As an internist who has used population health management techniques for a decade, I have no illusions about the challenges and costs of matching PHM care with value-based payment models, but I have found successes through a shift in mindset and care delivery approaches.
Information technology and other support mechanisms are in the early stages of aligning to support the evolution in care delivery, so it’s difficult to assess the final destination that doctors will eventually reach.
Primary care providers should enjoy their work more and see increased reimbursement within VBC models, as PCPs on the front lines can have the greatest impact—and coordinated care planning opportunities—on the “sickest” or most complex chronic care patients.
Within my practice, we have navigated, and continue to navigate, through private insurance programs, PCMH initiatives, a CMS Shared Savings ACO and, just this year, the beginnings of our status within CMS’ new Next Generation ACO model.
Through it all, the paradigm shift as been around responsibility; what’s the nature of my responsibility to my patients and how do I approach and track that? Is my responsibility encounter-based or is it more longitudinal in terms of my entire patient panel?
I see it as a more holistic approach away from episodic or even repeat visits to thinking about what happens between encounters and what resources can be matched to needs around social determinants or medical history or basic communication.
Embracing the care team approach is key to those mindset and care delivery paradigm shifts that are necessary for providers to succeed with value-based care. And the care team should not just be in a practice silo. It should include all transition of care or referral settings, the hospital coordinator, the PharmD, the dietician and all staff liaisons, the spectrum of the clinical and non-clinical elements patients can have access to between visits.
A quality manager, with provider direction, can really help make all of this work smoothly. This is someone who can proactively oversee and coordinate the care team and processes and be responsible for the outcomes measures that are reportable to payers for these value-based care programs.
Patients will increasingly embrace the care team approach and the increased access or the personal touch it can bring them. They will come to value the levels of care they thought only “their doctor” could bring.
There are other challenges for providers as we are transitioning to more VBC programs, but there are also solutions. Currently my practice is involved with at least 10 reimbursement programs, each with its own set of standards and patient populations within my overall panel.
Quality measure standards. Population-level risk. Utilization and cost of care. In- or out-of-network. Care teams and effective technology capabilities are critical for sorting through these variations and delivering high-quality care. Automating the quality program expectations and requirements helps our care teams know what they need to focus on for each patient.
A lot of this work needs to be done in my office, but this is also where the health system can be a support system.
I currently practice within a layered structure. I’m a hospital-employed physician, with the hospital itself owned by a multi-state health system. My large, multi-specialty employed physician group as well as many independent primary and specialty care practices are all part of our local health network. Here is where support comes in. The network contracts with payers on behalf of the providers, takes responsibility for VBC IT, aids with quality program certifications or recognitions, and is a care management process educator and facilitator. Our network really helps bring our healthcare community together and rallies us around our growing number of VBC programs.
As a primary care physician, I see a lot of frustration and an increasing rate of burnout in medicine. However I do think that the transition to VBC and team-oriented care has a lot of promise to help physicians rediscover the joy of practice that has often been eluding us.
Simply getting out of a production-and-visit volume mindset can help a lot. If we are spending our time with our sickest patients and leveraging our care teams, we will make more of a personal impact, which is rewarding. Being financially rewarded for delivering high-quality care also fits well with physician personalities and will help us feel like we are being compensated for the value we want to provide – high-quality care.
Our EHRs have significantly reduced our productivity and focused our time on a lot of meaningless clicks that don’t bring value to anyone, so the coming transition in the meaningful use program to focus on using technology to improve patient outcomes – rather than using an EHR just to use an EHR – will hopefully improve our day-to-day patient care experience.
Other changes should help as well, such as increased use of telemedicine. Value-based care should also allow telemedicine to live up to its potential, which can help the many providers and patients in rural areas get access to specialty care that may be difficult or impossible to obtain in a FFS world. This will benefit specialists and health systems and expand their reach and open markets as well.
For our practice and network, the past decade has provided a good foundation for our ongoing transition to VBC, which is about to accelerate and become even more detailed for my Medicare population. The MIPS and APM payment tracks within the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is something we look at more as an opportunity at this point, rather than a challenge. We’ll know more about the proposed rule this year, but we’ve learned enough about how to succeed with other programs that we know we will do well, whatever the MACRA requirements may be.
A lot of the frustration with medicine that we see from both providers and patients is actually rooted in the FFS payment model and its emphasis on volume. Rewarding providers for delivering high-value care and delivering that care using a proactive care team approach enabled by the right technology can improve not only clinical and financial outcomes, but also improve the human satisfaction of those who both use and deliver healthcare services.
As physicians, we should not only embrace the transition to value-based care, we should push it along any way that we can.
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