Reform Update: Docs see value in shift from fee-for-service

Fee-for-service isn't going away just yet, but a trio of doctors told physicians attending the American Medical Association House of Delegates meeting that moving toward value-based payment allows them to use creativity in caring for certain patient populations while getting better work satisfaction.

The education session, called “New Models of Care,” featured AMA President Dr. Ardis Hoven speaking with Dr. Donald Klitgaard of the Myrtue Medical Center, Harlan, Iowa; Dr. Alan Spier of Cardiac, Vascular and Thoracic Surgery Associates, Falls Church, Va.; and Dr. Grace Terrell, CEO of Cornerstone Health Care, High Point, N.C.

The group shared stories of “burning-the-bridge-behind-you” moments, shared savings, regulatory concerns and creative payment arrangements. Their message was that, when you can get off the “hamster wheel,” you can more readily practice the way you want.

“The more we unhook ourselves from the fee-for-service world … the better we can do,” Klitgaard said. “It opens up a lot of doors. I didn't realize about how the way things we do day to day is driven by how we get paid.”

Cornerstone, which had been a medical home since 2003, transformed itself by becoming a “population health management hub” only recently, Terrell said. She noted, however, that this didn't start with primary care.

The practice applied population health techniques to specialty care first, beginning with cardiology and embedding pharmacists and psychologists into the care of their heart failure patients. This was followed by oncology and embedding an internist, social worker and palliative-care specialist into the team.

The program grew to include an embedded psychiatrist into the team treating Medicare-Medicaid dual-eligible patients and then special teams for the frail elderly and “poly-chronics”—patients with two or more comorbidities.

Terrell's message was that getting away from fee-for-service unlocks innovation and creativity. She added that dealing with Medicare shared-savings programs can be stressful, but it also led to having cost data they were never given before.

Besides Medicare, the group first solicited agreements with small local payers, then pursued “BUCA,” referring to BlueCross, UnitedHealth, Cigna and Aetna.

With Medicare, Terrell said, “You get 100% of the data as it relates to cost—you don't get that with BUCA.”

Dr. Clay Hays Jr., a cardiologist and third-generation physician from Jackson, Miss., said he was grateful to hear such stories after constantly having recommendations to seek hospital employment “stuffed down my throat.”

“It gives me hope,” Hays said. “I just wanted to say 'thank you.' ”

But Dr. Paul Wertsch, a family physician from Madison, Wis., was not yet sold. “Keep in mind, this has been tried before,” Wertsch said, pointing to the failed push toward managed care in the 1990s. “History tends to repeat itself.”

“Parts of it are very, very good, parts of it could be a lot better,” Dr. Regina Benjamin, U.S. surgeon general from 2009 to 2013, said about the Patient Protection and Affordable Care Act as she spoke to the American Medical Association's Medical Student Section on Saturday. “It's a start.”

The key is that it expanded coverage, she said. Getting Americans health insurance is the “first step in eliminating healthcare disparities,” she said.

Benjamin, however, was at the meeting to inspire the future doctors, and she knew that talking about policy and legislation wouldn't do that.

“I learned patients had problems a prescription pad could not solve,” Benjamin said. “We have to address the social determinants of health—like poverty.”

The AMA's Young Physician Section received praise from its over-40 colleagues for submitting a resolution on healthcare cost transparency for consideration by the AMA House of Delegates. The resolution calls for the AMA to study ways patients can get price data from providers, facilities, insurers and others; to support including cost transparency as part of medical education; and to go “on the path toward enhancing price transparency of cost within the U.S. healthcare system.”

“This is probably the most important thing we can deal with at this conference,” said Dr. Marcy Zwelling-Aamot, an alternate delegate from California who urged delegates to take the transparency movement personally.

“Put your big-boy pants on and post your prices,” she demanded.

Zwelling-Aamot said she's been posting the prices charged at her Los Alamitos, Calif., concierge practice for years.

Dr. Leonard Lichtenfeld, a delegate with the American College of Physicians, said what the younger doctors are asking for may be more difficult to obtain then one would expect. Lichtenfeld said the American Cancer Society, where he is deputy chief medical officer, has been using a “secret shopper” survey to obtain cost data for basic procedures like colonoscopies.

“It's been an arduous—and enlightening—task,” he said.

Delegates will vote on the Young Physicians' resolution—along with some 250 other policy measures—sometime between June 9 and 11.

The New Jersey delegation submitted a resolution calling for the AMA to support raising from $10 to $100 the “transfer of value” reporting threshold mandated by the ACA's Sunshine Act provision. The law calls for pharmaceutical and medical-device manufacturers to report to the CMS anything they provide to doctors that's valued above $10.

The New Jersey resolution calls this “unduly burdensome and expensive” while not achieving “the laudable goal of transparency.”

“It's insulting, debasing and just gets us very angry,” said Dr. Charles Moss, a vascular surgeon from Elizabeth, N.J. “Over-regulation is bad. Sensible transparency is good.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks