Yes – but only if insurers do their part.
Thousands of primary care providers transformed their practices to patient-centered medical homes in preparation for performance-based payment models. No doubt some groups submitted NCQA application for PCMH recognition status, but little changed in their day-to-day work flow. They just churned through as many patients as possible because their fee-for-service payments remained the key to their economic survival.
However, some of us actually made substantial investments in how we delivered patient care. We believed these new payment models promised to economically align payers, providers and, dare we even say it, patients. We examined and changed everything we did to prepare, with the full understanding that we were going to risk our payment if we missed the mark on quality and cost. We even considered alternative payment models (APMs), where we would pay money back to the payer if we missed the mark. Of course, these opportunities were touted to yield much bigger payments than the best of the fee-for-service contracts, but who would have ever “thunk it” -- doctors leaping head first into a risk-based payment model where they might have to refund payments to the payer for failure to meet cost benchmarks!
At first, it worked. High-performing practicesimprove patient outcomes and experience and lower the overall costs of care. But in many markets, the APMs that would provide long-term economic sustainability to these high-performing groups never materialized.
A North Carolina physician recently summarized the problem in a powerful essay, “The Impending Death of the Patient-Centered Medical Home,” published in JAMA Internal Medicine.
Edward Bujold, MD, transformed his solo family-medicine practice to an advanced PCMH over a 17-year period. However, due to “the changing financial environment,” he writes, “in 2016 my practice lost the equivalent of 1 month of gross revenue.”
Now, Dr. Bujold’s office is evaluating whether to “dismantle part or all” of its PCMH -- despite its apparent success. (The practice achieved an 80% reduction in hospital admissions and 5 years of bonuses from the Centers for Medicare & Medicaid Services Meaningful Use and Physician Quality Reporting System, he notes.)
PCMHs across the country are facing this same plight due to Medicaid value-based payment cuts, more self-pay patients (caused by rising insurance premiums), and the decline in hospitalized-patient visits (resulting from reduced hospitalizations). Yet payers are enjoying significant cost savings created by these value-based practices. As Dr. Bujold writes, commercial payers must invest in the system that benefits them, and coverage must be made affordable to patients. In an accompanying editorial, two recent CMS leaders support this view.
“Primary care delivered by a care team accountable for the quality of care of a population of patients requires sustainable funding to support staffing and other requisite infrastructure," write Laura L. Sessums, JD, MD, and Patrick H. Conway, MD, MSc.
They suggest that payers and practices could collaborate to change the payment and care delivery landscape in a state. (These statements are promising, especially given that on Oct. 1, Dr. Conway became president and CEO of Blue Cross Blue Shield of North Carolina.)
As CMO of Continuum Health and a practicing internal medicine physician, I could not agree more strongly. Value-based care is simply not economically sustainable without the progression to APMs.
With Continuum’s clients and within my own practice, I have seen the necessity of working closely with insurers toward our common goals of improving outcomes and lowering overall costs of care. It’s fine to start with per-member-per-month payments and/or shared savings incentives as an introduction to value-based care. But the physicians that “get it” and perform well must have the opportunity to earn more of the premium dollar if we want to recognize real value in the health care our patients receive.
To learn how Continuum Health can help your practice enhance care, earn value-based payments and move toward risk, please email firstname.lastname@example.org or call (856) 782-3300.
As Chief Medical Officer for Continuum, Dr. Renzi advises the Integrated Care Team as to the clinical effectiveness of advanced care coordination and practice transformation initiatives. He also provides guidance on programs involving patient-centered medical care, healthcare information technology and shared savings reimbursement models.A sought-after speaker and educator, Dr. Renzi presents at several conferences across the country annually.