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Family Docs Embracing Value-Based Care Despite Skepticism

News  |  By MedPage Today  
   December 01, 2017

Nearly half pursuing value-based payment arrangements, small survey says

This article first appeared November 29, 2017 on Medpage Today.

By Joyce Frieden

WASHINGTON -- More family physicians are incorporating value-based payments into their practices, but they are still skeptical about whether it really works, a small survey found.

Nearly half of the 386 family physician respondents this year -- 47% -- said they were pursuing opportunities for value-based payment, which is generally defined as payment based on the quality and outcome of care, rather than on the volume of services provided. That percentage was up slightly from 44% in 2015, according to the survey, which was sponsored by health insurer Humana and conducted by the American Academy of Family Physicians (AAFP). However, 62% of respondents -- the same as in 2015 -- agreed that one barrier to implementing value-based payment was "a lack of evidence that using performance measures results in better patient care."

"Physicians are a skeptical bunch, and very skeptical of change," said Amy Mullins, MD, medical director for quality improvement at the AAFP, said at a briefing Wednesday morning. "It took 15 years for doctors to be convinced to give a patient an aspirin when they walked into the emergency room with chest pain ... To change the way someone's going to get paid, that's a bigger context than saying, 'Hey, take this aspirin.' But even though a lot of them are skeptical ... more of them are moving in that direction."

Other barriers to implementing value-based care contracts included a lack of uniform performance reports from payers, a lack of standardized performance measures, and the unpredictability of the revenue stream. That last item, although the percentage of physicians citing it dropped from 81% in 2015 to 76% today, is still seen as a "huge barrier," Mullins said.

In addition, "We need real-time data exchange," said Mullins. "The data we get is not actionable -- it's 6 months old, given to us in forms we can't interpret, and 10 payers send it in multiple ways we don't have time to sort through. So we need real-time data that is standardized in a consumable way for very busy physicians."

Lack of interoperability between electronic health records systems also continues to be a problem for physicians who are switching to more value-based payments, the panelists agreed. "I don't know if there's a light at the end of the tunnel on that, or not," said Mullins. "We have to have cooperation from a lot of different players to make that happen, but if we can get it to happen, it would be great."

The survey showed an increase in the percentage of physicians whose revenues from value-based contracts were shared directly with them based on quality measures rather than funneled through the practice's administration -- from 18% in 2015 to 37% in 2017.

"That's the biggest positive change -- the idea that value-based payments are trickling down to front-line doctors," said Jeff Micklos, JD, executive director of the Health Care Transformation Task Force, a coalition of patient, payer, provider, and purchaser organizations in support of the change to value-based reimbursement. "Without that financial incentive, it's hard to convince a medical professional to see a sustainable business model there."

Other survey results were also positive for VBP, Mullins said. For example, the percentage of respondents who said they were "not at all familiar" with value-based payment dropped from 12% to 7%, and those who said they were holding off on making changes to their payment models declined from 22% to 19%.

In addition, while the percentage of those updating or adding to their health information technology held steady at 54%, more respondents said their practices had hired or were hiring care management coordinators (43% in 2017 versus 33% in 2015), and those making no changes dropped from 26% to 14%. "So physicans are moving; they making the changes they need [make] to be successful in VBP," said Mullins.

One issue that had surfaced earlier in the transition to value-based payment -- the reluctance of physicians to take on sicker, more complex patients for fear that they would ruin the practice's outcomes -- doesn't really appear to be a concern any more, said Roy Beveridge, MD, senior vice president and chief medical officer at Humana. "Given that today we've got fairly sophisticated risk adjustments, there's no disincentive I've seen in terms of [physicians treating] complex patients, because the more complex the patient, the higher their risk score is and the more they get reimbursed. I don't see any issues with that."

And the recently released Medicare Access and CHIP Reauthorization Act (MACRA) rule also has a complex patient bonus built into it, noted Mullins. "That was just a 1-year provision; hopefully it will continue. People are starting to see that taking care of complex patients is hard. I wouldn't see people dumping their complex patients, but there are some plans that are building in bonus points for taking care of patients that are really complex."

The survey data came from a randomly selected sample of 5,000 active AAFP members in September; respondents could complete the survey either in print or online. The sample base for the survey underrepresented female physicians and newer physicians compared to the entire population of AAFP members, the academy noted.


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