Background/Purpose: The current fee-for-service model rewards providers for the volume of services. The model is designed to deliver higher compensation for care of more complex cases. Rheumatologists in tertiary care institutions, who provide care for a larger proportion of complex cases, however, are under increasing pressure to care for a higher volume of patients in shorter time intervals.

Purpose is to examine if care for more complex rheumatology cases provides higher financial compensation compared to less complex cases, in an outpatient, academic rheumatology practice

Methods: We conducted a financial analysis of different faculty outpatient rheumatology clinics at the University of Rochester of Medical Center from July 2012 to June 2013. One clinic session was defined as a 4 hour block. We compared three clinics: one dedicated to care of patients with systemic lupus erythematosus (SLE) comprised of patients with complex medical problems, one comprised of rheumatoid arthritis (RA)patients, with conditions of moderate complexity and a general rheumatology (GR) clinic comprised of patients with less complex problems. The following independent variables were collected: total patient numbers, coding levels and procedures including joint injections and ultrasound. The outcome variable, average revenues for an average clinic, were analyzed.

Results: On average, a total of 7.5 patients, (0.6 new, 6.9 established patients) were seen in the SLE clinic. This compared with a total of 8.9 patients in the RA clinic (0.9 new, 8.0 established) and 6.5 patients in the GR clinic (1.2 new, 5.4 established). The SLE and RA clinics performed on average 0.7 and 1.9 joint injections respectively while the GR clinic had 4.3 joint injections and 1.2 ultrasounds per clinic. The coding patterns for the different clinics are shown in Table 1. The average revenues received for each level of visit, ultrasound and procedures was used to calculate the total revenue for each individual clinic. The average revenues and RVUs for the SLE clinic were calculated to be $1,034.58 and 13.3 respectively. The RA clinic generated 6.2% more in revenue ($1,098.66) and 19.3% more in RVUs (15.8) while the GR clinic collected 24.5% more in revenues ($1,287.81) and 65.9% more in RVUs (22.0) than the SLE clinic. The difference in payments for a year (based on 8 clinics a week for 46 weeks) was calculated to be $23,578.85 more for the RA and $93,186.36 for the GR clinics compared with the SLE clinic.

Conclusion: The current pay structure provides greater financial and RVU compensation for the care of less complex rheumatology cases than the care of complex multisystem diseases. Procedures may be a major contributor to the difference in revenues.  Payment reforms are therefore needed to adeqaute compensation for the care of patients with complex rheumatologic problems.

Table 1: coding patterns in percentages for the different outpatient clinics

	FU 2	FU 3	FU 4	FU 5	NEW 3	NEW 4	NEW 5
SLE	0.2%	16%	39.5%	44.3%	3.5%	46.3%	50.2%
RA	0.2%	35.2%	65.2%	0.4%	0%	40.6%	59.4%
GR	0.6%	41.25	55.9%	2.3%	1.4%	27.2%	71.4%

FU= established patients; NEW= new patients

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/problems-with-fee-for-service-payments-for-academic-rheumatology-practices-a-need-for-payment-reform/