Physicians Need More Education on Managing New Payment Models
Abstract
While new payment models offer several benefits, they’re changing the way doctors practice medicine.
Physicians need more help managing data to deliver the best care possible in the wake of health care reforms, according to a new joint study by the AMA and the nonprofit research organization RAND.
The research results were presented last month at a press conference at the National Press Club in Washington, D.C., at which representatives of RAND, hospitals, health plans, and the AMA gathered to discuss the findings.
“We found that changing the payment system probably isn’t enough to ensure that patient care will improve,” said Mark Friedberg, the study’s lead author and a senior natural scientist at RAND, at the press conference.
The research involved a survey of 34 physician practices in six areas across the country: Orange County, Calif.; Little Rock, Ark.; Greenville, S.C.; Miami; Lansing, Mich.; and Boston. The aim was to determine the effects that alternative health care payment models—such as episode-based and bundled payments, shared savings, and pay for performance—have on physicians and medical practices. From April to November 2014, 81 physicians and practice leaders, including five psychiatrists, shared responses, Friedberg said.
Payment Model Definitions in AMA-RAND Report
Fee for service: The rate of payment is a flat rate per service unit, usually following service-unit descriptions in the CPT codes.
Capitation: Payment is per patient per time period, with the time period typically being one month.
Episode-based and bundled payments: Episodes of care are used as the basis of payment. Episodes can be defined in a variety of ways, typically according to a set of diagnoses and services provided over a specified timeframe.
Pay for performance: Basis of payment can vary widely, and the rate of payment is variable.
Shared savings: Shared savings models are added to an underlying fee-for-service payment. The basis of payment is per patient per time period, as in capitation models, or per episode of care, as in episode-based payment models.
Retainer-based payment: Also known as subscription or concierge models, retainer-based payment is a capitation payment (typically per patient per year, or per month; also known as a membership fee) that is typically paid from the patient to the physician practice directly.
Medical homes: There are many definitions of medical homes and many models for payment. In almost all medical homes that are not part of a larger organization taking global capitation, the underlying chassis of fee-for-service payment exists as the practice’s main revenue source.
Accountable care organizations (ACOs): There are many definitions for ACOs and multiple ways to pay. Broadly, ACOs are large health systems or collections of physician practices that jointly enter an ACO contract with a payer.
The researchers looked at a variety of payment models, including three “underlying” types that can stand alone: fee for service, capitation, and episode-based and bundled payments. Three other “supplementary” models—pay for performance, shared savings, and retainer-based payment models—were included as well. Supplementary models can coexist with one or more of the above underlying payment models. Their aim was to discover the impact that alternative health care payment models (models other than fee-for-service payment) have on doctors and practices in the United States. Accountable care organizations and medical homes—two newer models—were also evaluated.
The study showed that attitudes toward alternative payment models and the impact on the stability of physicians and their medical practices ranged from neutral to positive. On the upside, new payment models have encouraged more team-based care to help prevent disease progression, and access to care has also improved.
One psychiatrist in a large multispecialty practice told researchers that the practice with which he is associated has implemented collaborative care and included behavioral health care as part of the current shared-savings contract. He said their aim is to find patients who have diabetes, hypertension, cardiac problems, and some mental health comorbidities and to see whether it is possible to improve adherence and outcomes if mental health care is fine-tuned. “Somebody finally decided behavioral health has a lot of influence on medical outcomes,” he said.
None of the practices surveyed reported financial hardship due to new payment models.
Friedberg said that while some physicians are making larger investments in collecting and analyzing data, participants reported management problems due to the proliferation of payment models and performance measures. A common theme across all of the markets studied is that multiple payment programs and performance measures can strain medical practices by adding to administrative burdens.
One physician respondent in a large multispecialty practice said, “There’s a lot of burnout in primary care. It’s a really hard job, and we’re trying to figure that out to keep good people practicing.”
Friedberg reported that physicians forgave some operational errors—if the practice did not receive a bonus that it did in fact earn, for example—in new payment programs, but with the expectation that they would be corrected in the near future.
The AMA is taking a “hands-on” approach to the research findings, said AMA President-elect Steven Stack, M.D., an emergency physician from Lexington, Ky. “The release of the study directly supports our work. For delivery systems to be effective, all stakeholders need to be committed,” he said at the press event. “The AMA is deeply committed to better understanding how all participants, including physicians, can be more collaborative and constructive in advancing care. We all realize that it’s an unsustainable enterprise in its current form.”
Stack said that unfortunately discussions often include health care stakeholders (physicians, health insurers, and medical systems) who are at odds with each other and not in possession of the same set of shared facts and data. He said that the AMA is trying to rectify that and partner with others to bring the various data sources together and collaboratively work toward positive solutions.
“Many have held for a long time that behavioral health is underfunded and underattended to,” Stack said. But the data being collected under the newer payment models have the potential to help support the integration of behavioral health and general medical care, he said.
Chet Burrell, president and CEO of CareFirst BlueCross Blue Shield, was among the panelists at the press conference. He addressed mental health care payment issues and the company’s change of tack.
“One of the first areas that was capitated or bundled was the [mental] health and substance abuse area, and it was done for many years by many payers, us included. It [mental health] was carved off,” said Burrell. “Everybody disassociated it from the medical side, and that is what gave rise to the drive toward parity and toward greater integration. We are deeply committed to the idea that it [mental health care] has to be fully integrated, and we have set up our whole program that way. We no longer bundle it or capitate it. It is all integrated together with general medical.”
Burrell added, “If there was ever a lesson in what not to do, that was it.”
The AMA’s Stack wrapped up the press conference saying that the AMA-RAND report provides missing information on the real-world impact of payment reforms. “Today is an exciting day, not because we will solve all of the world’s problems in one day,” he said, “but because it is another important step forward in trying to work together to make [health care] better for the patients in this country and the participants who serve them.” ■
“Effects of Health Care Payment Models on Physician Practice in the United States” can be accessed here.
