Colorado Medical Society

Colorado payment reform: Primary care physician’s perspective

Thursday, March 01, 2012 12:26 PM

Marilyn Rissmiller, Senior Director, Health Care Financing

Alan Aboaf, MD, is a primary care internist practicing in a three-physician and one-physician assistant group in Aurora and Parker. Colorado Medicine shared the health plan payment reform grid from pages 20-23 and asked him to respond to the following questions:

Q. What do you think of the payer payment reform initiatives?
A. I’m always cautious about what exactly is involved and what those implications are for my practice. I’m suspicious sometimes because these programs are frequently geared toward costs, and not necessarily toward the quality care the patient needs. The physician can’t act on some of the things being measured as they are developed based solely on claims data and not the actual care delivered to the patient. Payers don’t come to your office to verify what you actually did, but rather base their decision on only the claims data they received. Even if you have the data in the chart, you may not get credit if the reviewer can’t find it. Many of these programs don’t even allow an appeal process if you disagree or have proof that the information you receive was inaccurate.

Q. Are you currently participating in one of these programs?
A. I am currently participating in Anthem’s AQI program, which is geared to large groups. It may be difficult for smaller groups or individual physicians to have the incentives apply since they just don’t have the numbers.

For other primary care physicians (PCPs), they may not participate because they don’t know about the program or they ignored the mailings. The insurance companies should set the bars at achievable levels and make it easy to enroll.

Q. What will it take for you to successfully participate in these programs?
A. These initiatives use the typical measures that PCPs are familiar with to evaluate performance. These performance measures are not a barrier for us and are really the right thing to deliver quality patient care. The programs need to be better tailored for small practices. The initiatives are really for large multi-specialty groups, not for individuals. In addition, the incentives need to be substantial to justify the efforts and additional work required.

Q. What is your perception of your colleagues’ ability to do this now?
A. I think docs in general have the right skills to do this and they want to do it because it’s the right thing for patients. The incentives are not geared to small groups.

The biggest barrier is the infrastructure; specifically, health information systems – and many folks just don’t have that. The electronic health record (EHR) helps with improving the infrastructure. It would be helpful if the insurance company would provide you with an accurate list of individuals who haven’t had tests performed and if they have sent them reminders.
EHRs would make this easier to achieve, as you would be able to generate your own reports/lists of measures that certain patients haven’t had and be able to contact them easily. The paper record is not conducive to doing this. There are significant upfront costs that self-employed physicians have to pony up to make EHRs a reality. The government incentives in the Affordable Care Act are helpful, but the cash outlay upfront is the sole responsibility of the physician.

Q. What advice would you give to physicians in terms of what they can do?
A. There is a significant variance on what/how docs do things. Part of the problem is that the payment system doesn’t encourage change. The current fee-for-service system is a “churning system.” It has to change and become a value-based system. The younger docs are going to drive the way things get done. It’s easy if you’re older to stay on the sidelines and pretend it doesn’t exist since you’ll likely retire in the very near future. But if you’re not or can’t, then you need to understand how these systems are going to affect your practice and how you will adapt to them. You can pretend it is going to go away, but the earlier you get on board and adapt, the better off you will be in the future.

Small changes are easy to make, such as electronic prescribing via free software and the Physician Quality Reporting System (PQRS) reporting on Medicare patients through your billing systems. By doing these you get incentives and avoid penalties. The next step is evaluating and identifying EHR products that will work for your particular type of practice. After that is the big plunge into an EHR and learning to use it. That takes months.

It is also important to work and collaborate with other providers and affiliate with other PCPs or specialists such as IPAs and/or physician/hospital organizations. Remaining completely solo and unaffiliated is unlikely to be beneficial in the long run.