The way forward is to accelerate the evolution of how physicians are paid for providing care
Primary care is in the midst of a crisis. Many practices face the possibility of closure as they deal with fallout from the COVID-19 pandemic. So what can physicians do to save their practices and treat their patients effectively? Farzad Mostashari, M.D., says physicians should embrace risk.
And by risk, he means value-based care. Mostashari contends that the fee-for-service system has exacerbated these financial struggles and that the way forward is to accelerate the evolution of how physicians are paid for providing care. In a wide-ranging conversation, we discuss value-based care, telehealth and what the ideal primary care practice of the future should look like.
Mostashari is the former director of the Office of the National Coordinator for Health IT and current CEO of Aledade. Based in Bethesda, Maryland, Aledade assists small practices with transitioning to value-based care models. This interview has been edited for length and clarity.
Medical Economics®: What is the state of primary care right now? What are practices going through and how do we fix primary care so that they can succeed in the future, given the challenges?
Mostashari: Primary care has never been more needed. We have obviously a lot of need for primary care on the front lines of COVID-19. We all hear about hospital workers who are at risk of being infected with COVID-19, but those patients who end up in the hospital first went to their primary care practices. And those primary care doctors aren’t like you and me, who get to stay home and socially distance ourselves. Those primary care practices are exposed to every patient who walks in the door, and they care for them. They close the door, they’re in a room with them, often with inadequate personal protective equipment, because the supply chain for those small practices is broken, they could not order masks.
These primary care heroes have been caring for patients, helping patients stay home and healthy and telling them, “Don’t come in if you don’t need to.”
But that means under their current business model of primary care, they are struggling financially, because the only way they had been getting paid is by doing visits — not by answering phone calls or reaching out to patients. And so, at the very time we need primary care the most, we see more and more practices that were fee-for-service threatened with going out of business.
So it’s not a good time for primary care. They’re worried about themselves. They’re worried about their family members. They’re worried about their staff, and they’re worried about how to make payroll.
ME: What do you think needs to happen to save these practices from financial ruin?
Mostashari: This is quite topical. [Recently] BlueCross BlueShield of North Carolina announced a program that we’ve been working with them on for some time now, where they are leading the way on this issue for any health plans, in terms of thinking of what should be done to save these independent primary care practices. Quite simply, what they’re saying is, we will give you a lump sum payment to make up the loss of revenue that you had this year. There’s no clawback, if they miscalculated; there are no additional reporting requirements.
The one requirement is that you enter into a total cost-of-care accountability contract. Aledade is honored to be the partner helping support those practices and succeeding in these value-based contracts.
And guess what? If you’re in one of those value-based contracts now you’re less dependent on fee for service. Our North Carolina practices, like those in other parts of the country, are getting hundreds of thousands of dollars in payments — not for patients walking in the door, but for patients being healthy and at home and not having to go to the hospital. That is what we should be doing. We should be keeping independent primary care practices whole and using this as an opportunity to move toward value-based care.
How do you see value-based care approaches evolving, given this cataclysmic event?
Mostashari: It’s a cataclysmic event as far as fee for service goes, with hundreds of billions of dollars of bailouts required to compensate hospitals and others for lost revenue from people not walking in the door for fee for service. Value-based care is fine. It hasn’t needed a bailout. The ACO [accountable care organization] models are pretty robust. You have to say, “Can we be better than if we weren’t in an ACO? Can we respond faster to the needs of the patients? Can we educate the patients? Can we take care of their preventive care? Can we deal with care transitions? Can we deal with our medication issues?” All of the things that we are working on with our practices to do a good job on the value-based contract is exactly what you would want to do for your mother at the time of COVID-19. Right? You would want her primary care practice to reach out and let her know she can call us first, we’ll see her on video, we’ll talk to her on the phone. If she has any problems, we’ll send her a 90-day prescription so she doesn’t have to go to the pharmacy in person. It’s all the things that you would want done for her. And if she does end up in the emergency department, we’ll call to see how she’s doing and follow up. That’s what we should be doing anyway. It’s just that the current payment system didn’t support it.
ME: Telehealth utilization has skyrocketed. What is the link between telehealth and value-based care and how can we strengthen that link?
