John Campanelli

	About five years ago, Tom Davis, MD, started suffering occasional vestibular migraines. Sometimes he felt unstable on his feet, but most concerning of all: He began losing his hearing. 

	But in July 2016, Davis experienced complete hearing loss. “I was sitting out on my front porch during a rainstorm, and I wasn’t able to hear the water falling,” he remembers. “That’s when I said, ‘If I can’t hear the water falling, I certainly can’t represent myself to my patients as a full-service clinician.’”

The definitive guide to patient engagement

	Davis says he is sharing his story not to highlight his problems but to show how fortunate he is to have long-term disability (LTD) insurance.

	LTD insurance is coverage that replaces a portion of a physician’s income should he or she become unable to work because of illness or injury. It begins paying benefits after a set length of time, called an “elimination period,” usually 90 days, during which short-term disability coverage may apply.

	Securing LTD coverage can be complicated, confusing and expensive. But insurance experts, advisers and physicians who’ve suffered injury or illness all agree: Doctors need it.

	A 2014 survey by the American Medical Association revealed that roughly 75% of doctors had a long-term disability insurance policy. That number should be 100%, Davis says, especially in light of disability statistics.

	According to the Social Security Administration, about a quarter of today’s 20-year-olds will become disabled before they turn 67. It’s a sobering fact that many young adults, including young doctors, simply ignore. “They think they’re exempt, that it’s not going to happen to them,” says Marc Feiner, MD, a retired OB/GYN. “Your health is something you can’t gamble with.” 

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	Feiner should know: He spent the years from age 61 to age 65 on disability after his psoriatic arthritis became so bad he could no longer do surgeries and deliveries. Without the insurance benefits, he says he would have been forced to pull money from his retirement account. 

	“What would have happened if I had not had the disability insurance? I would’ve been screwed,” he says.

	Davis says uninsured and underinsured physicians need to start viewing themselves as a valuable asset. 

	“If you don’t have disability insurance, it’s like having a million dollars and just leaving it out on your front lawn,” he says. “You can hope nothing happens to it, or you can invest $300 and buy a safe.”

	Unlike a safe, however, LTD insurance is a complex financial product that experts say should be customized for each physician depending on specialty, age, gender, medical history and financial situation.

	Here’s what physicians need to know about long-term disability insurance and how to get the right coverage and policy.

5 ways to increase the value of a medical practice

	Physicians have unique jobs and have high incomes, so when it comes to individual insurance policies only a half-dozen companies offer LTD insurance to doctors: Ameritas, Berkshire/Guardian, Mass Mutual, Ohio National Financial Services, Principal and The Standard. 

	Policies can be purchased from independent insurance brokers or “captive” agents, those working with only one of the big six.

	Independent brokers are able to offer more options and more plans because they don’t favor one company over another, says Stephanie Pearson, MD, FACOG, who became an insurance adviser to physicians and an independent agent after an on-the-job injury ended her career as an OB/GYN.

	She acknowledges that some captive agents may be able to offer discounts to which independent agents don’t have access. “I think that there are some really solid captive agents out there who know their product, and it’s great,” Pearson says. “But if you don’t know what your other options are, you can’t really make an educated, informed decision.”

	As for when to buy coverage, the consensus is the earlier the better. LTD insurance, like life insurance, is cheaper at a younger age. Insurance companies often offer discounted policies-sometimes without medical underwriting requirements-to residents.

	A young doctor may also find it easier to secure LTD insurance before age-related  medical issues (chronic back pain, for example) can jeopardize coverage. Preexisting conditions may torpedo a doctor’s chances for a policy during the underwriting process.

	Davis advises physicians to start LTD coverage with their first paycheck. “Paying right out of the gate, you never miss the money,” he says. “Premiums [for my wife and I] were eventually about $900 a month, and that’s a chunk of change, but we never missed it, because we started it from day one.”

	Pearson says that it is also crucial for female physicians to get LTD insurance before they start a family. “The list of what can happen during and after pregnancy is huge,” she says. “Women really need to get it before they try to get pregnant.”

	Whether a physician is buying a comprehensive individual LTD policy or supplementing an employer-provided group policy with individual coverage, disability insurance should be customized, says Pearson.

