The need for payment reform is critical, but the process is fraught with risk and confusion for physicians and medical practices. Increasingly recognized as foundational for a successful healthcare system, primary care must be supported through improved payments in visible, understandable and quickly generalizable ways. Family physicians are a cornerstone of primary care in this country. In rural areas where Medicare beneficiaries are likely a significant percentage of the medical practice demographic, the role of family physicians to provide the right care, in the right place, at the right time is paramount to a successful new healthcare delivery model. Ensuring that family physicians are well informed is necessary for them to embrace and be invested in new value-based payment (VBP) models.

The American Academy of Family Physicians (AAFP) represents over 129,000 members nationally. In 2015, the AAFP surveyed 5,000 members and the responses of 626 clinically active members were summarized. The good news is that team-based care is the norm for family physicians: 71 percent have incorporated either an advanced practice registered nurse or a physician assistant into the practice, 28 percent have a care coordinator, 40 percent are designated as a patient-centered medical home, and 38 percent are affiliated with accountable care organizations (ACOs). However, only 70 percent of these members are familiar with the concept of VBPs, and 12 percent are not at all familiar. Only 33 percent are actively pursuing some type of VBP model. The most common active model is pay-for-performance (P4P), but less than half of members have P4P programs in their market. Only 29 percent have per member per month (PMPM) programs, and shared savings models impact just 27 percent of these practices. Based on these responses, more work is needed to ready primary practices for this pivot to value-based payment.

Distribution of savings from VBP models is also crucial for eventual success, especially given the significant administrative processes associated with large organizations and ACOs. Twenty-six percent of family physicians are aware that value-based payments are received by the practice, yet these payments go to administration and are not targeted to the physicians.

Critical factors for success of VBP models are practice sustainability and clinical outcomes. Unfortunately, the sustainability of primary care practices is negatively impacted by the current longstanding fee-for-service payment models that weight heavily toward subspecialty care. Many new family physicians are moving between or seeking to be employed by existing practices rather than adopt the older model of starting their own practice, and many senior physicians are considering retirement rather than wait for a more appropriate VBP model to be fully implemented.

Significant barriers to the implementation of VBP models include lack of staff time, the cost of efficient health information technology (and the reality of little or no interoperability, making sharing critical patient information very difficult), and an unpredictable revenue stream. Physicians are not at all convinced that the performance measures by which they are evaluated result in improved patient outcomes, especially as evidence suggests otherwise for some cases; for example, monitoring hemoglobin A1C levels as an indicator for diabetes control rather than outcomes such as avoiding hypoglycemia or hospital admissions. There is also a real concern among primary care providers that VBP will further increase physician workload without providing patient benefit.

Emphasizing the value of primary care for our patients in the shift to true VBP models is an important focus of the Learning and Action Network (LAN) and partners such as the Centers for Medicare and Medicaid Services, and it is exciting that progress is being made in this area. The AAFP was invited to be a member of the Health Care Payment LAN Guiding Committee, as were several patient advocacy groups. Having these voices at the table provides a view from the trenches on how providers and patients see the transformation of paying for value. Two of the LAN’s white papers, the Alternative Payment Model Framework, and Accelerating and Aligning Primary Care Payment Models, help lay a foundation for a culture change that realigns payment to better reflect the increasingly appreciated value of primary care, especially in the context of patient-centered and team-based delivery models.

An important next step is to expand these discussions beyond boardrooms to include clear, consistent and regular bilateral communication with medical students and residents. Primary care practices, especially those in family medicine, as well as state chapters, must also be involved in these discussions. We must pursue the implementation of these value-based payment models in a manner that allows physicians to spend more time on patient care and less on administrative functions.  These changes are aligned with what our patients are demanding as well. Now, we need to focus on how value is determined and tracked, how best to pay for this value, and how to make it not only easy, but exciting for practices to transform to meet the expectations of new delivery models, as these kinds of changes will have far-reaching impacts for health and healthcare.

Reid B. Blackwelder, MD, FAAFP, is a member of the Health Care Payment Learning & Action Network’s Guiding Committee. He is Professor, Family Medicine at the Quillen College of Medicine at East Tennessee State University in Johnson City, Tennessee. He also serves as Director of the Medical Student Education Division for the Department of Family Medicine.

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