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National Association of Managed Care Physicians Fall Forum 2019

Are Value-Based Models Helping or Hindering Care Delivery for Primary Care Providers?

Jaime Rosenberg
Value-based models continue to enter the healthcare system, affecting a variety of fields, including primary care. And while success stories have been shared by payers and CMS touts these models as a way to “save” primary care, that's not the current reality, said Theresa Hush, chief executive officer of Roji Health Intelligence, LLC, during a session on population health management at the National Association of Managed Care Physicians 2019 Fall Managed Care Forum, held October 10-11 in Las Vegas, Nevada.
 
Value-based models continue to enter the healthcare system, affecting a variety of fields, including primary care. And while success stories have been shared by payers and CMS touts these models as a way to “save” primary care, that's not the current reality, said Theresa Hush, chief executive officer of Roji Health Intelligence, LLC, during a session on population health management at the National Association of Managed Care Physicians 2019 Fall Managed Care Forum, held October 10-11 in Las Vegas, Nevada.

When asking the audience of primary care physicians (PCPs) if value-based care is shaping up to be organized and directed where every practice has a good option, just a few hands popped up. When Hush changed direction and asked if value-based care is shaping up to be chaotic and overwhelming, with physicians struggling to find the right fit, the majority of hands shot up.

However, changes made by CMS show urgency and intent in pushing value-based care in primary care, said Hush, who outlined a multitude of changes announced by the agency in just the last year. These changes include the overhaul of the Medicare accountable care organization (ACO) program, the announcement of consumer reports for comparing hospital quality, and Medicare Advantage being pushed to maximize competition.

Hush singled out another change that has particular implications for primary care: CMS Primary Cares Initiative, which will offer PCPs 5 new models that they can implement under 2 paths: Direct Contracting, which is focused on larger groups with at least 5000 Medicare lives and is similar to an ACO; and Primary Care First, which is designed for smaller groups that have historically not participated in value-based care. Both of these models, explained Hush, are meant to stimulate risk among PCPs.

No matter what value-based models providers are participating in, whether it be the 2 under the Primary Cares Initiative or under ACOs, physicians are at risk; however, the financial implications differ based on the model, said Hush.

While Direct Contracting, ACOs, and Medicare Advantage models all leave providers responsible for their costs of care, the extent to which they are responsible may differ. For example, Direct Contracting offers partial and global capitation. Meanwhile, under Primary Care First, there are rewards and penalties for hospital utilization.

But, no matter which model physicians choose, they’ll still require the same tools, including coordination of care, communication with hospitals, and risk stratification, said Hush.

However, the increasing presence of value-based models and concurrent push toward risk for PCPs are happening alongside primary care downsizing. According to The Physician’s Foundation 2018 Survey of America’s Physicians, 22% of PCPs are limiting or refusing Medicare patients, 46% plan to change career paths, 80% are at full capacity or are overextended, 17% plan to retire, and 22% will reduce hours in the next 1 to 3 years.

At the same time, physician leadership is fading, according to Hush, who explained that there are fewer physician owner and more hospital owners practice sizes are growing, and internists are increasingly practicing in large multi-specialty groups.


 
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