR? We are talking about top Fortune ranked companies worth hundreds of billions. Why didn’t they come to our support before UR? And do they reinvest their profits into the subspecialty? Have they deployed billers and admins at their expense to be there to bail out a practice in trouble? No. They have not. But what they have done is to go under water on pricing, to lure practices away from UR. The 800-pound gorillas in the room are doing what they can to hurt us.
Rheumatology is small. Is there a need, a value to multiple networks and groups? Or are we weakened by splitting ourselves up?
It’s personal for me
I have been vocal and active in trying to find a voice for rheumatology for decades. I tried in many ways. I found limited successes and kept trying, until experience and circumstances led me to establish United Rheumatology.
By 2014, many of you knew me, and knew of my vocal support for our patients regardless of who might be on the other side of the table. Fran and I were humbled that UR was referred to so often as “Max’s group.” After a time, we felt it essential to create awareness that UR is much more than that. While I do know many of our members personally, there are many more friends in UR’s ranks I have yet to meet. You’ll see many other faces speaking at our meetings, because we have been able to recruit the most experienced and effective leadership team to achieve our goals. But while UR is much more than “my group,” that does not mean that I have pulled away at all.
I serve as Chairman of our Medical Policy Committee, Chief Medical Officer and Executive Chairman of the Board. At every phase where there needs to be an active voice for rheumatologists and practices, I am involved. And you have the right to expect that neither UR nor I are resting on our accomplishments to date. We will keep working on the GPO front. We will expand the resources we allocate to helping practices in trouble, and practices who need support. We will expand and reinvest in our staffing to be rapidly responsive to your needs. We will listen, make changes, and implement initiatives as needed.
The idea of creating a soft-landing pad for physicians seeking to leave institutional employment came from UR member, Jeff Petersen from Seattle. Our conversation led to UR leadership hearing the need and then making a strategic decision. We are small enough to hear you and take direct action. We know our membership as our most valued asset, and never take our responsibility and commitment to you lightly.
We make decisions with the mission of UR in mind. We want to be in a position where we can sit at the table with payers as the subject matter experts and have our voice in the discussions about the value and quality of care. We want to find new ways to provide the most cost-effective care, while we keep our skin in the game. But most importantly, to provide the voice on behalf of our patients and make them feel appreciated.
Building Our Executive Team
Our new leadership is comprised of experienced executives from different areas in health care. It was particularly interesting during one discussion with one of the top recruiting firms in the country, when we learned that we had scooped them in attracting Jim Albano to be our EVP of Operations and Payer Strategies. UR, with less than 20 staff, had attracted a man who could have joined any of a number of large companies.
Doug Tardio, who joined me in 2014, had decades of experience, first with payers, and then as COO and President of CareCore National. Those who know of CareCore may say as I did after first meeting Doug, “You seem very bright, I like you, but I don’t like what you did.” CareCore was one of those companies that managed the imaging benefit for payers and sent us the letter saying we hadn’t gotten prior authorization for that MRI. Doug responded, “Max, if I can teach you how to use benefits management strategies for the benefit of rheumatology and its patients, can you get a network built?” I said yes, our members said yes, and that is why there are 650 of us.
Doug then brought over Bill Moore, former CareCore Chief Technology Officer, to be our CTO. Bill had built the platforms which enabled CareCore to handle 40,000 requests a day for advanced imaging. Now, Bill works for us. He helps us access the data from our EMRs and turn that data into actionable information. We don’t ask you to change your EMR like other groups do. We work to find ways to interact with over 35 different types of EMRs that our members use. Patrick Murphy, who is our CFO, was being recruited by large national firms. He looked at UR and came to work with us.
Many of you knew Kelley Jewett, now Senior Vice President, Recruitment Specialist and Pharma Contracting, from her years with Centocor, and then Crescendo. Kelley knows rheumatology and rheumatologists better than almost anyone from pharma. She too could have gone to a much bigger company. But she saw what all are seeing; a commitment to the mission of UR and the integrity of that commitment. And a chance to contribute to a transformative company.
