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Physicians should be driving value-based solutions


Doctors need to identify and address barriers to care, be given necessary resources then be held accountable for delivering high quality care.

One group is directly responsible for physician pay lagging behind inflation and for medical practices being micromanaged by payers and government regulators: physicians themselves.

That’s according to Harold Miller, president and chief executive officer of the Center for Healthcare Quality and Payment Reform in Pittsburgh, who delivered this message at the American College of Cardiology’s (ACC’s) 65th annual Scientific Session and Expo in Chicago on April 4.

“[Physicians] haven’t stepped up with solutions and allowed themselves to be seen as drivers of costs,” Miller said.

Miller described three possible futures for physicians in the post-sustainable growth-rate Medicare-payment formula world, made possible by the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA).

The first involves some mix of pay-for-performance (P4P) and value-based payments, Miller said. He criticized P4P as a poorly executed solution to the problem of paying low-quality doctors the same as high-performing physicians.

Under pay-for-performance schemes, physicians are required to deliver high-quality care but are not adequately compensated for it and get penalized for factors beyond their control, Miller said.

He wasn’t optimistic that the Merit-Based Incentive Payment System (MIPS) created by MACRA would generate better results, dubbing the initiative “pay-for-performance on steroids.”


The second possible future involved alternate payment models that seek to correct deficiencies with fee-for-service systems that do not compensate physicians or their staff for time spent discussing care plans with patients or coordinating care with colleagues.

While Miller said per-member, per-month fees cover these services in the patient-centered medical home practice model, other methodologies, such as shared savings rewards, don’t provide much benefit for practices that are already providing high-quality, low-cost care.

Let Physicians Take the Lead

Ultimately, most payment models are designed by payers for the benefit of payers, Miller said. But what is needed is a physician-designed system that identifies and removes barriers to better care, provides doctors with the resources and flexibility to provide that care and then holds them accountable for doing so.

Miller directed his audience to review a guide to seven physician-directed alternate payment plans he developed with the American Medical Association, but also pointed out to examples of physicians who have already developed their own working models.

One was developed by Lawrence Kosinski, MD, a gastroenterologist in Elgin, Illinois, who developed a payment and care model to manage his medical group’s treatment for the 200 most critically ill of their patients with Crohn’s Disease. The model is described as a specialty intensive medical home program and is a collaboration with Blue Cross Blue Shield of Illinois.


Miller also told of the “BirthBundle” model developed by Steve Calvin, MD, medical director of the Minnesota Birth Center in Minneapolis, where high-quality care is provided at 28% lower cost.

Larry Sobal, executive vice president for business development for MedAxiom, a cardiovascular practice consultant in Neptune Beach, Florida, also voiced some optimism through programs presented by the Centers for Medicare & Medicaid Services, notably accountable care organizations (ACOs).

“I believe we’re starting to see two things from CMS that normally I can’t say exist: flexibility and creativity,” Sobal said, describing how there are now 434 Medicare Shared Savings Program ACOs providing care to 7.7 million beneficiaries.

Although CMS is being flexible with ACO risk levels and patient population size, Sobal added that attaining shared savings is still difficult, so both patience and preparation are required.

“I will tell you, it’s not easy money,” he said. “You do need to recognize the transformation necessary to become a full ACO is measured in years.”

While “there is no clear road map” to become a successful ACO, Sobal did have some advice to provide.

“Maximize what you do well,” he said, and decide what good ideas “you shamelessly steal from others.”

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