	“There are little pieces of the puzzle that make up a complete policy,” she says. “Physicians want to make sure that they’re being told what those nuances and differences are.” Here are definitions of some of the important puzzle pieces:

	This provides a disabled physician with benefits if unable to perform the exact duties he or she was performing before injury or illness. Almost all LTD policies sold to physicians are “own-occupancy” plans. 

	For example, Davis says that even with hearing loss, he can still perform some types of work, but not the broad spectrum of clinical tasks that he was doing before becoming  disabled. And he certainly can’t earn the same paycheck. But because he has own-occupancy coverage, he receives benefits based on his previous earnings as a primary care physician. 

 4 benefits to the Medicare annual wellness visit

	An illness or injury doesn’t always mean 100% disability. Often, a physician might be able to continue working part-time, but with fewer duties or in a limited setting. “Partial or residual disability” coverage provides benefits in these cases. 

	“It takes away the all-or-nothing,” says Keller. If a disabled doctor loses income by being able to work only part time, he or she will get benefits to help make up the difference.

	This means that regardless of the health of a physician, the policy cannot be canceled and premiums cannot be increased, provided he or she continues to pay the premium. 

	This allows policyholders to increase coverage as their income grows without having to undergo additional medical underwriting. 

Why your practice should look beyond the 401(k)

	This feature allows benefits to increase annually, usually by 3%. The COLA kicks in when benefits start, not when the policy is purchased.

	If a physician is covered by a group plan, the premium was likely paid by the employer with pre-tax income. That means benefits from a group plan are usually taxable, significantly reducing the benefit amount a disabled physician might receive. Individual policies that stand alone or supplement group plans are paid for with after-tax funds, meaning the benefits are tax-free.

	Physicians covered under an employer group plan should request a detailed description of the policy and read it carefully, says Pearson. “A lot of times what people think is getting covered is not actually what’s getting covered,” she says. “Companies don’t have to give you the fine print unless you ask for it.”

	Pearson speaks from experience. When she was injured, her group plan did not cover injuries suffered on the job (a rare exclusion). Fortunately, she had supplemental individual LTD coverage.

	Losing a physician to a long-term disability can be crippling for a small to mid-sized independent practice: A chunk of income disappears, while the practice’s overhead remains the same.

	This means that in addition to individual coverage, physicians and partners in smaller practices may want to consider “key-man” disability insurance, which pays the practice should an important employee become disabled, or business overhead insurance, which covers operating costs should a physician go out on disability.

	“A lot of docs in private practice probably haven’t thought about that,” says Jim Dahle, MD, FACEP, founder of the WhiteCoatInvestor.com, a website that seeks to educate physicians on financial matters. “Eventually if you’re long-term disabled for years and years, your practice is going away. But if you’re only disabled for nine months, it sure would be great to have a practice to come back to.”

	The drawback for these products is the price. When Davis and his partners were growing their practice in Missouri, they bought key-man insurance on each other. “It was breathtakingly expensive,” he says. “As we got larger and larger, the need for that disappeared because you could share the loss around a greater number of doctors, so eventually we just discarded it.”

2018 payment outlook shows new opportunities, old challenges

	Because LTD insurance is expensive and can include wide varieties of coverage, riders, exclusions and terms, physicians need to educate themselves, says Keller. 

	“You might not ever be an expert,” he says, “but you should have a really good idea of what it is you’re buying.” 

Articles

Securing LTD coverage can be complicated, confusing and expensive. But insurance experts, advisers and physicians who’ve suffered injury or illness all agree: Doctors need it.

Understanding the need for long-term disability insurance

	Bradley Bullock, MD’s 12-year-old son injured his foot during gymnastics last year and needed an X-ray. Bullock, who practices internal medicine and pediatrics, took him to an imaging facility near one of his practice’s two locations in suburban Nashville. He’d referred countless patients to the facility, largely because of its convenient location.

	A couple of weeks later, he got the bill: $225 for a simple foot X-ray.

	“I was shocked,” says Bullock, who counts himself among the growing number of Americans-now about 30% of employees-who carry a high-deductible insurance plan. “I’m in healthcare, so if I’m shocked, I’m sure other people would be shocked.”

