DOCTORS SHIFT WITH PAYMENT RULES CHANGE
Driven to results more than quantity, but new system has pitfalls
Tim Layman has high blood pressure but stopped taking medication for it more than two years ago because “it’s not really for me.”
“I believe there is a God that supersedes that natural order,” says the Rogers, Ark., pastor. “I’ve been made this way, and I’m not concerned about it.”
His doctor is. Mark Miller is worried about his friend and patient’s health, but he’s also concerned about his bottom line. Soon it will take a hit if the health of patients such as Layman does.
While Washington determines the fate of the Affordable Care Act, a less- known rule change overhauls how doctors get paid and the kind of health care they deliver. The rule, finalized last fall, replaced a muchcriticized formula that put doctors at risk of annual double- digit pay cuts with one that links their payments to the quality of their service. Still, it’s hardly perfect. “I can make all the recommendations, but if the patient doesn’t comply, I may not meet the goals,” Miller says.
Miller supports the rule, which was part of the Medicare Access and CHIP Reauthorization Act ( MACRA), and he is part of an effort to improve the quality of care and reporting in his area. He just finds some patients harder to treat than others, even in his relatively healthy area of Fayetteville near the Walmart headquarters.
“Some patients, because of diet and lifestyle, are going to have more heart attacks,” Miller says. “That makes me look worse than the quality of care I’m really trying to deliver to the patient.”
At 55, Layton gained insurance when Arkansas expanded Medicaid under the Affordable Care Act. Layton has decided to ignore low- fat eating: “Gravy and bacon are back on the menu for me.”
“The only concern I have about food is that at 255 pounds, I’m not trying to get any bigger,” says Layton, who is 6 feet tall. “I try to moderate howmuch I intake, but what I intake is of no consequence to me.”
Since the ACA’s passage in 2010, the Centers for Medicare and Medicaid Services has tried to accelerate the move away from paying doctors and hospitals for the quantity of services to focus more on the actual results. The new rule consolidated several “merit- based” incentive systems into one that reduces the possible penalties doctors face while making them eligible for potentially larger bonuses.
Most doctors aren’t sure of what the new payment system requires of them, says Tom Giannulli, a doctor who is chief medical information officer of the physician software company Kareo. Miller, one of Kareo’s clients, is an exception.
“A lot of them are not clear on why ( regulators) are doing it,” says Giannulli. “It’s for everyone’s benefit and so we can finance Medicare in the future.”
MACRA is “a really significant signal to the market ... that health care is fundamentally shifting,” says Jack Stockert, a physician who heads business development for the health care technology company Health2047. The American-Medical Association was one of the initial investors in Health2047, which is helping doctors prepare for health care delivery at the century’s midpoint.
Doctors, says Stockert, “have always held themselves accountable to delivering the best health outcomes.” But the proof in whether they were succeeding was typically anecdotal.
James Walker has practiced family medicine in Washington state and rural Oregon since he graduated from medical school in 1980. It’s been a bumpy road for a once- solo practitioner, in no small part because of Washington, D. C.
Walker sold his practice to a hospital in 2010 when it became “totally infeasible from a financial standpoint” to remain independent. That hospital will soon spend about $ 11million for the technology needed to meet federal requirements for data and electronic records.
Stockert, Walker’s son- in- law, works to make the shift to high- tech health easier for doctors. While he was training to be a doctor, Stockert found it wasn’t like the “Norman Rockwell painting” he expected and that he saw in his father- in- law’s enjoyment of the doctor- patient relationship.
“We should all want that in our medicine, in our doctors, in our patient experience,” he says.
He hopes helping doctors overcome health IT challenges will make health care more rewarding.
“MACRA causes a shift and drives innovation to begin to show more clearly what is effective,” Stockert says. “And by paying for better outcomes, the legislation ensures that decisions that deliver healthier people are rewarded appropriately.”
Miller tries to stay ahead of quality reporting. He just hired a “care navigator” at his TruHealth Family Care and expects her to “pay for her salary” many times over, given the effect her work will have on his Medicare payments.
“I’m actually pretty excited about it,” Miller says of payment changes. “I’m embracing it because I know it’s the future.”
“I can make all the recommendations, but if the patient doesn’t comply, I may not meet the goals.” Mark Miller, Fayetteville, Ark., doctor