William Golden, M.D., medical director for Arkansas Medicaid, discusses how primary care practices are adjusting to new payment models during a recent national summit that focused on the Medicare Access and CHIP Reauthorization Act.
Transforming the way physicians are paid was never billed as an easy task, yet according to one state Medicaid official, many primary care practices in Arkansas have already completed the difficult steps of changing how they deliver care.
During an event held here Nov. 30-Dec. 2 that focused on new payment models established by the Medicare Access and CHIP Reauthorization Act (MACRA), William Golden, M.D., medical director for Arkansas' Medicaid program, emphasized that physician practices participating in alternative payment models (APMs) need to move away from viewing a successful day as one filled with appointments maintained via a "bare bones operation."
Speaking as part of the National MACRA MIPS (Merit-based Payment Systems)/APM Summit,(www.macrasummit.com) Golden discussed how practices in Arkansas are using prospective payments to change how they operate.
- Thanks to a statewide initiative, primary care practices in Arkansas are using prospective payments to change their operations.
- According to one expert, real practice transformation is only possible if multiple insurers in a state or coverage area change their payment methodology.
- Health officials continue to debate issues such as how much risk a practice should assume when it moves to an alternative payment model.
Such payments allow practices to handle more telemedicine visits, telephone calls and email correspondence with patients or even to hire more staff. There is a trade-off, however, said Golden.
"Prospective payments are not new money," he said. "It is an investment, and we expect something back in return. In a way, it is a risk-based payment."
Cutting Administrative Burden Through Practice Transformation
Increasingly, health policymakers and other officials are aware of the demands on physicians' time when it comes to maintaining patient records and billing. In the fee-for-service model, physicians are devoting two hours of time to administrative tasks for every hour they spend on patient care, according to Golden.
To address the problem in Arkansas, the state made a transition to value-based payment with the launch of the Health Care Payment Improvement Initiative,(www.paymentinitiative.org) and several family physicians began changing their care protocols for both acute care episodes and the type of continuing care provided in the medical home.
The initiative is a partnership of Arkansas Medicaid, the Arkansas Department of Human Services, Arkansas Blue Cross and Blue Shield, and QualChoice of Arkansas that is intended to transform the state's health care and payment system.
One lesson learned early on, said Golden, was that relying solely on claims information to assign patients to a practice meant, in many cases, that the volume of patients matched to that practice was too low. Some patients visited a practice for years but did not appear on the panel. By also gathering data on specific clinical metrics, payers were able to get a much more accurate picture of provider participation, as well as gauge the quality and cost of that care to determine potential shared savings.
The estimated 780 primary care physicians who are participating in the initiative collectively provide coverage for 309,000 Medicaid patients, which represents 80 percent of the state's Medicaid-eligible residents. Many participating practices are also enrolled in the Comprehensive Primary Care initiative managed by Medicare.
According to Golden, real practice transformation is only possible if multiple insurers in a state or coverage area change their payment methodology. In Arkansas, several private insurers agreed to participate in the Medicaid initiative, and state Medicaid officials encouraged practices to focus on chronic care and care coordination, follow-up telephone calls, substance abuse needs, and increased patient satisfaction. Less emphasis was placed on such basic tasks as testing for hemoglobin A1c levels.
Expanded access for patients is an essential step, so Medicaid offered the practices $5 per member, per month payments to set up a 24/7 live answering service, which Golden said was sufficient to launch the service. State officials verified participation by calling the practices at night to verify that a live voice was available after hours.
The majority of practices complied, said Golden, with only about a dozen failing to do so. "That is a major transformation in the patient experience, and it can improve outcomes," he explained.
Some Pieces Yet to Fall Into Place
One part of the transformation that has not yet been realized, said Golden, is apparent in the feedback he hears from physicians who say that the monthly payment is merely passed on to electronic health record (EHR) companies for uploading data and to cover other fees. He predicted that will change within the next three years, however, when the Office of the National Coordinator for Health Information Technology completes a data-sharing network that will be managed much like a state utility. No longer will practices have to purchase data for a fee from their EHR vendor, Golden explained, they will simply extract it from a network.
"Increasingly, the payers realize that primary care practices need data," Golden said.
Among other unresolved issues with payment transformation is how to handle patients who are covered by high-deductible plans, he said. One possible solution would be to exempt more primary care services from the deductible.
Golden also acknowledged that health officials continue to debate how much risk a practice should assume when it moves to an APM. A rural practice with 150 patients, for example, can't be expected to take insurance risk if a patient contracts a rare disease or has chronic care needs, he noted.
Teaming Up for Success
One Arkansas practice, SAMA HealthCare Services in El Dorado, transformed its entire operation(www.achi.net) by pairing each physician with a nurse practitioner (NP), along with other nursing personnel and care coordinators, and assigning color-coded uniforms for each team. NPs consult with their team's physician daily about their patient panel so the patient knows during an office visit that the nurse is part of a physician-led team.
Patient access has been vastly improved, and more visits are recorded each day. Rarely now is a patient turned away when requesting a same-day appointment, said Golden. Moreover, satisfaction among physicians and other care providers and staff has improved. So much so, in fact, that staff members from other medical institutions began calling the practice seeking employment, he added.
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