	For everything they buy, from cradles to cars to condos, consumers have the ability to compare prices. Yet while pricing information elsewhere has grown more accessible, in healthcare it remains elusive, even as prices continue to rise.

	Lack of price transparency is the biggest problem in American medicine today, says Joseph E. Scherger, MD, MPH, vice president of primary care at Eisenhower Medical Center in Rancho Mirage, California, and member of the 

 Editorial Advisory Board. Early in his career, while in private practice, he offered patients easy price availability.

	“We posted our fees,” he says. “Everybody knew what an office visit cost depending on how complex it was.” That was before the insurance companies began what Scherger calls their “game-playing” of working out deals with providers with little concern for a practice’s fee schedule.

	Today, it’s not uncommon for two patients receiving the same treatment on the same day in the same location to pay different prices depending on their employer and insurance carrier. It’s also common for doctors not only to have no idea what an imaging referral might cost but even what their own services cost, Scherger says.

	Yet in every crisis there is opportunity, and a physician able to offer price transparency today, in the form of listing self-pay prices (and perhaps provide a discount for those paying cash) can save patients money and stand out in the market, he says.

	“I think it can give you a competitive edge to be more transparent about your pricing. It’s a smart practice today, because more and more healthcare costs are falling on patients, especially if they have this $5,000 or even $10,000 deductible to spend every year. They don’t want somebody taking advantage of that with excessive pricing.”

	Physicians in smaller practices are in a unique, advantageous position when it comes to price transparency, says Neel Shah, MD, MPP, founder of Costs of Care, a nonprofit organization working to lower healthcare costs, and assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. 

	“Small- to medium-sized practices often have more insight than large tertiary medical centers when it comes to the cost of services,” Shah says. “They’re running their own businesses, and they’ve got a good sense of what goes into providing services and what gets charged.”

	When creating a price list, practices should take into account how much the most-used insurance carriers are reimbursing for the listed procedures along with what other practices in the market are charging, advises Scherger. They should examine relative value units for each procedure and consult the pricing and financial resources available from the American Medical Association and Medical Group Management Association.

	“It’s complex, running a medical office, much more complex than any other retail store, but those things are available easily for you,” he says.

	Bullock’s six-physician practice has a price list for services and shares it with patients who inquire. It gives a 25% discount to those who self-pay and offers a sliding scale to patients with limited incomes. 

	The practice has also implemented price transparency with its referrals. Shortly after the shock of the bill for his son’s X-ray, Bullock says, a patient mentioned Healthcare Bluebook, a company that provides price information to large, self-insuring employers and third-party administrators. Bullock researched it and reached out to the company.

	The result has been a pilot project started in early 2017 that gives Bullock and his staff access to Bluebook’s mobile app, allowing them to look up the prices of referral procedures. If one of his patients needs an echocardiogram, for example, he can compare prices throughout the area and refer them to a low-cost provider.

	Bullock used to base his referrals on the quality of the providers and their location and convenience for patients; now price has become a major part of the equation, he says. “The first day, I used it three times,” he remembers. “It did change my referral patterns, and it probably made a difference of almost $2,000 between the three patients.”

	Bullock did something else with the new app: He searched nearby imaging centers and discovered that he could have paid as little as $67 for his son’s X-ray. “I did pay too much,” he admits. 

	Every physician in Bullock’s practice uses the app multiple times a day, he says. They know the locations that offer the most common procedures at the most affordable prices. The overall savings to patients is tough to estimate, he adds, but he’s sure that total would be “mind-boggling.”

	Prices for the same procedure in the same ZIP code often can vary by a factor of four or more, says Bill Kampine, MBA, an economist and co-founder of Healthcare Bluebook.

	The company has built its pricing database over 10 years, using commercial claims data, public records, government data and submitted pricing information. (Less-costly providers often are eager to share their prices.) A version of Bluebook is available for free to medical practices via an app.

	One of Bullock’s favorite imaging facilities turned out to be costly and no longer gets his practice’s referrals. Bullock says he’s expecting a call soon from the facility’s general manager, asking where the referrals have gone. He’s told his staff to “tell the truth: They’re expensive.”

	The practice had also been sending patients needing colonoscopies to a doctor whom Bullock calls superb: highly qualified, good service, prompt feedback. When they checked his prices on the app, they noticed the costs of the procedure varied significantly between the doctor’s two practice locations. 

