National MACRA Summit

Incentive Payment Designs Need Fine-tuning, Say Panelists

December 19, 2016 01:45 pm Michael Laff Washington, D.C. –

The Medicare Access and CHIP Reauthorization Act (MACRA) is ushering in physician payment reform, but specific payment model designs still need some revision, according to physicians who spoke at a recent conference.

Grace Emerson Terrell, M.D., former CEO of Cornerstone Health Care, (left) discusses incentive payments during a panel discussion moderated by Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, at a recent national summit on the Medicare Access and CHIP Reauthorization Act.

Panelists in a session devoted to payment at the National MACRA MIPS (Merit-based Payment Systems)/APM (alternative payment model) Summit,(macrasummit.com) held here Nov. 30-Dec. 2, noted that existing payment methods do not yet account for all that physicians and staff do for patients. Payment design needs to incorporate the full range of services while also accounting for data sharing and integrated care, they said.

New incentive payments are leading some physician practices to venture out of their comfort zone and change their operations. But while both physicians and insurers want to improve the payment system, some roadblocks remain.

Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform and moderator of the payment discussion, asked the panelists why more physician practices are not adopting new payment models.

Story Highlights
  • Panelists at a national summit said payment design needs to incorporate the full range of services while also accounting for data sharing and integrated care.
  • Prospective monthly payments are encouraging some shift from office visits, but a gap remains between what insurers will pay for and what practices do each day.
  • New payment models come with the expectation that physicians and hospitals will share data and agree on shared risk with insurers.

"Day to day they are tied up taking care of patients," said Grace Emerson Terrell, M.D., former CEO of Cornerstone Health Care. "To sit down and think about EMRs (electronic medical records) and MIPS … for many physicians the level of complexity is overwhelming, and the payment systems are slow to respond."

Physicians need strong office management to handle the new demands of record keeping and performance measurements. Practices that created teams often employ daily "huddles," but time limitations pose a problem to smaller practices.

"A lot of practices don't have time to stop and think about how they do what they do," said Barbara McAneny, M.D., former chair of the AMA.

Physicians are skeptical about how new payment models will account for the time spent interacting with patients that is not paid for directly by insurers. Although prospective monthly payments are encouraging some shift from office visits, a gap remains between what insurers will pay for and what practices do each day.

"All payments hinge on face-to-face meetings," McAneny said. "Nobody is paying us for the time spent by nurses who are talking all day with patients on the phone. The expense side of the ledger is still on us, and the revenue accrues to the payer."

Introduction of new standards does not mean that physicians should take on every new administrative task themselves. Stephen Zabinski, M.D., director of orthopedic surgery at Shore Medical Center in New Jersey, told the audience that he delegated an employee to handle MIPS standards.

Some incentives reward coordinated care, which sometimes requires physicians to use resources other than new technology such as electronic health records (EHRs). McAneny said physicians searching through EHRs for vital patient information sometimes can't find it among all the extra data.

"You're searching for that one needle in a haystack," she said about EHRs. "It's more efficient to pick up the phone and talk to somebody."

With new payment models comes the expectation that physicians and hospitals will share data and agree on shared risk with insurers. Such interaction represents a sea change from the current environment where physicians, hospitals and insurers often view each other with suspicion.

Miller asked the panel whether practices have to get bigger if they are expected to manage more diverse care for patients. McAneny responded that practices need to be like "speed boats," not "battleships," each making quick adjustments to its population's changing health needs.

Terrell also dismissed the notion that practices have to get bigger. She cited gas stations as an example of integrated service. In the past drivers would fill up with gas while an attendant checked under the hood. Today, consumers want a place where they can fill up the car, purchase convenience items and use the restroom. Everything a driver needs is available in a single site, and the facility's size is not relevant.

In the medical field, integration means addressing physician health, mental health, substance abuse and social determinants in a single location.

"It's not about bigness," Terrell said. "We need to design around need and integration. That is the way we need to think about it."


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