AMA Pres: Alternate Payment Rules Can't Keep Changing

Doctors need to see consistency and predictability from alternative models if they are going to buy into them, says Steven J. Stack, AMA president.

Stack's thoughts come after CMS' new multi-payer initiative was announced earlier this week, aimed at improving primary care. CMS says the Comprehensive Primary Care Plus (CPC+) initiative will be implemented in up to 20 regions, accommodate up to 5,000 practices, and have an effect on more than 20,000 primary-care doctors in January 2017. It will give practices an upfront care management fee that they'll get to keep if they meet various performance-based quality and utilization performance thresholds.

While Stack says this model is a step up over previous efforts from the government, it remains to be seen whether or not it will get physicians on board with alternative payment models. A 2015 survey from Physicians Practice found that at present time, most doctors are not interested in value-based payment models.

Stack spoke with Physicians Practice for a two-part interview on the new payment model, how to win physicians over with government-based payment programs, and more. Part one of the interview is here. Part two is below.

Have you had any feedback from your members on putting income at risk for quality care - or on this kind of model in general?

We did a study in 2014 on how physicians were responding to new payments in delivery models in their practices. We found that physicians - and I am guessing there are physicians that would be surprised at this finding - but there were many who said they were willing and interested in addressing the payment system. The current system is frustrating for everyone. It's frustrating for patients navigating it, it's frustrating for physicians who feel there are constraints on what they can and cannot do…and it's frustrating for people footing the bill. They are all frustrated because the cost of care continues to escalate in a relentless way. So that study showed us physicians are eager to make transitions to some new payment methodologies, as long it's done thoughtfully and in coordination with delivery reform, which enables them to do what's right for patients and supports them, so they can have a professionally viable career. The current version is leading to physician frustration, demoralization, and burnout. All sorts of things that are horrible for our healing workforce, if they themselves are not well.

In that study, physicians said they were not given sufficient resources on the front-end to invest in their practices, that the models were designed in such a way, even if they did well, the rewards were small, and that the penalties were substantial if they failed. They said the ratios for the amounts of shared savings often … were not worth it. In the general construct CMS proposed (with the new payment model), there is evidence that those lessons have been taken to heart.

What can be done to win back the hearts and minds of physicians, as many are dismissive of government-based payment models?

There needs to be predictability and stability. We need to not be changing the rules every 12 months to18 months. You can't run a business when the payment method is changing year over year. Predictability and stability are important. The other thing is there needs to be candor and transparency.

Some of the methodologies for the current programs - the Value-Based Modifier or Meaningful Use - have set physicians up for failure. They are not good methodologies to do some of the things that are required. The likelihood of failure is high. Meaningful Use is an all or none, pass/fail paradigm. You get 100 percent you pass, you get 99.9 percent, you fail. Those kinds of things I think most Americans would feel are unreasonable and not fair.

CMS has to (design) programs that are reflective of the variation in healthcare that's appropriate and (accommodate for the fact) there are multiple ways to achieve different outcomes. If CMS can design programs that reflect the variation in physician care and patient needs, and hold physicians accountable for more reasonable deliverables … if that's able to be done over a period of years, physicians can come to learn to be accepting of CMS and less frustrated by it.

CMS could make my life harder by putting out well-thought-out programs with the necessary resources … and by designing a reasonable system that gives physicians a chance at success and hold them accountable for delivering reasonable outcomes. It would put me in the unusual position of perhaps having to admonish physicians to do better, instead of having to admonish CMS for unleashing unreasonable programs. I say that tongue in cheek, but not hatefully. We value our collaboration with CMS. As I said, on our first review, we're happy to say this new primary-care plus initiative appears to be responsive to inputs we've previously made. If this is a sign of things to come and CMS continues to be willing to revise the programs in response to thoughtful input, there could be opportunity for CMS to do really good work to help deliver programs that are higher quality and more affordable for patients.

Do you think, ultimately, this kind of model will help primary care become more appealing to physicians - amid concerns over primary-care shortages and physician burnout?

I think if the payment system supports the ability for primary-care physicians to provide high-quality care for patients, as well as run a sustainable and pleasant work place for themselves and their staffs, then I think this will be a positive force helping primary care in its work. There are other issues that also need to be addressed to draw and engage people into primary care. I'd say this is one piece of a much bigger puzzle for primary care's needs.