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Tips for independent practices to survive value-based care


The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) ushers in a new age of “value-based payment reform” and forces the question, “How does one become more interdependent without losing one’s identity?”

I live out west where there is a tradition of rugged individualism. Although I romanticize such autonomy, it becomes harder and harder each year to reconcile with our brave new interconnected world.

And so it goes for the independent private practice physician in the new healthcare marketplace. The Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) ushers in a new age of “value-based payment reform” and forces the question, “How does one become more interdependent without losing one’s identity?”

Much like the family farmer or the family grocer gave way to corporate concentration in yesteryear, there are concerns that healthcare conglomerates will ultimately take over the ambulatory healthcare sector completely. What will, therefore, be the best strategy for staying independent in the era of value-based payment?

For those treating Medicare patients, MACRA offers two options. The first is the Merit-based Incentive Payment System (MIPS). The hardest path moving forward for a solo physician would be to simply engage MIPS head-on. To do so would require the physician to build ever-more complicated infrastructure for checking off boxes in hopes of achieving what may be tantamount to “Meaningful Use Stage 99.”


Short of that, MIPS becomes a potential 9% pay cut.  One possible outcome here is that many solo or independent physicians would then elect to stop seeing Medicare patients rather than take the cut. Some are predicting worsening physician shortages.

On the other hand, private sector physicians can band together to take advantage of MACRA’s Alternative Payment Models, such as Comprehensive Primary Care Plus (CPC+) or a Next Generation accountable care organization (ACO). 

Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program, the Next Generation ACO Model offers a new opportunity in accountable care-one that sets predictable financial targets, gives providers and beneficiaries greater opportunities to coordinate care and aims to attain the highest quality standards of care. But this path does require independent primary care and specialty physicians to work together under a convener or physician service organization.

Some private sector primary care practices will courageously choose to maintain autonomy by evolving into Direct Primary Care. This subscription-based membership model of direct contracting with patients rejects fee-for-service payments. At least 16 states now have laws that specifically enable DPC as a business model. Interestingly, this market is seeing capital infusions from private equity partners and venture capitalists, a rare phenomenon in ambulatory healthcare.

Like the independent physician, there are still family grocers and family farmers in my town, but they don’t do business the way they did 40 years ago. Maintaining autonomy in the era of value-based care will require new business strategies for payment. Physician-led ACOs and Direct Primary Care are showing the most promise.  


John L. Bender, MD, MBA, is the chief executive officer of Miramont Family Medicine in Fort Collins, Colorado, a diplomate for the American Board of Family Medicine, and an editorial adviser for Medical Economics. Do you think interoperability will improve healthcare? Tell us at

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