Physicians lead on new payment models

Physicians across a number of specialties are taking the lead to test developing new payment and delivery models. A few of them described their projects at a Brookings Institution forum on physician payment reform.

The need for new payment models is well known and understood in the physician community. The current fee-for-service system (FFS) is unsatisfactory, both from a payment perspective and quality of care perspective, and it is getting in the way of accelerating new payment and care delivery models, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform at the forum held in the middle of November.

Adoption of new payment models is fundamental to bipartisan congressional proposals to repeal the sustainable growth rate (SGR) formula for determining Medicare physician payment. “If these models were implemented, they would more than pay for the offsets of $150 billion over 10 years needed to pay for the SGR,” said Miller.

Without a way to pay for SGR repeal, Medicare cuts of 24 percent to physician reimbursements will take effect in January.   

What passes as payment reform currently are top-down approaches that are difficult to implement because physicians don’t know which patients they are accountable for, what measures they are expected to meet until after the fact, and are rewarded with small bonus payments on top of the FFS system, he said.

If physicians had more support, their efforts at advancing new payment and delivery models would accelerate, Miller said.

But even without that extra support, some physicians are making strides, such as the oncology patient-centered medical home at John Sprandio’s practice, Consultants in Medical Oncology and Hematology.

With incremental changes across its four sites and 10 physicians, the group was able to improve resource utilization, reduce emergency room visits and admissions per chemo patient per year, and increased hospice length of stay.

“We got better at executing survivorship care plans, and we had better coordination working with primary care physicians and other treating specialists,” he said. The program has been recognized by the National Committee on Quality Assurance (NCQA).

Tom Lewandowski’s Wisconsin-based practice implemented a model called Smart Care for angioplasty patients. His group examined the significant variation in heart attack care and the wide use of angioplasty and found that cardiologists and primary care specialties each accounted for 4.7 percent of total spend in cardiovascular medicine. However, 50 percent of imaging studies that start the cardiovascular process toward angioplasty were ordered by the primary care providers but attributed to the cardiologists who read and billed for them.

If other practices were to implement Smart Care, a program that tracks patients through the care process and provides decision tools at each step along the way, there is the “potential of decreasing the stress studies, the diagnostic catheterizations, and angioplasties down to about 40 percent from their current levels, amounting to billions of dollars across the country on a yearly basis,” said Lewandowski, who is governor of the Wisconsin branch of the American College of Cardiology.