The ACP Advocate Blog

by Bob Doherty

Tuesday, October 4, 2011

Primary care physicians don’t have to be treated like Rodney Dangerfield

Like Rodney Dangerfield, primary care physicians say that they can’t get no respect.

As evidence, they note that they get paid little or nothing for all of the work they do outside an office visit. They complain that Medicare and other payers dangle a small amount of “token” money in poorly-constructed pay-for-performance schemes, that different payers use different measures to judge their performance, that they are being asked—and sometimes required—to invest in “practice transformation” and expensive health information technologies with little or no financial support from payers. They complain that they can’t afford to spend more time with their patients, because they have to see as many patients as they can per hour just to make ends meet. And many believe that government agencies don’t listen to their ideas to improve payments and delivery systems.

And they desperately want someone to step up and say that what they do has great value-- and to pay them appropriately for it.

As I have blogged many times before, their complaints have merit: primary care physicians are over-worked, under-appreciated, over-managed, and under-paid (at least relative to other specialists).

But why then, when someone offers to do just what asked for—recognize that what they do has great value, and pay them appropriately more for it--the first reaction of some primary care doctors is to say no? Especially if it involves them doing things differently in return for higher pay?

You could see this reaction in some of the comments to last week’s post about Medicare’s Comprehensive Primary Care Initiative. Predictions that it would “fail” or that physicians were being “lied to” or that “if you think that Comprehensive Primary Care Initiative will result in greater pay to the Internist I have a nice bridge in Brooklyn you might like to buy.” I am not picking on those of you who made those comments—as always I am glad that you expressed your opinions, and there is no doubt in my mind that many of your colleagues would agree with your comments. And you deserve a response—the reason for this post.

But in this case, I think the cynics are wrong, and I hope that most primary care physicians keep an open mind about the Comprehensive Primary Initiative. Mainly because it addresses just about every one of the complaints from primary care physicians about lack of respect that I described in the second paragraph.

Pay primary care doctors for the work they do outside the office visit? Yep, it does this, through a risk-adjusted average of $20 per patient per month from Medicare, in addition to their usual Medicare fee-for-service payments. (And their FFS payments will continue to include the Medicare 10% primary care incentive payment that already is law because of the Affordable Care Act.) And no, their FFS payments will not be discounted or lowered to offset the PPPM payments.

Stop paying “token” amounts for poorly-constructed P4P schemes? $20 PPPM is hardly “token” money, and it could be much more if private payers and Medicaid join with Medicare to participate in the Comprehensive Primary Care Initiative. And this isn’t the kind of P4P program that pays practices after the fact for reporting successfully on an a la carte basis for a bunch of process and outcomes measure. Instead, it is a prospective payment program—the practices get the money upfront, on a monthly basis, and can get even more from shared savings.

Different measures from different payers? The program will require that participating payers agree to use standardized and established measures.

Being required to invest in health information technology and practice transformation with no financial support from payers? The Comprehensive Primary Care Initiative is unique in that it is predicated on the idea that all payers have to help pay for practice transformation and information technology systems. This is how CMS describes it:

“Without a significant enough investment across multiple payers, independent health plans-- covering only their own members and offering support only for their segment of the total practice population—cannot provide enough resources to transform entire primary care practices.”

Not having enough time to spend with patients? By providing a substantial revenue stream in addition to fee-for-service, physicians would have the option of spending more time with patients who really need it, rather than just seeing more patients to generate enough volume to keep the doors open.

Government agencies don’t listen to physicians’ ideas to improve payments and delivery systems? Well, in this case, this is not a top-down government program, but one that came up from the physician community. The Patient-Centered Medical Homes concept was designed by physicians, for physicians and their patients. It was ACP, the American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association that in 2007 developed the guiding joint principles on PCMHs that CMS is now offering to support with real money. The payment model that CMS decided to use is the same as that recommended by ACP: risk-adjusted care coordination plus fee-for-service plus shared savings. ACP, not the government, developed the PCMH-Neighborhood concept that is a key part of the new CMS program.

And as I said earlier, primary care physicians desperately want someone to step up and say that what they do has value and to pay them appropriately for it. My admittedly back-of-the-envelope calculation is that Medicare’s Comprehensive Primary Care Initiative would pay a participating practice with 800 Medicare patients $192,000 more in the first year (800 patients x $20 average PPPM x 12 months), the same in the second year, and $144,000 per year in the third and fourth years, when the average PPPM drops to $15—but they can potentially earn more than that in the third and fourth years when the shared savings component kicks. But they will also get more revenue from non-Medicare payers, because in order for the program to be launched in a particular locality, other payers will have to join with Medicare to pay more for the participating primary care practices. One expert I know who has hands-on knowledge of the Comprehensive Primary Care Initiative estimates that practices could see a 30 to 50% increase in total practice revenue.

