The Dallas Morning News

Ad­vance monthly pay­ments: Could they be health care fix?

- MITCHELL SCHNURMAN mschnur­man@dal­las­news.com

Can a short­term fix for the coro­n­avirus be­come a blue­print for a bet­ter health care sys­tem? Many pri­mary care doc­tors are get­ting be­hind that idea, urg­ing the govern­ment and pri­vate health plans to make ad­vance monthly pay­ments on their usual billings. It’s one way to help med­i­cal prac­tices close the gap on their de­clin­ing rev­enue, and Medi­care re­cently started of­fer­ing the op­tion to its providers.

But some doc­tors want to go fur­ther. They’re call­ing for so­called prospec­tive pay­ments to con­tinue beyond the cri­sis, even­tu­ally re­plac­ing the tra­di­tional fee­for­ser­vice model. They be­lieve it’s bet­ter for pa­tients as well as their prac­tices.

“It’s a no­brainer,” said Dr. Stephen Buksh, a fam­ily physi­cian in Eu­less for 21 years. “Pa­tients still need care dur­ing the coro­n­avirus, and I’m still help­ing them — and I know I’m gonna get paid the same amount.”

That’s true for roughly half of the busi­ness at his prac­tice. North­east Tar­rant In­ter­nal Medicine As­so­ci­ates gets about half of its rev­enue from Medi­care Ad­van­tage and Medi­care pa­tients, and the for­mer al­ways uses a set monthly pay­ment and the lat­ter has the same deal tem­po­rar­ily.

The com­pany’s re­main­ing rev­enue comes from tra­di­tional pri­vate in­sur­ance, which pays for each ser­vice af­ter it’s pro­vided. That’s a prob­lem dur­ing a pan­demic be­cause of­fice vis­its have fallen sharply amid stay­at­home or­ders and gen­eral anx­i­ety about go­ing to a doc­tor’s of­fice.

The prac­tice has beefed up its tele

health vis­its dur­ing the pan­demic, but they don’t cover the rev­enue short­fall. Still, it’s in bet­ter shape than many oth­ers.

In a sur­vey con­ducted April 7­8, al­most half of the med­i­cal prac­tices said they fur­loughed work­ers and al­most a quar­ter laid off staff. Re­spon­dents pro­jected the num­bers would be higher next month.

Buksh said his prac­tice, which has nine doc­tors, 36 em­ploy­ees and three lo­ca­tions, hasn’t laid off any­one. The con­sis­tent monthly pay­ments make a big dif­fer­ence, but they may not be enough if the eco­nomic down­turn lasts long.

“The com­mer­cial busi­ness is half our rev­enue, and that’s the hard­est part to swal­low,” Buksh said.

The idea of pay­ing providers a monthly amount has been around for decades. In the 1990s, health main­te­nance organizati­ons grew in many parts of the coun­try, as em­ploy­ers and in­sur­ers sought to im­prove care and lower costs. But HMOs were less pop­u­lar in Texas, where providers and pa­tients of­ten com­plained about var­i­ous re­stric­tions.

In the past decade, ad­vo­cates have pro­moted “val­ue­based care,” which can in­clude a monthly pay­ment per mem­ber, along with a mech­a­nism to re­ward bet­ter per­for­mance.

With the pan­demic dis­rupt­ing the fi­nances of so many providers, the lat­est push is for prospec­tive pay­ments. In ad­di­tion to Medi­care’s pro­gram, Blue Cross of Idaho and Blue Shield of Cal­i­for­nia re­cently agreed to make ad­vance pay­ments to doc­tors based on their usual billings. The ad­vances can be re­paid as busi­ness re­cov­ers.

On Monday, the Texas Med­i­cal As­so­ci­a­tion sent a let­ter to Gov. Greg Ab­bott, ask­ing for ad­vance pay­ments from Med­i­caid and two plans cov­er­ing re­tired state work­ers. The let­ter also urged Ab­bott to look beyond the cur­rent cri­sis and ad­vance “Texas’ long­term goals to pro­mote value­based pay­ment ini­tia­tives.”

Dr. Christo­pher Crow, pres­i­dent and co­founder of Cat­a­lyst Health Net­work in Plano, has long pro­moted this ap­proach, in­sist­ing that pri­mary care wasn’t well­suited to fee­f orser­vice pay­ments. Pri­mary care docs should be call­ing pa­tients to mon­i­tor progress, re­fill med­i­ca­tions and of­fer help with diet and ex­er­cise — things that keep peo­ple healthy and may keep them out of the doc­tor’s of­fice.

“It’s a com­pletely dif­fer­ent shift from re­ac­tive medicine to proac­tive,” Crow said, and fee­for­ser­vice pay­ments of­ten ex­clude that help.

Doc­tors have tools that didn’t ex­ist in the 1990s, when HMOs fell out of fa­vor. Telemedici­ne, data on large pop­u­la­tions and other tech­nol­ogy en­able a pri­mary care doc to work as a quar­ter­back for your health, Crow said.