	When Bullock’s practice asked about it, the doctor wasn’t even aware of the difference. “We only refer to him at the less expensive location now,” Bullock says. “It let him know we’re paying attention.” That awareness-that physicians and even consumers are watching prices-offers the true potential of price transparency, Kampine says. 

	Bullock estimates his practice has likely saved hundreds of thousands of dollars for patients. Scale that up to every practice in Nashville, in Tennessee, in all 50 states, and the savings will be substantial. “That is the great promise,” Kampine says. “In a free and transparent environment where patients get to see the cost before consuming the service, they will vote with their feet.”

	And when the more expensive providers see their volume diminishing? They’ll have only one choice, Kampine predicts: find a way to lower their prices.

	The price transparency problem may not exist much longer. Silicon Valley has invested tens of millions in data-driven healthcare pricing ventures, including the well-publicized Amino, which lets consumers search and rank nearby doctors using criteria such as patient outcomes and cost. Within months, not years, Shah says he expects a Yelp-like service that will provide consumers with a transparent list of practices’ prices and services. 

	But physicians owe their patients much more than that, he says. Shah advocates not just for price transparency but for doctors proactively discussing costs of care with patients. His passion was ignited a decade ago as a medical student in Providence, Rhode Island, an area with many poor residents. He realized that doctors didn’t seem to consider how their decisions impacted patients’ financial health. 

	Knowing the price of a procedure, thinking about how that price might affect a patient’s financial situation and then weighing the value of it all seemed like it should be the physician’s responsibility, Shah says, but the subject of discussing costs with patients wasn’t being taught in medical school.

	“Not only was I not taught very much about healthcare costs in medical school, but I was actually specifically told that it was not my job to take that into account,” he says. “I think there was a legitimate concern that if you are thinking about costs while you’re caring for patients that you might skimp on necessary care.”

	In reality, Shah says, patients want their doctors to bring up costs. 

 reveals that 80% of adults believe that doctors should discuss the costs of recommended treatment ahead of time.

	So how can doctors broach the topic? Shah urges physicians to screen for financial concerns with simple questions, such as: Are patients worried about healthcare costs? Do they have high-deductible insurance plans? And if patients have financial vulnerabilities, the physician needs to have resources-information on financial counseling, elder care, etc.-available to assist patients.

	With surveys showing that most Americans don’t have enough savings to cover a $1,000 medical bill, physicians need to make a habit of discussing the costs of a treatment plan with patients, Shah says.

	Bullock also knows this is now part of a physician’s job description. To properly fulfill his duty to his patients, he must not only care for physical and mental health but for financial health as well, he says. That is true holistic care, Bullock says.

	“I can’t have tunnel vision and think that price doesn’t matter,” he says. “Of course it matters.” 

Physicians should consider revealing prices to meet.

How to provide patients the up-front price of treatment

	Like most people, Gary L. LeRoy, MD, a primary care physician in Dayton, Ohio, usually just wants to go home after work. He puts in long days as an assistant dean at Wright State University's Boonshoft School of Medicine and doing clinical work at the East Dayton Health Center, where he's practices for two decades.

	Still, he finds time for an impressive list of volunteer obligations, including hours at a local free clinic, homeless shelter, the Red Cross and local schools.

	“I have to admit that sometimes when my volunteer night at the clinic comes up, I go somewhat begrudgingly. I’ve worked all day and I feel kind of burnt out,” LeRoy says. “Without fail, those hugs and handshakes make you feel, ‘Oh my gosh, that’s why I keep coming back to this thing.’

	“I’m dragging in the door, and I’m skipping out.”

	The hugs and handshakes prove his volunteer work helps others. The “skipping out” proves that’s it’s somehow helping him too. 

	It’s a refrain repeated by other physicians who give away their time to charitable causes: Volunteering has its own rewards. And the research bears it out. After adjusting for socio-demographic factors, multiple studies have shown that adults who volunteer enjoy better mental and physical health and lower mortality rates. 