Sure, it is not a free ride for practices. To be selected and qualify for the higher payments, they will have to have a plan to manage high risk patients effectively, ensure access to care through such things as open scheduling, deliver preventive care, engage patients and caregivers, coordinate care with other specialists, have a certified EHR, and be able to report on measures on each of these domains. But aren’t these exactly the kinds of things that good primary care physicians and practices should be doing anyway? But instead of doing it for today’s low payment rates, the Comprehensive Primary Care Initiative recognizes that what they do for patients (patient-centered care) has value and will pay them appropriately more for it.

None of this guarantees that the program will succeed, of course. But it has enormous potential to provide very substantial revenue support from multiple payers to the 500 or so primary care practices nationwide serving over 300,000 Medicare patients that will lucky enough to be in one of the 5-7 regions selected by CMS. It could become the way forward for primary care physicians, at least those that are willing to embrace change themselves. And maybe, just maybe, they will stop seeing themselves as the Rodney Dangerfield’s of American medicine.

Today’s question: Will primary care practices seize the opportunity offered to them by the Comprehensive Primary Care Initiative to be paid appropriately more for their services if they can demonstrate that they provide patient-centered care—or cynically reject it?

2 Comments :

Blogger DrJHO7 said...

Physicians who practice medical specialties whose job descriptions include "primary care" lost their respect within the greater medical profession a long time ago when they allowed themselves to be labeled as "primary care providers", rather than physicians. It's not a financial thing, it's a cultural thing, but you get what you get when you're at the bottom of the ravine and "it" rolls downhill.

This having been said, the government's suggestions about how to enliven "primary care" are interesting and heartening because they start to bark at the root of the problem which is: a healthy and high functioning medical system is based on a foundation of access of patients to physicians who are willing to assume the primary medical care role and do it well, utilizing in-house and shared community resources, emphasizing the importance of the physician-patient relationship and the absolute necessity of physican colleagues working together on behalf of patients in a setting of limited and precious clinical and financial resources.

The financial support that is proposed will be essential although I think Bob's estimates of increases of revenue to practices are a bit rosey. Effective patient-centered care, and resultant savings coming primarily from decreased utilization of expensive inpatient and redundant/unnecessary outpatient care will result in some savings to the system. The reinvestment of these savings will be primarily to cover the new costs of non-physician personnel associated with more intensive "care-supervision" that will be performed by these staff necessary to assure that such cost savings occur.

Patient outcomes should improve, as should the effectiveness of the performance of community medical systems in general, and this is great. However, I suspect that the majority of extra funds that flow into medical practices will flow to non-physician personnel and the cost of HR and IT processes that are not currently happening. The work day of the primary care physician may be somewhat different, hopefully better, with less administrative hassle, and more appropriate utilization of their talents and time, but I am not foolish enough to expect a wind-fall for those that will bear the responsibility of the the system's success. Strong medical leadership will be essential for success.

October 5, 2011 at 1:11 AM  
Blogger DrJHO7 said...

Physicians who practice medical specialties whose job descriptions include "primary care" lost their respect within the greater medical profession a long time ago when they allowed themselves to be labeled as "primary care providers", rather than as physicians. It's not just a financial thing, it's a cultural thing, but you get what you get when you're at the bottom of the ravine and "it" rolls downhill.

This having been said, the government's suggestions about how to enliven "primary care" are interesting and heartening because they start to bark at the root of the problem which is: a healthy and high functioning medical system is based on a foundation of access of patients to physicians who are willing to assume the primary medical care role and do it well, utilizing in-house and shared community resources, emphasizing the importance of the physician-patient relationship and the absolute necessity of physican colleagues working together on behalf of patients in a setting of limited and precious clinical and financial resources.

The financial support that is proposed will be essential although I think Bob's estimates of increases of revenue to practices are a bit rosey. Effective patient-centered care, and resultant savings coming primarily from decreased utilization of expensive inpatient and redundant/unnecessary outpatient care, will result in some savings to the system. The reinvestment of these savings will be primarily to cover the new costs of non-physician personnel associated with more intensive "care-supervision" that will be performed by these staff necessary to assure that such cost savings occur.

Patient outcomes should improve, as should the effectiveness of the performance of community medical systems in general, and this is great. However, I suspect that the majority of extra funds that flow into medical practices will flow to non-physician personnel and the cost of HR and IT processes that are not currently happening. The work day of the primary care physician may be somewhat different, hopefully better, with less administrative hassle, and more appropriate utilization of their talents and time, but I am not foolish enough to expect a wind-fall for those that will bear the responsibility of the the system's success. Strong medical leadership will be essential for success, for sure.

October 5, 2011 at 1:21 AM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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