FEATURE
( continued from page 9 ) MIPs includes the Physician Value-Based Modifier Program , a new quality incentive , quality scores based upon standard measures , physician practice improvements to self-identified areas , and use of interoperable electronic medical records . The data obtained this year will impact individual physician payments in 2019 . The APMs function more at organized physician level with the Next Generation ACO , Shared Savings Models , and Comprehensive Primary Care Plus . APMs have much greater upside rewards but also carry equal opportunity for losses . Because there is less published currently than last year , physicians may forget that they are now in a time of data collection which will impact them in the future .
More recently commercial insurers and Medicaid plans are moving into the value-based purchasing arena . The CMS programs , as confusing as they can be , are at least the same set of programs across the country . But since Medicaid is state operated , there will be significant differences in how the Value-Based Reimbursement programs are constructed . By the same token the number of insurers a practice accepts will be expressed in the variety of VBP programs the practice may participate in . Certainly , clinical practices won ’ t be able to make significant efforts to identify patients for specific services if their insurer has only a small fraction of the doctor ’ s practice . But for the top several health plans in a practice , the physicians and managers will need to plan ahead carefully . This will require that the electronic medical record is capable of identifying patients with specific conditions by ICD-10 coding so that those patients can be tracked according to their insurer ’ s required quality scores . Reminiscent of a decade ago when health plans competed for employer business by touting how many “ quality measures ” they used in their transparency tools , we may be finding ourselves in a similar spot as health plans position themselves as experts in Value-Based Purchasing . If the new health plan incentives become too disparate or too taxing , then physician ability to participate will decline .
The newest twist on the Value-Based programs is that of Value-Based Insurance Design ( VBID ). By adjusting health plan benefits , the goal is to start creating incentives for the members / patients to be more engaged . This is a concept that physicians have requested for decades . Doctors are often frustrated that benefit designs , approved by State Departments of Insurance , have not held the member / patient culpable for their behaviors that contribute to morbidity . The Rand Corporation and the University of Michigan Institute for Healthcare Policy and Innovation have been providing encouragement of health plans to make modifications of benefit design within the allowable framework of the Affordable Care Act ( ACA ). Employees covered by a VBID health insurance may have incentives for obtaining preventive services , adherence to prescribed medicines or engagement with a wellness coach . Members will have positive incentives for seeking care at the appropriate level and greater penalties if they don ’ t . This might be lower payments for seeking out a Primary Care Physician ( PC ) or urgent care center rather than going to the ER . There can be even greater member financial responsibilities for seeing a physician whose quality and utilization scores are below region adjusted averages . Greater use of telemedicine is considered part of VBID so that there is access for primary level services even if the member ’ s regular physician is not available . Some of these new Value-Based Insurance Design elements will be supported by physicians but other aspects will be viewed with great caution .
The concept of payment for accountability is now shifting more to choices that our patients make . No longer are the hospitals and physicians the only ones that the public and private payers base payment on how they meet process or outcomes measures . This is a significant change from the recent view that consumers are passive recipients of care . The new value-based purchasing and value-based benefit designs put responsibility for health outcomes on the member / patient as well as the physician . If the execution meets the promise , then this new direction holds hope for greater patient responsibility .
Dr . James is the Senior Medical Director for Highmark Inc . in Pittsburgh , PA .
Citations
1 .) Ryan AM , Krinsky S , Maurer KA , Dimick JB , Changes in hospital quality associated with hospital value-based purchasing . NEJM 376 ; 24 , 2358-2366 , June 15 , 2017
2 .) University of Michigan Institute for Health Policy and Innovation , Policy Brief Value-Based Insurance Design : Shifting the Health Care Cost Discussion from How Much to How Well , Oct . 2014 http :// ihpi . umich . edu / sites / default / files / IHPI-VBID . pdf
3 .) Fendrick AM , Chernew ME . Precision Benefit Design-Using “ Smarter ” Deductibles to Better Engage Consumers and Mitigate Cost-Related Nonadherence . JAMA Intern Med . 2017 Mar 1 ; 177 ( 3 ): 368-370
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