	For physicians, there are additional benefits. Volunteering, even to causes unrelated to medicine, can be a sort of inoculation against what’s become an epidemic of physician burnout, says Gail Gazelle, MD, FACP, FAAHPM, a hospice and palliative care physician in Boston who also provides executive coaching for physicians and physician leaders.

	Primary care doctors are especially at risk, she says, because they deal with problems that have no easy fixes, including rising costs, government scrutiny and administrative hassles. “Doctors become disconnected from their sense of meaning and purpose and accomplishment,” Gazelle says. “That’s the biggest problem with burnout.”

	Even as they continue to help patients, doctors can begin to feel isolated, that they are not accomplishing much, that they’ve lost a sense of meaning in their work. Emotional depletion, feelings of inadequacy, cynicism and depersonalization soon follow. One client Gazelle coaches, an oncologist, told her that interactions with patients had started to feel like “business transactions.” 

	Volunteering can be an antidote, Gazelle says. “Volunteering is like a dose of ‘I’m efficacious and I have things to contribute in the world,’” she says. “It’s kind of like a reset, to help somebody get back on the path of being able to see the worthiness of what they do and then their inherent worth.”

	About a decade ago, the economic crisis began clobbering the already-struggling rust belt community of Youngstown, Ohio, near where Thomas E. Albani Jr., MD, has his solo primary care practice. He began seeing and hearing about more people who couldn’t afford health insurance and who were unable-or unwilling-to get public assistance.

	In 2008, Albani and a group of volunteer nurses opened the Midlothian Free Health Clinic to provide primary care to low-income adults without insurance. The clinic is open two evenings a month at a local church.

	In the nine years since, the clinic has served thousands of patients, expanded services to offer physical therapy and dental care and has grown into an operation with about two dozen other physicians, nurses and volunteers. The clinic providers have caught cancers, diagnosed heart problems and spotted other conditions early, saving the lives of people who would have otherwise likely received care only when it was too late, he says.

	“When you watch the impact it has on their lives and you see their faces, the tears and the hugs, it really humbles you and makes you recognize that what we do has a lot of value,” Albani says. “We can truly make a world of difference for people.”

	Albani says his work at the clinic leaves him feeling refreshed, partly because it allows him to focus on just one thing. “There is no need to worry about insurance forms and all of the red tape that we deal with in our private practice,” he says. “We can take care of our patients and simply focus on medical care. It takes it back to why you got into medicine in the first place.”

	LeRoy gets that same feeling when he volunteers, especially when he’s called upon to do what he calls “instant volunteerism,” from helping sick passengers on an airplane or volunteering at Dayton’s annual air show in the medical tent.

	“When I went to medical school, that’s part of why I wanted to be a primary care physician, so I could respond to any kind of situation,” he says. “Sometimes divine intervention happens, and you’re like, ‘This is why I do what I do.’ It recharges your batteries instantly.”

	For physicians new to a community or those in solo or smaller practices, volunteerism can have another benefit: It’s great public relations. “People in the community pay attention to these things,” Albani says. “They watch what’s going on in the community. They acknowledge what you do. It’s a thumbs-up sign in the community.”

	About two-thirds of physicians do some sort of volunteer work, according to a 2015 survey by the

. Pro-bono medical teaching was the top volunteer activity of doctors (54% said they did it), followed by providing free care at their practice (39%) and volunteer work at a clinic or outreach program (38%).

 survey of physicians who volunteered at safety-net clinics in California confirmed that many viewed their work as an “escape hatch” of their regular jobs. The biggest challenge to volunteering? Finding the time to do it. “Time is a physician’s most precious commodity, and they don’t have enough of it,” says Gazelle.

	So how can physicians who want to volunteer carve out time in their already packed schedule to do it? One answer seems obvious, says LeRoy: “Make it part of your schedule, so that nobody intrudes on it.”

	Albani suggests starting small. “They will be happy to have you come out and help, even if it’s just for a few hours once a month or maybe once or twice a year,” he says. “I have clinic volunteers and physicians who may only be able to come out once every month or two.”

	Physicians who already feel that they don’t have enough time for their families, their faith or their community should be strategic about their volunteering, says Vania Manipod, DO, a psychiatrist who specializes in treating burnt-out physicians and medical students in her practice in Ventura, California.