What’s needed is a pay­ment model that aligns the in­cen­tives for physi­cians, pa­tients and pay­ers. The COVID­19 cri­sis, which has ex­posed some of the short­com­ings in fee­for­ser­vice, is creating an op­por­tu­nity for real change.

“We’ve been talk­ing about value­based health care for over a decade,” Crow said. “Why not use this mo­ment to fix a short­term prob­lem and set up the fu­ture?”

Dr. Darla Kin­caid, a pe­di­a­tri­cian in Cop­pell, is in­trigued. Her prac­tice, which in­cludes seven doc­tors, a part­time psy­chi­a­trist and three ad­vanced prac­ti­tion­ers, had to lay off six em­ploy­ees and fur­lough four oth­ers be­cause rev­enue fell sharply.

But all her busi­ness comes from fee­for­ser­vice, and the prac­tice’s busi­ness and pa­tient man­age­ment sys­tems are de­signed around that model.

“It’s scary,” she said about the prospect of a ma­jor change. “We’re run­ning the num­bers to make sure we’ ll be able to make ends meet.”

She hopes the pan­demic will push ev­ery­one for­ward, in­clud­ing in­sur­ers and em­ploy­ers.

“The cri­sis has forced all of us to move out­side of what we’ve done in the past,” Kin­caid said.

Dr. Sue Born­stein, ex­ec­u­tive di­rec­tor of the Texas Med­i­cal Home Ini­tia­tive, had a sim­i­lar take. “This is the op­por­tu­nity to bring peo­ple to the ta­ble who wouldn’t come be­fore,” she said. “If we don’t fo­cus our en­ergy now, I don’t know when we will.”

Crow, whose group in­cludes al­most 800 pri­mary care doc­tors and over 1 mil­lion pa­tients, said he’s been talk­ing with ma­jor in­sur­ers and em­ploy­ers. It’s dif­fi­cult to sug­gest chang­ing health ben­e­fits, given that so many com­pa­nies are cut­ting costs and lay­ing off work­ers.

Crow said he re­minds them that con­sol­i­da­tion has not been good for health care prices. And with­out some­body’s help, many doc­tors will re­tire early or join hos­pi­tal groups, and that will lead to less com­pe­ti­tion.

“This isn’t a bailout,” Crow said. “It’s about pay­ing doc­tors to keep do­ing what they’ve been do­ing — just pay­ing them prospec­tively.”

Em­ploy­ers, who pay for most of the pri­vate health cov­er­age in Texas, may be ready to em­brace the idea, said Mar­i­anne Fazen of the Dal­las­Fort Worth Busi­ness Group on Health. Sev­eral have ex­per­i­mented with plan de­signs that en­cour­age more pri­mary care, of­ten mak­ing it low­cost or even free to see a fam­ily doc­tor.

“They’ll pay a monthly fee if they’re sure em­ploy­ees are get­ting good man­aged care,” she said.

Com­pa­nies won’t change ben­e­fits in midyear, Fazen said, but they’re weigh­ing strate­gies for 2021: “This would be a good time to set it up,” she said.

We’re still in the mid­dle of a pan­demic, so there’s a ques­tion of how much can be han­dled, said Ben­jamin Is­gur, a con­sul­tant who leads Price­wa­ter­house­C­oop­ers’ Health Re­search In­sti­tute. Even if peo­ple agreed to switch to prospec­tive pay­ments, some heavy lift­ing would be re­quired by in­sur­ers, em­ploy­ers and busi­ness of­fices, not just clin­i­cians.

“We may have more rea­sons to do that, but do we have the ca­pac­ity at this mo­ment?” Is­gur said. “And will we have the will as the pan­demic winds down?”

 ?? Tom Fox/Staff Pho­tog­ra­pher ?? Stephen Buksh, a Eu­less fam­ily physi­cian, hasn’t had to lay off any staff at North­east Tar­rant In­ter­nal Medicine As­so­ci­ates. He sup­ports so­called prospec­tive pay­ments re­plac­ing the fee­for­ser­vice model.
Tom Fox/Staff Pho­tog­ra­pher Stephen Buksh, a Eu­less fam­ily physi­cian, hasn’t had to lay off any staff at North­east Tar­rant In­ter­nal Medicine As­so­ci­ates. He sup­ports so­called prospec­tive pay­ments re­plac­ing the fee­for­ser­vice model.
 ??  ??
 ?? Tom Fox/Staff Pho­tog­ra­pher ?? Dr. Stephen Buksh’s prac­tice serves adults whose in­sur­ance pays a monthly fee and those whose in­sur­ance pays a fee for each ser­vice. He prefers the for­mer.
Tom Fox/Staff Pho­tog­ra­pher Dr. Stephen Buksh’s prac­tice serves adults whose in­sur­ance pays a monthly fee and those whose in­sur­ance pays a fee for each ser­vice. He prefers the for­mer.
 ?? Staff Graphic SOURCE: The Physi­cians Foun­da­tion and Mer­ritt Hawkins ??
Staff Graphic SOURCE: The Physi­cians Foun­da­tion and Mer­ritt Hawkins

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