Quality matters to patients and it certainly matters to physicians, but as health care attempts to alter the current reimbursement paradigm physicians are wrestling with how to make quality pay.
“Quality matters” is more than just a nice catch phrase — quality matters to patients, and it certainly matters to physicians. But as health care attempts to alter the current reimbursement paradigm physicians are wrestling with how to make quality pay.
Paul Bergeron, MD, is the chief medical officer for the Central Massachusetts Independent Physician Association, LLC, a 200-physician medical group. He’s in charge of handling risk contracts based on quality metrics. In other words, it’s his responsibility to make certain that quality pays.
“What we have is over 20,000 covered lives on risk-based contracts,” Bergeron explains. “My role specifically is to work within the contracting guidelines that have been negotiated; work with the physicians to improve care through quality and utilization metrics. That’s my job.”
Bergeron and his team take a multi-prong approach to their goal of making quality pay. One of those prongs is meeting with all the physicians — in particular, primary care physicians — on a six-week cycle.
“That’s where the bulk of the performance is, on the primary care physician side,” Bergeron says.
The benchmarks are already in place. Insurance plans have their network benchmarks, and there are also external benchmarks such as HEDIS (Healthcare Effectiveness Data and Information Set) that enable Bergeron and his team to assess all physicians in terms of where they are, and where they could be. But they don’t measure quality based on location.
“I think the better way to approach it is per physician,” Bergeron says. “What we’ve found is that you’ll see variations amongst the physicians within a practice. So we’ve kind of chosen to take the per physician approach, because we believe that’s a better approach. It brings the accountability to the level of the physician.”
Bergeron points out that it’s extremely important to build close relationships with payers.
“Some people will tell you that it’s us against them,” he says. “We don’t believe that. We believe we can work much better together to improve patient care and costs.”
He recalls that in the 1990s “there was capitation all over the place,” creating a lot of friction between insurance companies and groups. In some respects, that friction still exists. But Bergeron’s experience has been quite different.
“What I’ve found, particularly with the payers we work with, we’ve been very pleasantly surprised that it’s a very collaborative relationship,” he says. “They want to help and we want to perform well. So, it’s a critical piece of the puzzle. And I have to say I’m very impressed in our particular market with how engaged the insurance providers and carriers are. Very impressed.”
Ask Bergeron about frequency — about how often he and his team step back and ask, okay, “how are we doing?” — and he responds with an unequivocal, “it depends.”
“It depends what metric you’re looking at, it depends what kind of data you have to look at, and what the frequency is,” he explains.
For example, Bergeron and his team will look at internal claims data, but they’ll also examine data provided by insurance companies.
“When you’re doing your own analysis, you really want to make sure that it’s consistent with other data that you get,” Bergeron explains. “It’s great to have several different pieces of data to look at the same thing. So, we look at the insurance company data so we can reconcile it with our data to understand whether we’re performing well or not.”
Making quality pay
Bergeron says he bundles two philosophies when he determines whether quality pays. He explains that quality means reaching certain outcomes and metrics, while efficiency means achieving certain financial metrics. As an example, he says that if a patient receives care from a medical group that’s less costly and has achieved some efficiencies, the patient pays less. The group will also benefit from that, because of the way contracts are structured.
“It’s basically saying, ‘okay, here’s a patient population I want you to manage,’” Bergeron says. “It’s called a risk contract because if you manage them very well both in quality and efficiency, you will reap a financial benefit. If you do not perform well, you will get a financial penalty. So we’ve created an incentive plan. We have certain criteria that physicians are scored on; they get a scorecard for their performance. And that performance essentially gets graded and people get paid for it, depending on what their grades are.”
The providers, he says, are ultimately the winners if they perform well.
“It’s truly a financial incentive,” Bergeron says.