We’ve also added Dr. Andy Concoff as our Executive Vice President, Chief Value Medical Officer. Andy practiced a combination of Rheumatology and Sports Medicine at St. Jude Medical Center for the past 15 years, where he served as Medical Director for Outpatient Rehabilitation. His published research reflects his broad clinical focus, including contributing to numerous position papers for national medical societies, to a network meta-analysis of care for knee osteoarthritis, and to numerous health economic analyses in the rheumatic diseases. Andy recognizes the goals of UR as his own and we are fortunate to have him on our team.
Gerard Maher, our Senior Vice President, Recruitment and Retention is the most recent addition to the leadership team to help further accelerate growth and services to member physicians and their patients. Gerard has led numerous rheumatology product launches at several top pharmaceutical organizations. He understands the complex landscape and will help United Rheumatology forge new relationships as we continue to grow beyond 650 providers in 2020.
And now, with our size, it is time to prove that we are taking the power provided to us by your numbers to be that voice of subject matter expertise, and to define value the way we as practicing rheumatologists see it. We don’t follow any other organization. It is the voice of our members, amplified by our Medical Policy Committee that leads the way. Is UR led by rheumatologists? Absolutely. Have we got non-rheumatologists on the team? Absolutely. And they are the best in the business.
Payers are at the table
Our goal is to be at the table with payers. We are making progress and encountering some surprises along the way. We announced at our last October meeting the launching of a collaborative undertaking with a major payer that will reveal many dimensions. We have executed a letter of agreement with Horizon Blue Cross Blue Shield of New Jersey and are close to executing a letter of intent with Blue Cross Blue Shield of Texas to begin developing value based shared savings arrangements on behalf of our members. In addition, we continue to have conversations with other payers around the country.
In the course of conducting the negotiations, we were pleased to be asked: Can UR help a payer who wants to underwrite a major research project that has as its goal bringing precision medicine to rheumatology? Finding the biomarkers that define different RA phenotypes? The biomarkers that predict drug response or non-response? The biomarkers that can accurately be used to track disease activity? Our PT/INR? Our BP? Our BRCCA genes?
UR is the only group in the country who can aggregate 10,000 RA patients. After multiple meetings with the major payer, we said yes to this project, which essentially is looking for the holy grails for RA and beyond.
We brought together an expert panel in early January. We assembled a panel of investigators whose life work has been to apply advances in technology: single cell analytics, an assessment of all of the “omes,” bio banking of tissue, synovial fluid and blood, etc. The panel included experts from Europe and the US. It was fascinating to listen to the discussion. Even as one of the country’s largest payers they were amazed at how we pulled the group together. We don’t think they could do what we did. The physician scientists asked, how did you get a payer to this table? How did you get them to see the needs, and provide the funding? The scientists could not have gotten this payer to the table. UR was able to, by virtue of decades of relationship building, and by virtue of the size and strength of its membership.
Continuing to Build Engagement
While this study is of remarkable importance, again, we came to it while we sought payer engagement. And we will announce during 2020 on a national scale the first of multiple care program innovations that bring truly cost-effective shared savings programs into rheumatology.
Working with payers has provided major upsides as above, and then disappointing challenges. While all payers complain about the cost of inflammation drugs, some when offered an effective approach to managing cost will respond; yes, it’s important, but we don’t have a team that can handle what you offer.
Be careful what you wish for, because someone might give it to you. Some payers haven’t yet learned to take “yes” for an answer. Other payers are known to be the slowest to innovate, the fastest to copy. UR continues to expand its investment in its payer team. As care contracts are generally designed one to two years out, the results of our work may not appear as quickly as we would like. However, this aspect of our mission is clearly the most important.
And so, while UR is now every member’s group, for all of you who signed on in the beginning when this was Fran and my dream, know that it remains my dream, and my commitment. I am still as present as always, as committed as always, and as vocal as always. I am there for my patients, your patients, your and my practices, and our subspecialty.