March 4th, 2019
Recently, the director of the Center for Medicare and Medicaid Innovation, Adam Boehler, announced an incoming new voluntary value-based payment model in primary care, centered around telehealth and online consultations. This idea could be beneficial for both doctors and patients, however the details of this model have yet to be announced, and there are some key questions that need to be answered before primary care doctors will want to jump on board.
We’ve written many times about efforts to switch from fee-for-service payments to value-based payments. Paying doctors based on patient outcomes rather than per service provided would ostensibly reward doctors for doing better rather than doing more. CMMI should be commended for creating more value-based payment models that can help keep patients healthier and reduce overuse.
One way primary care doctors can increase patient engagement and keep their patients healthier is by meeting patients where they are. Patients may have trouble accessing their primary care clinician, if their only option is to meet them during weekday office hours. This can drive patients to urgent care clinics or even the emergency department, where prices are much steeper and the clinicians have little opportunity to develop long-term relationships with patients.
As Dr. Victor Montori and others have pointed out, expecting patients to travel to the doctor for each appointment can put a significant burden on patients if they have to take time off work or secure child care for multiple visits. Having primary clinicians available for phone or video consultations outside of daytime and weekday hours has the potential to improve doctor-patient relationships. Paying doctors for virtual visits rewards doctors that already make themselves available, and provides an incentive for other doctors to follow their lead.
While this new payment model has the potential for benefit, there are reasons to be skeptical. Previous value-based payment models have hit numerous obstacles, such as exacerbating providers’ administrative burden and punishing providers that serve higher-risk populations.
Before we embrace the CMMI model, there are some key questions that need answering:
Will the reimbursements for primary care doctors make the program worth their time? Primary care doctors are under an increasing administrative burden. Some doctors may want to be available for patients after office hours, but find themselves already out of time and energy. Any new model expecting primary care doctors to dedicate more of their time to patients should make sure they are reimbursed enough so they do not have to take on more patients than they can successfully manage.
Many doctors find current incentive programs too burdensome already. “The requirements of the Maryland PCP program are so onerous that most practices (including mine) have to hire extra staff just to manage it, to rigidly follow the program rules (which are ill-defined) or risk losing much of the incentive money, and to have incessant meetings and generate copious reports every week,” said Andy Lazris, a primary care doctor in Columbia, MD.
Another crucial problem with paying doctors based on patient outcomes is that, without accurate risk adjustment, doctors who care for high-risk patients will be penalized. If the program is revenue-neutral, this makes it even more likely that small practices with poorer and sicker patients will be penalized, because some doctors would have to lose money, and larger practices often have more resources and healthier patients. Clinicians should be assured that they will not be risking their financial health just because they see more low-income patients or patients with more chronic conditions.
What would a successful primary care incentive program look like? Lazris has a vision for a program that could truly improve comprehensive care. First, the program has to commit to investing money in primary care (not be revenue neutral) with the goal of increasing primary care provider pay. Second, the program should avoid unproven quality indicators, excessive regulations, or difficult rules. Third, the program should give practices flexibility to provide care outside of the office in the way that doctors deem best for their patients, not just in ways mandated by the program.
Overall, a successful program would be based more around the Direct Primary Care model, where doctors are paid a monthly fee directly by patients instead of being paid fee-for-service by insurers. Because providers are not paid to see patients in person, they can rely more on telemedicine for patients when they are healthy, while giving other patients home visits and longer office visits when necessary. However, it will be difficult for CMMI to replicate this success if they do not invest the necessary resources in primary care.
“Unless the primary care provider can determine how best to care for patients and is given the power and money to do this, this program, like so many others like it, will fizzle very quickly,” says Lazris.