Solo and small-practice family physicians in rural America have expressed frustration that they are largely left out when it comes to experimenting with new payment models.
Donald Klitgaard, M.D., enjoys taking care of patients, but he recently gave up clinical practice to serve as chief medical officer of a national accountable care organization.
With fewer financial resources, small staffs and no bargaining power with payers, many of these independent-minded physicians know they're missing out on game-changing affiliations with accountable care organizations (ACOs).
Not so for Stephen Veit, M.D., of Cherokee, Iowa. He's been caring for patients in this town of 5,000 for 30 years -- first in a two-physician practice and then as a solo shop when his partner retired.
Veit is a charter member of the Heartland Rural Physician Alliance (HRPA),(www.Heartlandrpa.org) now in its third year and operating under a mission statement that pledges support to "independent-minded physicians, clinicians and practices in managing their own future, improving patient care and continuing to support their own communities."
"We (HRPA) have an interest in small family practice; we think it's a good model and we'd like it to succeed," said Veit, who also serves as HRPA's secretary and treasurer. "We were trying to find a way for small, independent rural practices to align to get the incentives to provide the rural care that is needed in Iowa."
- Solo and small-practice family physicians who have joined Iowa's Heartland Rural Physician Alliance have seen doors open to accountable care organization (ACO) opportunities.
- Many Iowa family physicians were interested in exploring team-based, coordinated patient care and new payment methods but lacked payer clout and connections to ACOs.
- Family physicians enjoy additional income, more choices when referring patients to subspecialists and facilities, and access to robust health information technology.
HRPA President and family physician Donald Klitgaard, M.D., of Harlan, Iowa, told AAFP News that there'd been much interest in the patient-centered medical home (PCMH) around the state in the past few years. Some practices proceeded with securing PCMH recognition from the National Committee for Quality Assurance, but many did not.
"There really weren't any payers in Iowa willing to pay differentially for PCMH recognition," said Klitgaard. "You can change a lot within a practice, but you do reach a point where it's difficult to make wholesale change when the payment system is still lagging behind."
Klitgaard said many practices around the state -- his included -- were engaged, interested and wanted to provide quality PCMH-type care but were hungry for support. The biggest private health insurance company in the state, for example, was not interested in changing its payment model to support the PCMH.
Into that atmosphere the physician alliance was born. "It was a grassroots attitude -- we needed to do something to change an environment," said Klitgaard.
Enter Medicare Shared Savings ACO
When HRPA had the opportunity to become part of a national Medicare shared savings ACO -- in conjunction with a Massachusetts-based group called Accountable Care Associates(www.acafirst.com) -- the physician alliance took the plunge. "Our initial core group of HRPA practices in Iowa became an Iowa subgroup of this larger national ACO," Klitgaard explained.
The ACO differs from the traditional model that usually is limited to one hospital system, one practice group or a defined geographic location. This ACO started with participants in eight states and now has grown to include people in 13 states, said Klitgaard.
"It was a way for primary care practices in Iowa -- especially the small independent groups -- to participate. Before, the only offers they were getting to be part of a meaningful ACO group was to become part of a bigger health system," he added.
Klitgaard said HRPA leadership wanted to get as many practices as possible into an ACO model "to learn and grow and figure out how they could participate and survive in this world of payment change but still stay independent."
The PCMH is at the center of it all. "You really need that solid, integrated, coordinated primary care to make an ACO work; if you don't have that, your ACO is probably not going to be successful in the long term," he said.
Two groups of Iowa practices are involved in the Medicare shared savings ACO, said Klitgaard. The first round signed on in 2013; the second group of practices just began ACO participation in January 2015.
It's not a hard sell because there's no risk, he added. "If you fall on your face and you don't save any money, you're not out anything other than your effort," said Klitgaard.
"So it's been an opportunity for physicians and practices to grow and learn and figure out how things like care coordination and quality metrics work in an outpatient clinic setting," he said.
Additional Opportunities Arise
Interestingly, the experience has served as a platform for other ACO opportunities. "Once you get a group of practices that come together and commit to better care and figuring out how ACOs work, then all of a sudden, other opportunities start to present themselves," said Klitgaard.
For instance, take the state's biggest commercial payer. "Individually, none of these practices would have gotten the time of day from that payer," Klitgaard said.
But within a year of working with the Medicare shared savings ACO, that insurer approached the physician alliance about creating an ACO. HRPA turned down the original offer, but it is negotiating with the insurer to beef up both data-sharing and physician payment in the offer, said Klitgaard.
Bottom line: "These small, rural primary care practices now have a way to participate in a ACO with multiple payers and to start to get paid differently for doing high-quality primary care," said Klitgaard.
George Kappos, M.D., a family physician in rural Iowa, likes solo practice because he can take as much time as he needs with each and every patient.
Physicians See Benefits
Veit is one of those FPs who will see a check from the federal government for generating savings by coordinating patient care. He wouldn't speculate on how much would receive but said, "I would expect there will be a check that makes it all worth my time."
Veit is happy with the way he's able to practice now that he's part of a larger community of physicians. "I really like the flexibility; I can choose hospitals and (sub)specialists that are favorable for my patients in terms of their history and geography and their preferences. If their insurance covers it, we can coordinate that care, and I find that to be an incredible advantage to this form of an ACO," he said.
George Kappos, M.D., a solo family physician in Polk City, Iowa -- population: 5,000 -- hasn't been in the ACO long enough to earn a check, but still, he's happy with his choice. In fact, Kappos joined the alliance primarily to gain access to the ACO. He now serves on the HRPA Board of Directors.
"Solo physicians need to find affiliations with other doctors so they'll have more connections and more pull," said Kappos.
He also appreciates having access to a robust health claims data system that allows the national ACO to collect data and then present those data to physicians in a useable and actionable form. The technology also keeps physicians on task following ACO quality metrics.
With just two staff members -- a full-time certified medical assistant and a part-time receptionist -- the time saved on data retrieval is important to Kappos.
This family physician returned to independent practice after a 10-year stint with a large hospital system. He's hoping that HRPA and its ties to the national ACO will offer enough support to allow him to stay independent.
"Solo practice is smaller and more personal. I know my patients better, and I can take the time I want with them," said Kappos.
As for Klitgaard, he recently -- and reluctantly -- gave up patient care to assume the role of chief medical officer for Accountable Care Associates. "Big picture, this is about empowering family physicians to realize the power they have in this world," said Klitgaard.
Related AAFP News Coverage
Proposed CMS Rule on ACOs Draws Sharp Response From AAFP
More From AAFP
The Patient-Centered Medical Home