Mostashari: Telehealth has a long history of problems with reimbursement, because the concern on the part of the health plans and Medicare and others is it’s not going to substitute for face-to-face visits, that it’s just going to be additive, it’s going to increase costs, it’s going be harder to trace for fraud and abuse purposes. All of those issues are suspended now, because we can’t get any face-to-face visits, and this is a substitution for the loss of care. But when things go back to normal — and things will go back to normal — the question is whether this [telehealth surge] is just a blip or whether this is going to be the new way of delivering care. And I think people are being too optimistic to assume that all the flexibilities and parity that have come with telehealth during this period will continue.
I think the solution is to take risks. The solution is saying to the health plan, “Hey, we’re not going to run up the bill on telehealth because we have an incentive to care about the total cost of care.” More risk is more freedom, in that sense, because if you’re on the same side as the payer, then they’ll say, “You’ll deliver the care however you want to deliver it, I don’t care, because you have the same incentives to keep the person healthy and out of the hospital, as opposed to running up the bill.”
ME: Things are starting to open up in much of the country while there also is a surge in cases in many places. So you have to navigate this fine line of doing what’s right in terms of not seeing patients in person while keeping your business afloat. What are some ways to navigate these challenges?
Mostashari: The good thing about working with independent practices is that the north star is what’s best for the patient, sometimes to the detriment of their business, right? But if you work for an organization that has a big finance department, then the finance people can tell you how you should practice medicine. That’s not the case with these independent practices; they do what’s right for the patient.
What’s right for the patient in this case is: If we can deliver care to you remotely, we should do it that way. And if you have potential COVID-19, then we need to keep you and other people safe. So a lot of it has work done in terms of creating new workflows and protocols for how to do testing in the parking lot, how to keep separate entrances, how to put people behind [acrylic shields], how to keep the waiting room empty. We have to reopen the practices so that we can get primary care in person to the people who need in-person care, but we have to do it in a way that’s safe for the practice staff and safe for other patients.
ME: Let’s talk about the strain and mental toll this is taking on physicians. What do we need to do to take care of them?
Mostashari: I’m very worried about burnout. I’m very worried about the pressures that are on our frontline primary care doctors and their staff. The worry that that we all feel — that uncertainty is compounded when you’re a small-business owner. You’re worrying about your finances, you’re worrying about your employees, you may have to do layoffs, you worry about their safety and you’re worried about bringing COVID-19 home to your family. I don’t think it’s appreciated enough the daily toll it takes to go in, expose yourself and then come home. I talked to one primary care provider who told me, “I come home and just scrub myself raw.” Living with that is taking a toll.
Caring for those who care for us, right now we need to do that. And we need to go beyond bumper stickers or signs that say thank you for the essential workers. We actually need to, as a country, follow through on providing them with the support they need.
ME: Let’s get more optimistic. What do the ideal primary care system and practice of the future look like?
Mostashari: I think the key is to really break the fallacy that fee for service is a good way to pay for primary care. We’ve kind of limped along and made it work based on compassion and professional ethos. And now I think we’re seeing this is just no way to run the zoo. We shouldn’t be basing primary care payments on that. It should be on the value created and we need to move toward more person-based rather than transactional [encounters]. Primary care is very much a person-based, longitudinal relationship kind of work, and we should be paying for it based on person-based longitudinal care and holding people accountable for total cost, total quality, total experience of care.
And I think that’s the optimistic view, that we will get to the point where we’re going to have more freedom for primary care to deliver care the way they see fit.
ME: What do you think the pandemic has revealed about our health care system?
Mostashari: We’ve talked a lot about how broken fee for service is and how we don’t have the systems to really support these independent smaller practices. The plus side is you never thought you’d see things move so quickly. We saw change within days on policy, regulations, payment models, technology adoption and telehealth. We saw a change in days that you would have thought would take years under the normal course. So that to me is the positive. We have responded. It’s shown that our health care system [is] getting up, sprinting and realizing, “Oh, I didn’t realize I could still sprint!” It is a good reminder that we can do it when we need to.
But even as we’re in the midst of an emergency, we need to be thinking around the bend.