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ISMA colleagues react to new timeline for value-based reimbursement
e-Reports, March 9, 2015
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Physician leaders consider the recent call from Health and Human Services Secretary Sylvia Matthews Burwell to accelerate Medicare’s use of alternative payment models. (See previous coverage here.) Untitled document
Hsieh Meyer Park
Jesse Hsieh, MD
medical director for Care Delivery Innovation,
The South Bend Clinic
Paul Meyer
chief executive officer,
The South Bend Clinic
Ben Park, MD
president and CEO,
American Health Network
Ratliff Oppman
Wesley Ratliff, MD
president, Premier Healthcare,
Bloomington
Robert Oppman, MD
president,
The South Bend Clinic

How prepared is your physician group to practice under value-based (quality)-reimbursement contracts?

Dr. Hsieh – “At the South Bend Clinic, we’ve been fortunate in that the various payer reports we have received historically have consistently shown positive quality performance by our group and physicians on the various metrics being tracked. As a result, as more of our payment shifts to value based, we’ve fared well and have not been forced to make major changes. That said, we also see the metrics from payers and HEDIS getting tighter each year, so we can’t rest on our laurels.”

Meyer – “We’ve added several population health staff members who help track quality metrics, gaps in care and outreach to patients to encourage their engagement, as well as reporting to payers. The result has been increased reimbursement that more than covers the incremental cost.”

Dr. Park – “American Health Network is prepared and excited about value-based care. We have made major investments in IT, process improvement and training for the past seven years anticipating this change.”

Dr. Ratliff – “I suspect that at Premier Healthcare we are as well prepared as most groups. We have been active in the use of information technology (IT) and practice analytics for a number of years. We are now in year three of a Medicare ACO and participate with Anthem's EPHC program. Certainly what Secretary Burwell envisions is much more robust, but we have some baseline experience in newer models of care/reimbursement that attaches value (i.e. dollars) with quality. Hopefully, this will give us a head start.”

How prepared do you think Indiana physicians are in general?

Dr. Oppman – “Indiana really is blessed with many outstanding physicians, so the baseline quality is there in most instances. Where most of us are lacking is in the time, staff and IT resources to really commit and be successful in value-based contracts.”

Meyer – “All of these resources require investment. Larger groups may be more able to spread that investment over their members while smaller groups and individuals are really strapped to take it on. Finally, while most physicians are now on electronic health records, the data is likely in the systems; however, the ability to extract the data for meaningful reporting is more difficult than any of us would like.”

Dr. Park – “I believe most physicians embrace this change and are prepared. What I am unsure of is how many have made the investment in IT systems and process improvement needed to practice in an environment where payment is tied to value.”

Dr. Ratliff – “I would guess about average but have no way of knowing. The East and West coasts are likely significantly ahead of us, but we are probably doing well among other areas.”

What will be the greatest barriers to moving away from fee-for-service?

Dr. Hsieh – “The big payers are all migrating to value-based reimbursement, but even with that, it’s a relatively small percentage of a physician’s total reimbursement. So we end up with one foot in value and another foot still in the fee-for-service world. It’s a very tough transition and one that – if done too fast or too slow – can truly jeopardize a physician’s or practice’s economic viability.”

Meyer – “Payers need to offer a bridge in the transition – perhaps a meaningful PMPM (per member per month) or care coordination type fee to assist physicians and cover both the investment in infrastructure that must be made, as well as the shift in patient volume and utilization during the transition.”

Dr. Park – “It is the mindset. For too many years we have been on a treadmill trying to see as many patients as possible. In the near future, success will not be measured by how many patients you see but rather by how well you care for the patients you see. Making that change is no small feat for physicians, of course, but also for payers.”

Dr. Ratliff – “I believe the real challenge will be for CMS (Centers for Medicare & Medicaid Services). How do they define quality and value? Despite a lot of work, this remains a cloudy issue. If we cannot really define quality, then expecting improvements in cost and result will be near impossible. The fiasco of MU (meaningful use) Stage 2 is a case in point. When moving from MU Stage 1 to MU Stage 2, the government appeared to have lost all sense of the word 'meaningful.'

“Additionally the design of these programs will be crucial. The ACO design is obviously seriously flawed and needs extensive change. When only 11 percent of the more progressive medical groups in the U.S. can be successful with an ACO shared savings program, then you have to accept that although the idea has great merit, the design doesn't work.”

What might be some surprises or unexpected challenges, especially here in Indiana?

Dr. Hsieh – “What we all might get surprised by is the diminishing returns over time. We can all improve, but the low-hanging fruit will gradually disappear and with it, some of the bonus or value payments we enjoyed early on. It may sound cynical, but it’s been seen elsewhere: Are these value payments a transient evolution that improves quality and cost but then goes away after we achieve a new threshold of performance?”

Dr. Park – “Indiana is a high cost state. Costs have to come down. In that environment, there will be some winners, but also some losers.”

Dr. Ratliff – “It is not only a change in the way we as physicians practice medicine, but also in how patients interact with their providers and staff. Patients will need to significantly increase their use of IT to keep pace and will need to be more active and open to discussions about evidenced-based medicine. Obviously, a major challenge will be cost. Despite government support with MU dollars, the IT platforms for these programs have high costs. CMS needs to recognize and provide for this in their plans.

“Finally it would appear that the timeline is very aggressive! Nothing wrong with that vision, but I suspect it will take longer as there will be starts and stops. Stick with the goals but don't get too tied up with the timeline.”

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