Small practices can survive in a value-based payment world

William Golden, MD, MACP, medical director, Division of Medical Services, Arkansas Department of Human Services

Healthcare’s transition from volume- to value-based compensation means practices will have to transform the way they deliver care if they are to survive. The changes required can be especially hard for smaller practices, but they are by no means impossible, says William Golden, MD, MACP.

As medical director for Arkansas’ Medicaid program and lead clinician for the program's Payment Improvement Initiative, Golden has seen practices of all sizes adapt to new payment models the state has implemented as it seeks to rein in Medicaid costs.

Golden explained these changes, and their impact on medical practices, during the C. Wesley Eisele Lecture at the American College of Physicians 2018 Internal Medicine Meeting in New Orleans. Afterwards he sat down with Medical Economics to discuss practice transformation in more detail.

Medical Economics: Define what you mean by practice transformation. Transformation from what to what?

William Golden, MD: Practice transformation can be many things, but we [in the Arkansas Medicaid program] have been involved with creating new models of payment. But alternative models in which we reward outcomes and effectiveness require a different way of organizing what you do. If you’re in primary care, you would get away from focusing on high-volume visits to how your patients are doing.

So your goal is no longer maximizing how many people you see per day, but making sure your visits and your outreach and your care models reduce ED visits, reduce hospitalizations and re-hospitalizations. It actually gets into things like outreach between visits, structured follow-up care, and not just focusing on making sure that your daily schedule is full and people come in for episodic care.

ME: And the goal here is to reduce the overall cost of care by reducing ED visits, by reducing hospitalizations, etc.?

WG: Well, there’s more to it than that. We’re also challenged by the fact that we have a lot of burnout because this volume-driven approach to how[physicians] survive in practice and the demands of clicking boxes in EHRs are driving people crazy. And transformation is a different way of doing business where you can be economically viable, deliver good patient care, and have professional satisfaction.

It’s not just saving money, it’s really how to be a happier and more effective clinician.

ME: What are the first steps involved?

WG: I think that many payers are realizing we need to do something different in our healthcare system. So they are beginning to organize alternative payment models.  And then the goal is to get involved with the folks who are designing those models and those systems.

When we put together the alternative payment models in Arkansas, we did lots of town halls and lots of webinars and we basically put things on a whiteboard and threw PowerPoint slides at people and said, “What do you think?” And the feedback was invaluable. So you can’t really transform the healthcare system as a payer without engaging the people doing the work. 

We then went out and sought stakeholder engagement, such as the AARP, American Academy of Family Physicians, and local hospitals. People all agreed that what we’re doing is not working and we need to do something different. Then we started coming up with different ideas to see what resonated and what didn’t. The notion of giving one check and having providers divvy up the money themselves [bundled payments] was a non-starter. Nobody trusted each other; nobody had the business relationships to make it work.

So then we went to a retrospective reconciliation, which meant that [physicians] didn’t have to change their business practices, but we started to reward different things. So aside from getting the dollars for seeing the patient visit, we were offering bonus money if you did something different and enhanced your outcome.

And the funny part about that was that it appealed to the “better” doctors. The people who actually were a little bit ahead of the game or doing better work, suddenly woke up and said, “Hey, you’re offering to pay better providers more. What a novel idea.” Those are your clinical leaders and the people who are going to embrace change. And when they spread the message to peer groups in local communities thinking there’s something in it for them, you’re well on your way to making change.

ME: Within a small practice, what do you find are the principal barriers to bringing this change about?

WG: Very often you’ve got to make sure somebody in the practice gets it. You really have to have the people doing the work embrace it. And we’ve had practices that frankly don’t get it. It’s the old joke about how many psychiatrists does it take to change a light bulb? Just one, but the light bulb has to want to change. If you don’t want change, you’re not going to.

If you’re not happy with the volume of what you’re doing, if you think it’s not how you want to practice, think about what changes you want to make and how the new dollars can help you have a better professional environment. The payers are giving you upfront money to do something different.

ME: Do you think CMS’s alternative payment models are helping the process along? What’s your general feeling about them?

WG: I think they’ve made a big investment in Comprehensive Primary Care (CPC) and CPC+. I think those are major steps forward, although they organize things out of Baltimore and sometimes there are voltage drops when it hits rural Arkansas where it doesn’t quite translate. But they’ve made a commitment to try something different. 

