The Dallas Morning News
Advance monthly payments: Could they be health care fix?
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?”