Payment reform is already changing the primary care landscape, but public and private insurers are still exploring ways to pay for the intangibles in patient care.
Panelists at the Patient-Centered Primary Care Collaborative Fall Conference discuss changes in physician payment. They are (from left) Jill Rubin Hummel, J.D., president and general manager of Anthem Blue Cross Blue Shield of Connecticut; Robert Berenson, M.D., a fellow at the Urban Institute; Suzanne Delbanco, Ph.D., executive director of Catalyst for Payment Reform; Christine Bechtel, M.A., CEO of the Bechtel Health Advisory Group; and Laura Sessums, J.D., M.D., director of the division of advanced primary care for the Center for Medicare and Medicaid Innovation.
Panelists who discussed sustainable payment for high-performing primary care during the Patient-Centered Primary Care Collaborative(www.pcpcc.org) Fall Conference, held here Nov. 9-11, noted that new payment models are gradually shifting the balance of payments toward primary care.
"We are finally addressing primary care payment," said Robert Berenson, M.D., a fellow at the Urban Institute.
Berenson, a board-certified internist who practiced for 20 years and a former CMS official in charge of Medicare payment policy and private health plan contracting, recalled being paid for patient care on a capitation basis. At that time, there were no risk adjustments, no quality metrics and no exceptions under which treatment for specific patients could qualify for higher payment.
Berenson discussed how payment reform could reduce inefficiencies and address the total cost of care for patients. One target is referrals, which have increased 160 percent during the past decade.
"You could reduce office visits by 50 percent by having the right conversation with the patient's caregiver or a specialist that occurs before the office visit," Berenson said. "But we need a payment system that permits that."
- Panelists at the Patient-Centered Primary Care Collaborative Fall Conference said that although payment reform is already changing the primary care landscape, payers are still exploring ways to account for the intangibles in patient care.
- Payment reform could reduce inefficiencies and address the total cost of care for patients, said Robert Berenson, M.D., a fellow at the Urban Institute.
- One key is achieving greater transparency regarding what medical services cost, so physicians and the public can compare prices.
He also noted that although measuring resource use may be an important element of new payment models, doing so can be difficult for practices with small patient panels.
"Being in primary care is about relationships," Berenson said. "(But) we don't measure relationships. We measure processes."
Christie Bechtel, M.A., CEO of the Bechtel Health Advisory Group, said when patients are asked what they want from patient-centered care, they cite four expectations: whole-person care, care coordination, appropriate access and patient support tools.
In the transition to new payment models that reward efficiency, there is a gap between what patients understand about physician payment and what practices need to provide care.
"Patients get very nervous when you talk about incentives," Bechtel said. "They ask, 'Why does my doctor need to get paid incentives to perform care?' We have to be aware of that."
On the flip side, patients may not by aware of practices' continuing ties to a fee-for-service system or know that payment for care coordination is still emerging.
"Patients want their doctors to talk to each other, but they don't get paid to do that," Bechtel said.
Berenson cautioned that even if such physician-to-physician communication had its own billing code, the documentation required for billing might consume more time than the service is worth. It would be unwieldly to create a payment code for everything that occurs in a physician's office, he said.
Some new payment models include an initial care coordination fee, but physicians have expressed concern about payment when that fee is discontinued. Suzanne Delbanco, Ph.D., executive director of Catalyst for Payment Reform, said insurers consider the fee to be a temporary payment for infrastructure so practices can invest in health technology or care coordination. Insurers then want to transition to a shared savings model.
CMS continues to test new models for payment and care coordination through the Center for Medicare and Medicaid Innovation. Laura Sessums, J.D., M.D., director of the Division of Advanced Primary Care at CMS, acknowledged that the agency is still trying to determine the actual cost of comprehensive primary care.
"We have to pay more for primary care," Sessums said. "We are asking primary care to do more now, and we can't just pay the same way."
If CMS and private payers intend to grade primary care and other physicians on value, greater transparency regarding what medical services cost is essential so physicians and the public can compare prices.
"We can't tell patients what something costs," Sessums said. "That is a problem for everybody."
Giving physicians and patients a good way to compare costs would empower consumers, decrease costs and increase quality, concluded the Catalyst for Payment Reform's 2016 Report Card on State Price Transparency Laws.(catalyzepaymentreform.org)
"Sometimes doctors have less access to payment information than their patients," Bechtel said. "That is the information we need."
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