	“I have seen physicians who feel like they aren’t getting time for their children or their religion,” she says. “My recommendation would be to volunteer at your kid’s school, go on a field trip with them or volunteer for religious activities to get reconnected with your spiritual place of worship.”

	Manipod says physicians, even if they work in a group practice, can easily fall prey to feelings of isolation. “I barely ever get to see my co-workers, because we’re just running back and forth,” she says. Volunteering, however, restores “meaningful connections” with others, Manipod notes. 

	More often than not, physicians will know where they are needed most in the community, just by listening to their patients, says Karen L. Smith, MD, who has a solo primary care practice in rural Raeford, North Carolina. 

	In 1989, while getting her medical degree in Philadelphia, Smith was asked to give a talk to her church about the then-exploding AIDS epidemic. “The community was just scared to death,” she remembers. “I was called upon to try to allay the fears of the people in the congregation. So here I was, a semi-health professional who could really talk about the issue that was sensitive to the population and bring it under control so people were not fearful but were understanding.”

	She realized the influence, and obligation, she had as not just a healer but an educator. She was hooked. 

	Today, Smith devotes most of her volunteer activities to education and advocacy, giving health presentations, speeches, even appearing regularly on a Friday morning radio show to talk about health issues. She sees her clinical work as helping one person at a time while her volunteer work helps scores.

	Smith suggests physicians find a health issue that they are passionate about, create a speech or presentation and then reach out to local chambers of commerce, civic groups and local libraries. “Ask them, ‘Do you need a speaker on healthcare topics that affect our community?’ I can almost assure you they will give you a yes response,” she says.

	Smith, LeRoy and Albani all have children, and they have all seen their volunteer activities make a strong impression on them. LeRoy’s oldest is a medical social worker. Three of Albani’s children have entered medical fields. And Smith’s daughter is getting a Master’s degree in public health. 

	“Sometimes we think that our children are not paying attention, especially when they’re teenagers and they’re shrugging their shoulders and rolling their eyes,” says LeRoy. “But that stuff we talked about and that she saw, it sank in.”

	Perhaps volunteering’s greatest benefit for physicians is both self-serving and world-serving: Volunteering makes the community a better place. And because of their training and education, physicians have an obligation to volunteer, to give back to their communities, LeRoy says. 

	“You help others in an unselfish way, not for money or fame or recognition, but just because you are living and breathing on this Earth,” he says. “You have a privilege of being able to help others, so that’s what you have to do.”  

How giving back to the community can recharge 

The benefits of physician volunteering

	Lawrence Ward, MD, MPH, an internist in Philadelphia, has been practicing for more than 15 years, witnessing the alphabet soup of quality-improvement programs that have been ladled out by the Centers for Medicare & Medicaid Services (CMS).

	The most recent, Comprehensive Primary Care Plus (CPC+), is not like the rest, says Ward, who’s also vice chairman for clinical practice and quality for the Thomas Jefferson University Health System.

	 “We’ve seen a lot of programs come that don’t lead to real change but involve a lot of extra work,” Ward says. “I think this one’s different. I think this is really what we’ve been waiting for from Medicare for primary care.”

	CPC+ is an attempt by CMS to get practices to deliver comprehensive care management while embracing payment reforms. It’s trying to lure practices into the program with generous, upfront financial incentives not tied to fee-for-service revenue-incentives designed to allow them to build their care-management infrastructure.

	CPC+ is an updated version of the original Comprehensive Primary Care initiative, which ended in 2016. The initial CPC was a four-year program. CPC+ will run for five years and will be implemented in two rounds. 

	Almost 2,900 practices in 14 regions are participating in Round 1 of CPC+, which launched in January 2017. To be eligible to participate, practices must have at least 150 fee-for-service beneficiaries recognized by Medicare.

	Until July 13, CMS will allow practices in four new regions-Louisiana, Nebraska, North Dakota and Greater Buffalo, New York-to apply for a second round of CPC+, which will launch in January 2018. Only practices in the new regions will be added to the program. Practices in the initial 14 regions and those in non-selected regions cannot participate.

	Like its predecessor, CPC+ offers upfront financial incentives to practices that transform their primary care by improving services, including access, continuity, care management and patient/caregiver engagement.

