Value-Based Payments: But Is There Any Value for Doctors?

Leigh Page


October 08, 2015

In This Article

Practices Should Propose Customized Arrangements to Insurers

For medium-sized and large practices, the value-based approach requires reaching out to insurers and developing payments for new programs that support the practice's clinical goals, Dr Holly says. "Most doctors have only been in a punitive relationship with insurers, but now they need to collaborate."

Rather than just accepting the insurer's P4P arrangement, practices can propose their own value-based targets, based on their in-house metrics, and ask the insurer to pay extra if the practice meets the targets. "The practice should propose customized arrangements that best reflect its own goals, and provide the data to back up the proposal," Dr Holly says.

Illinois Gastroenterology Group, a single-specialty practice with 47 physicians in the Chicago suburbs, has created such an arrangement with Blue Cross Blue Shield of Illinois to manage patients with inflammatory bowel disease, according to managing partner Lawrence Kosinski, MD.

Blue Cross gives the practice a supplemental fee to cover closer management of these patients, plus a per-member, per-month payment for each patient treated. The program involves continually tracking patients between visits. For example, patients receive short questionnaires to fill out, through their smartphones if they have that ability. The program started in 2014, and preliminary results show a 10% decrease in costs, Dr Kosinski says.

Dr Kosinski believes larger groups have more to offer insurers. Illinois Gastroenterology is the result of several mergers of smaller groups, and Dr Kosinski expects it to grow by 70-80 more doctors, so that it can cover every part of its geographic area when contracting with payers.

"Practices are caught between large health systems and insurers," he says. "When doctors aren't organized in larger practices and are sitting in their mom-and-pop shops, they're just cannon fodder for the bigger players."

Can Small Practices Survive the Value-Based Wave?

Keegan says small practices are at a clear disadvantage in the value-based world. "They don't have the IT structure to process data, they might not have the staff to coordinate care outside of office visits, and they certainly don't have the negotiating leverage with payers," she says.

Small practices that haven't learned to deal with value-based measurements may find themselves gradually squeezed out of insurance contracts, Keegan warns. For example, payers are starting to separate physicians into two tiers, based on their ability to meet value-based measures. Patients whose physicians are in the upper tier have lower out-of-pocket costs.

However, practices may be able to overcome their disadvantages by pooling their resources together in independent practice associations (IPAs). "The IPA may help small practices by providing limited resources to develop the infrastructure to measure cost and quality," Keegan says. "For example, small practices can collaborate on technology and data analytics to obtain the information needed to demonstrate value and process some quality measures."

Take Dr Brull. Although she runs a small solo practice in Kansas, she's also part of a loose group of five physicians who share staffing, billing, and an EHR system. They've become certified patient-centered medical homes and share the same evidence-based guidelines. "We discuss why we did things the way we did, and come to a consensus around best practices," she says.

In addition to joining such arrangements as the Aledade ACO, small practices can take advantage of a variety of programs. For example, the Centers for Medicare & Medicaid Services' (CMS') Transforming Clinical Practices Initiative is providing time-limited grants for practices testing out innovative staffing models. CMS anticipates making awards this summer.

Dr Brull says one of her payers provides its own care coordinators to reach out to her patients. And some insurers organize small practices into larger units that share care coordinators. For example, the CareFirst medical home program puts small practices into panels of about 10 physicians or nurse practitioners each.

Dr Damle thinks CMS' Merit-Based Incentive Payment System (MIPS), which was announced in January and starts in 2019, might offer a viable value-based option for small practices. Following in the footsteps of many commercial P4P programs, MIPS will offer clinicians an opportunity to participate in value-based payments without downside financial risk.


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