Engaging primary care physicians in value-based payment

It’s one thing to sit down with a payer and negotiate incentivized goals in a value-based payment contract. It’s a different thing entirely to change the behavior of the practitioners in your medical group in order to meet those goals.

Physicians who choose to sell their practice and become employees are typically relieved to unload much of the management burden. Those that have been employees for some years may indeed have experienced a period when the weight of that responsibility was reduced. However, the demands of value-based care (in all its many forms, current and future) require responsiveness and accountability at the practice level.

Achieving that responsiveness depends on acting on the business and clinical feedback that first presents in the practice setting. High quality care includes much more than what occurs in the exam room. It includes, for example, calling patients recently discharged from the hospital and preventing re-admissions by following targeted patients. That may mean physicians need to work with a care manager, or perhaps refer patients to a visiting nurse service.

It is the physicians who ultimately have to manage patient interactions, whether inside or outside the exam room, coordinating with all clinical and administrative staff to meet clinical care and patient satisfaction standards just as they did when in private practice. Small wonder that primary care physicians are at best conflicted, and often distressed, when they realize that they still have significant management responsibilities.

Start with Compensation
Physicians typically are not at the table when decisions about payer contracting are made, yet there is a direct link between what practitioners do on a day-to-day basis, and payer contracting. So how does the connection get made?

Primary care physicians impact care beyond their specialty, so engaging PCPs can be a powerful place to start shaping physician expectations, practice operations, referral behavior, and prescribing patterns in relation to value-based payment. The compensation plan is a much better place to get the long-term attention of primary care physicians than simply having a discussion—or even many discussions—about quality management.

The compensation plan needs to pivot from a focus solely on production (e.g., wRVUs) to one that starts to focus attention on value-based payment metrics, typically as a supplement to wRVUs. Yet few physicians—or any other employees—can respond to all the demands of all payers’ metrics. There are 275 indicators just for MIPS!

Physicians can effectively work on responding to perhaps five to seven specific measures at a time until they are internalized. That calls for a participatory process of selecting target metrics for the compensation plan. That process will work most effectively if physician representatives are active participants, since in many cases, it’s the physicians who must change behavior. Once the behaviors required to respond to the first set of metrics have been mastered, usually the next set suggests itself; there is no need to start a new selection process.

The specific incentives do matter, while the broader message that these convey is also important: Simply seeing patients in the exam room will not be rewarded is it was in the past.

Shaping the Continuum of Care
PCPs can have a greater positive effect on the continuum of care if they have the authority and responsibility to shape it. They participate in basic specialty care in cardiology, neurology, pulmonary health, gastroenterology, and behavioral health, as well as other areas.

Having specialists provide guidance on the components of a proper initial work up in each major specialty will sharpen PCPs’ use of specialist referrals and ultimately ensure that the specialists’ time is used appropriately.

Support in Patient Care Administration
Hospitals need primary care that participates in guiding all aspects of the patient experience—including the administrative aspects that many PCPs would rather avoid. Physicians are often the first to learn of burgeoning payment problems, patient compliance, staffing issues, or patient risks, so their involvement is essential.

Once expectations are set, it’s critical to provide support to PCPs in accomplishing these tasks. Common issues include:

Payer Complications
Physicians are face-to-face with patients, and their services generate the bills. They need to understand that they are responsible for assuring that there is a satisfactory resolution when a patient has problems with a payer—including discussing it with billing and/or office management personnel, or even calling an insurer when required.

Newly recruited physicians need to be sure that insurers have properly switched their patients to their new location, or that their patients have “re-chosen” them as their primary care physician.

Emergency Department Utilization
If PCPs are to be willing to prevent excess use of the emergency department, they need “structural assistance” within the practice. Patients with urgent issues need to be able to reach the practice after hours and get immediate guidance on where to go (or reassurance, if that’s what’s needed) from a clinician with full access to the patient’s record. If the practice is large enough, perhaps a block of daytime visits can be left open to handle urgent/emergency patients, so they can be told to come in during that block rather than going to the ED (assuming they are not in immediate danger).

Complaints and Guided Referrals
With electronic health records, it’s not hard for a practice to collect feedback on their visits from each patient. The question is what happens with that information. If the practice is the center of everything regarding the patient—and it should be—then it should be the practice that responds to the individual patient.

The practice should also determine what actions need to be taken in response to patient problems. This may require that physicians and managers receive regular summary reports on this information, and hold periodic review sessions to respond to reports. Primary care physicians should also receive rapid and detailed feedback on their patients’ experience with specialists to which they have made referrals, so that they are aware of that experience in making future referrals.

Practice management
Physicians in private practice are directly responsible for everything their administrative staff does. Employed physicians have the benefit of systems and administrative staff without needing to hire them or pay them, but they still need to work with non-clinical staff to discuss and resolve problems. It’s important to set the expectation that practice management is part of their role, whether or not they enjoy it, as it impacts not only patient satisfaction but also practice sustainability.

Hundreds of clinical and business decisions must be made in a practice daily. PCPs should be at the heart of all of these, as the physician is the one that hears and must act on what happens. To make this work, physician managers needs to be engaged.

Rudd Kierstead, MBA/MPP, Principal, Veralon
Rudd brings 25 years of experience in a range of provider settings to his work on physician initiatives. He has focused on enterprise performance improvement, medical staff planning, financial analysis, physician alignment, compensation planning, acquisition and employment analysis, and FMV projects.

In addition to his consulting experience with health system, community hospital, and academic center clients, Rudd has worked extensively with physician leadership in New York medical centers, managing physician networks, practices, and departments in several academic medical centers and in different specialties.

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