Oct. 24, 2018
Dive
Brief:
- Physician
practices, especially those covering multiple specialties and markets,
report high levels of financial risk aversion when it comes to adopting
new alternative payment models, a just-released RAND-American Medical
Association study finds. The problem is particularly acute among practices
that have suffered losses in APMs or have little experience managing risk.
- Smaller
practices view the debt they incur to fund infrastructure changes to
support APMs as yet another form of financial risk — on top of the risks
in the model itself.
- Part of the problem may be not
enough simple options for doctors. Practice leaders and market observers
across the board reported increasing complexity of payment models and
accelerating rate of change. The analysis of 31 physician practices in six
markets updates a 2014 study that seeks to understand how APMs affect
various aspects of physician practice.
Dive
Insight:
APMs
are vital in the shift to value-based care. According to a recent report by Health Care
Payment Learning and Action Network, slightly more than a third of
all healthcare payments in 2017 involved APMs, up 6% from the prior year and 13
percentage points higher than 2015's 23%.
Yet
41% of healthcare spend is still devoted to fee-for-service only care, the
report notes. A quarter is wrapped up in fee-for-service with some value-based
involvement, while the rest goes to APMs built on FFS foundations or straight
population-based payment.
The
RAND-AMA report points to persistent findings from the earlier study. Practices
have implemented new health IT, data analytics infrastructure and behavioral health
capabilities needed for success with APMs. They also continue to adjust APM
incentives before passing them along to physicians. "Individual physician
incentives based on costs of care were rare, even within practices with strong
cost-containment incentives from payers," the report says.
Other
continuing themes include increased pressure to have timely, high-quality data
and frustration with operational errors in APMs — particularly when they
prevent practices from collecting earned bonuses, which erode support for APM
participation.
The
updated study also revealed new findings. Chief among them is a growing
aversion to APM downside financial risk. Some practices have dealt with the
issue by shifting the risk back to payers or offloading it to third parties,
such as manufacturers.
Respondents
in all six markets believe APMs are changing more quickly, partly driven by
MACRA's Quality Payment Program. The pace of change is especially challenging
for small and independent practices that may rely on outside consultants for
advice, the report says, noting consultancies sometimes can't keep up with the
changes.
Particularly
challenging is when APMs are suddenly discontinued, upending investments and
commitments practices made with the belief the payment model would continue,
according to the report.
Payments
models are also becoming more complex, with more performance measures,
confusion about performance thresholds and interactions between different
payment models. Understanding the newer payment models requires significant
investment, which can be a barrier to participation.
However,
for practices that commit to understanding APMs, the return on investment is
often well worth it. "Some of these practices found ways to receive more
credit for their preexisting quality — without materially changing patient care
— by enhancing their documentation and data abstraction practices, thoroughly
coding risk adjustment diagnoses, actively managing patient attribution, or
purposefully selecting their performance measures to maximize the likelihood of
rewards," the report says.
Simpler
APMs and a more stable, predictable and measured pace of change could increase
physician practice buy-in with APMs, the researchers suggest. They also call
for more support to help practices come up to speed with the capabilities and
data necessary to succeed with APMs. And they caution against limiting
practices' access to upside-only APMs, saying this could scare them off
altogether.
CMS
is still being tight-lipped about how much it will force physicians to assume
downside risk. The agency has proposed an overhaul of
the Medicare Shared Savings Program that would shorten the time accountable
care organizations have to shift to a risk-bearing model.
This
study suggests an aggressive approach to imposing financial risk would not go
over well.
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