When CMS announced its episodic care payment program for orthopedics, it made the hospital the focus rather than the doctor. We got phone calls within an hour from a medical site asking why the docs couldn’t do this. They were so bought in that they wanted to have the docs be the accountable provider, not the hospital. 

So if you can make a red, rural state like Arkansas get to the point where they understand what alternative payment models are, and actually begin to incorporate that into how they think going forward, it can happen almost anywhere. But it means people have to start thinking about the patient journey and not just being a retail provider of a service.

ME: How about MACRA and MIPS? Are they a help, a hindrance, or is it too soon to say?

WG: Too soon to say. It’s very complicated and I am concerned that the data being used to drive it has got issues. 

ME: Do you think CMS shares those concerns?

WG: I don’t know. I have been on speed dial with CMS about data issues from EHRs on CPC+. I think that CMS has made a huge investment with ONC [Office of the National Coordinator for Health Information Technology] installing a big base of EHRs throughout the country.  I think the reality of the limitations of what EHRs can produce in terms of usable data has yet to be fully digested.

ME: That’s a nice way of putting it.

WG: I’m being as diplomatic as I can.

ME: You said in your presentation that our system of evaluation and management (E/M) codes is a hindrance to practice transformation. What did you mean by that? 

WG: I think it’s a diversion. I think doctors are clicking boxes documenting things they don’t need to document and not taking care of patients. People are spending more time in front of the computer than they are thinking about care and how they want to deliver care for their patient. And I think it’s counterproductive.

ME: The E/M visit has been around for long time. So maybe it’s more a problem of trying to fit it into the EHR clicking boxes format?

WG: I think that we’re getting to the point now where we have big databases and we can actually start doing population-based health and panel management and not necessarily paying for visits and procedures. That’s the big challenge going forward. If you want to have a sustainable healthcare system, it’s about Mrs. Jones’ diabetes over a course of time, not how you took care of her on Tuesday. And we’re paying for how you took care of her on Tuesday and not how she did over the last year and a half.

ME: How does a small practice get access to and make use of the data they would need to do population health?

WG: In our state, we have a quarterly report card we give to all the payers. We’re making investments in giving them big data and the payers can give doctors their individual data.

Your EHR might be able to do some of that if the vendor lets you and doesn’t charge you through the nose.  But increasingly payers give people data.  And we’re finding that as we give people data, they want more data. There is a data hunger and that’s why the payers now would love to have clinical data out of the EHRs to give doctors more real-time data. That’s why the payers, in our state, are saying they’re going to make investments to build an HIE [health information exchange] infrastructure that can equip practices, large and small, with that information. That’s a key next step forward.

ME: Going back to the E/M visit and playing devil’s advocate for a minute, don’t you need to  go through that procedure of clicking the boxes that everybody complains about in order to accumulate that raw data?

WG: Yes and no. We don’t look at ROS [Review of Systems] data. We’re looking at the billing codes, we’re looking at the drugs, we’re looking at ER visits, we’re looking at the patient journey. So increasingly, we want to know what your care plan is. We don’t need to know that you’ve done a 15-point ROS.  And we know what you’re prescribing.  We can get the lab data so we know which ones you ordered. And we know if your patient has been to the ED.

We know what your comorbidities are so we can risk profile your panel.  We can look at your visit rate.  We can look at your ER rate.  That’s what we’re going to be looking at.  That’s what people are going to be looking at in the future, not your 15-point ROS.

ME: So maybe it’s just a matter of redesigning the templates in EHR to get this data that you’re talking about?

WG: Yes, but that means you don’t need to get paid for a level-four visit.  So the vision going forward, as I said, is to look at the complexity of your patient panel, your up-front dollars, and basic visit fee dollars which requires a care plan but doesn’t require hundreds of box checks.

So increasingly, it’s going to be about what you’ve done, not what you’ve clicked.  You can figure out whatever you want in your practice to document and keep you on track but we won’t be looking at that note per se to value your practice.

ME: Is it realistic to expect small practices to take on risk?

WG: No.

ME: And yet payers seem to be trying to push more risk on them?

WG: Yes, but one of the key aspects of all of this transformation is you want to reward early adopters. If people who are risk takers and better providers take on a new way of doing business and don’t get rewarded fairly, you’re never going to get the rank and file.  If you burn the A students you’re never going to get the C students to take the leap.  So you’ve got to have winners in the program.  You’ve got to make it so that when people are successful in the new way, you want them to do business, it spreads through the community.