MMA Viewpoint
Reaching the Tipping Point
At Family Health Services Minnesota, where I practice, I’ve been trying to move our clinic toward payment mechanisms that will allow us to take a more team-based approach to care and reward us for keeping our patients healthy.
But let me tell you it hasn’t been easy. I’ve heard the theories behind the accountable care organization, shared-savings, medical home, and pay-for-performance models. Sure, they sound good on paper, but in the clinic, trying to implement them is like playing a game of chicken. Payers say they’ll pay us differently if we change the way we deliver care, and we say we’ll change how we deliver care if they pay us differently. So far, there’s been little movement on either side.
The reality is that payment reform is difficult because you still have to rely on office visits (the currency of the current fee-for-service system) to pay the bills, while at the same time try to implement new approaches that don’t yet generate revenue. It’s a little like trying to repair a hole in your boat while you’re at sea—you have to do the work of sailing, fixing the hole, and bailing water all at the same time, so you don’t go under.
We’ve felt that way about the DIAMOND project, an approach that pays primary care providers to manage patients with depression. We hired care managers to call patients who were identified as having depression and ask if they are taking their medicine, having side effects, getting better, or need a treatment change. For us, DIAMOND has been a clinical success—patients with depression have gotten to remission more rapidly. But it has also been a payment headache. The problem is not all insurers participate in DIAMOND. Medicare, Medicaid, and self-insured health plans do not. Because of this, care management services are not covered for about 40 percent of eligible patients. This left us in a situation where we have the ability to provide a great service that many patients either have to pay for out of pocket or do without, or we have to give it away for free.
Large integrated systems such as Fairview, Allina, and Mayo may be able to forgo reimbursement for these services during the transition between payment models. But as a physician-owned primary care practice with 70 physicians, we can’t afford to do that and have been searching for a way to subsidize the cost by increasing our contracted revenues for our general business expenses.
So the big question still remains: Should physicians go first in moving toward new payment models? I think we should take what steps we can because it is the right thing to do for our patients. In addition, Minnesota’s insurers seem to be more open to structuring payment arrangements that allow physicians to share in savings related to reducing hospitalizations and unnecessary tests. As large systems enter into such arrangements, smaller clinics are likely to follow.
In addition, the 2010 Patient Protection and Affordable Care Act should help move us toward universal health insurance coverage and more standardized benefits. This should make it easier to avoid the payment pitfalls we’ve experienced with projects such DIAMOND, provided such services are included as a standard benefit.
Now is a critical time for practicing physicians to engage in dialogue with payers and purchasers about new payment models. I’m optimistic that if we all focus on doing the right thing, we can make payment reform a reality.