	Practices can participate in either Track 1 of the program or a more demanding and ambitious Track 2, which offers bigger payments, but more reporting requirements and benchmarks. 

	Those financial incentives come in three forms:

	Every participating practice receives an upfront per-patient, per-month payment that is not tied to practice visits. The amount depends on the patient’s risk score and on the payer. For Medicare beneficiaries, fees average $15 a month per patient for Track 1 and $28 for Track 2. Participating commercial payers-there are 54 in Round 1’s 14 regions-negotiate the incentive amounts with participating practices. This money also is paid prospectively, but must be used for staffing and training related to the program’s objectives.

	These payments also go to practices and reward performance on quality and utilization measures. These are also upfront payments, but practices will have to return at least some of the funds if they do not hit performance goals.

 Comprehensive Primary Care Payments (CPCP)

	These payments go only to practices in the more demanding Track 2 of the program. (To qualify for Track 2, practices must do two-step risk stratification, offer alternatives to traditional office visits, develop care plans for high-risk chronic disease patients, and integrate behavioral health, among other requirements.) With this third type of bonus, CMS is experimenting with replacing some of a practice’s expected fee-for-service billings with upfront CPCP. These new payments will include an additional 10% of expected fee-for-service payments to help a practice deliver transformed care.

	Another benefit of CPC+ is that it qualifies as an advanced alternative payment model (APM). This makes small, independent practices eligible for an additional 5% lump sum Medicare payment under the Medicare Access and CHIP Reauthorization Act
	(MACRA) Quality Payment Program.

	For example, Ward estimates that a practice enrolled in Track 2 of CPC+ with about 500 Medicare beneficiaries would get roughly $200,000 in additional payments a year from the program’s incentives. This is separate from the 5% MACRA bonus.

	“If you had $200,000 each year for five years, that can be a nurse, a medical assistant and a social worker,” Ward says. “The nurse could do your care coordination, the medical assistant can assist you either in the office or can do outreach. And the social worker can do your integrated behavioral health.”

	CPC+ is a complex program with numerous rules, regulations and reporting requirements. The quality measures are ambitious, says Ward.

	“It’s a colossal effort,” he adds. But the requirements didn’t stop him. “When this came across our desks as an opportunity, we jumped at it. And we jumped with both feet in.”

	South Arkansas Medical Associates (SAMA), a primary care practice about 10 miles from the Louisiana border, hasn’t been shy about embracing innovations in healthcare. For example, in 2002 the practice became one of the first in the state to adopt electronic health records (EHRs). 

	 “CPC was a good experience, and we felt like we did well,” practice administrator Pete Atkinson says. The new “plus” version, he says, offered a chance to “take care to another level.”

	In 2012, the original CPC came at a perfect time for the practice. The four physician- owners sensed an inevitable transformation of primary care in America. They wanted to be proactive about being part of it.

	“We felt like healthcare was going to change and change dramatically,” says Gary L. Bevill, MD, a primary care physician and one of the four owners. Led by Atkinson, the practice hatched a plan to implement care coordination.

	CPC’s financial incentives allowed the plan to become reality. “They were going to give us the financial resources to hire some people to do some of the things we wanted to do. And we wanted to do care coordination,” he says.

	Using CPC’s care management fees, the practice hired care coordinators and reorganized the office into care teams. Over the next four years, the practice went from six providers and 30 employees to 14 providers and 70 employees. By following CPC’s core set of functions, Atkinson says, the practice didn’t just change the way it delivered care. The culture of the organization has undergone a transformation.

	“They’re enjoying practicing medicine today more than they have in the last 30 years,” Atkinson says.

	Not all practices were as eager as SAMA to jump into CPC+. 

	Philadelphia internist Ward assists independent practices that fall under the Jefferson Health umbrella. Only four, including his, applied for CPC+. The rest-more than 20-did not. 

	“I think it was because it was too overwhelming,” he says, “[The practices] knew it was going to be a lot of money, so they knew that there would be a lot of oversight and a lot of reporting.”

	Despite the financial incentives, practices weren’t sure what the reporting requirements would be, Ward adds. “A lot of practices were careful not to get involved in a program with the government that did not have every duck in a row and clearly set-out expectations.”

	Some of those concerns have been realized. For example, the launch of CPC+ was rocky at Radnor Family Practice, an independent two-physician, two-nurse-practitioner office in suburban Philadelphia, which provides a range of primary care services.

	“It was difficult at first because the program was just rolling out, and the government was a little behind in having information out there,” says practice administrator Debbie Brown, RN, BSN.

	She says the delays have caused headaches with the practice’s EHR. CPC+’s risk stratification scoring system, which requires patients to be scored and placed into four risk tiers, didn’t match the system in the practice’s EHR, which scored from zero to 100. And when the practice faced a Friday deadline in April to submit a batch of first-quarter reports, the dashboard to submit wasn’t up and working until the Wednesday before.

	Ward says his practice has been surprised by metrics and reporting requirements that CMS hadn’t disclosed earlier.

	Both Ward and Brown say the government has been hands-on in helping fix problems during the rollout. Representatives have been available to answer questions after business hours, and weekly webinars and other events update the participants.

	CMS hosts a robust social media platform. CPC Connect, for participants to share their experiences and knowledge online.

	Despite the problems, CPC+ holds great promise, especially for small independent practices, says Tracey Allen-Ehrhart, manager of the American Academy of Family Physicians' Center for Quality, who works with medical practices nationwide on practice improvements.

	 “This is a payment model truly designed for primary care,” she says.

	CPC+ was created for family medicine, internal medicine and geriatrics, which means the program’s technical support as well as payments are designed for them, she adds. 

	Michael L. Munger, MD, a primary care physician with Saint Luke’s Medical Group in Overland Park, Kansas, lauds these investments but says the benefits of CPC+ go beyond just the cash.

	“For me, the CPC+ program is taking that first step to really putting the value on what we deliver,” he says. “Through care coordination fees, it’s really placing value on the non-face-to-face care that we all do on a daily basis to coordinate care.”

	Finally, he adds, physicians are getting paid for the work-the emails, the calls, the extras-they do for patients beyond the exam table, the work that doesn’t have a CPT code.

	After four years in CPC and more than four months in CPC+, Bevill is seeing the transformation in his Arkansas practice, and he’s thrilled. The work of the practice’s care coordinators and support staff has given him more time to face patients rather than a computer screen.

	“I have a luxury now of if I’m going in to see a diabetic that’s, say, 65 with high blood pressure and maybe even with coronary disease, thanks to the care coordinator, everything is already available for me to see in the EHR before I walk in,” says Bevill. “I’m not having to click 14, 15, 20 screens to look at any lab testing or specialist reports.

	“I can focus on the important stuff and spend the whole time being very productive with that patient instead of-and you hear so much griping nowadays about it-being a doctor with his nose in the computer screen the whole time.”

	Brown and the other nurses at her practice have seen an unexpected benefit from CPC+’s care management requirements that direct practices to follow up with patients after they’ve been discharged.

	“We’ve really enjoyed getting to know our patients a lot better than we ever would have,” Brown says. “I feel like we’ve developed a nice relationship with people like, ‘Hi, it’s me again. How are you feeling today?’ That’s why we became nurses.”

	Ward encourages practices in the four new regions to apply for the second round of CPC+ before the July 13 deadline.

	“For a smaller practice, you really don’t have a lot to lose by applying for it,” he says. Practices can always not sign the contract or drop out of the program without penalty.

	Practices eyeing CPC+ should be thinking strategically, Munger says. “My advice is to start thinking about the blueprint of what you want your practice to transform into,” he says. “Think about whether you want to embed behavioral health as part of your practice or whether you need to ramp up your care coordination.”

	Practices might not get a chance to participate, even if they work in one of the selected regions. Since CPC+ is essentially an experiment, CMS wants to be able to evaluate its effectiveness. So some practices that apply for Round 2 will be randomly placed in a control group. That means they won’t be eligible for payments. 

	For practices that are selected, Allen-Ehrhart expects the second round of CPC+ to go much smoother. By then, she says, health information technology vendors will have figured out what CMS and practices need and will have built the systems to match.

	“There is going to be some growing pains,” says Bevill, “but the payoff is going to be worth every dime.”  

Comprehensive Primary Care Plus expands to four new U.S. regions for practices willing to revamp operations

Author | John Campanelli

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