Featured in the March/April 2012 Colorado Medicine.
Alan Kimura, MD
As someone who appreciates racing cars and metaphors, I find myself bewildered by physicians’ lack of desire to jump behind the wheel and drive payment reform down the road to better health care. Physicians already understand the value of a good team in their practice and should also know that their contribution to the bigger health care team is not only desired, but critical. Yet these days all too often I find myself the only physician voice at critical meetings where payment reform and delivery system redesign strategies are being executed that will reshape Colorado health care. It’s at these times that an old saying keeps rumbling through my mind: “Sometimes you’re the windshield and sometimes you’re the bug.”
Many of my peers may think that being a virtual spectator connected only through news stories and magazine articles is enough. It is not. To lead the team that is building the figurative car that is the health care system, you must become engaged, rev your curiosity and professional commitment, and accelerate your thinking on the road ahead by finding out what payment reform means for you, your practice and your patients.
The race is on
Let me be clear. Payment reform is very much a reality in Colorado thanks in part to the work of the Center for Value in Health Care (CIVHC). CIVHC’s efforts to achieve the Triple Aim are focused on transforming Colorado health care by 2018 into integrated delivery systems that utilize global payments. The 2015 “midway milepost” to this larger plan centers on a blended approach to payment reform that includes:
- Severity-adjusted bundled payments for specified chronic conditions and procedures;
- Care management payments to primary care practices for care outside bundled arrangements (some fee-for-service still);
- Fee-for-service payments to specialists for care outside bundled arrangements and
- Some “virtually integrated” systems in urban areas.
Perhaps you’re thinking, “What can I really do? The system is too big and complex, maybe I can just ride this out.” I’m here to tell you that physicians cannot and should not take their eyes off this road. We don’t have to look very far to see that we cannot afford “this” anymore. The evidence is right in front of our faces – from the failure of a permanent fix for Medicare funding (also known as the Sustainable Growth Rate, or SGR), to the federal deficit debate, to state budget holes, to an increasingly bellicose business community demanding lower costs. Our resources are finite and the pay-for-volume system is running out of gas. The bottom line is the bottom line, and efforts are accelerating to find the brakes for these runaway costs.
Shift from fee-for-service to bundling
I believe that physicians are at the apex of the health care delivery system. Either we step up and engage or we risk being bystanders in the process that will radically transform the practice of medicine. That’s why I represent the Colorado Medical Society on the CIVHC Payment Reform Implementation Work Group. This group of hospital administrators, physicians, advanced practice nurses, health plans and patient advocates identified a list of conditions and procedures that can be bundled into one payment that includes all work associated with the respective condition or procedure. These conditions/procedures include asthma, coronary artery disease, coronary artery bypass graft, hip replacement, total knee replacement and lumbar fusion unrelated to scoliosis. The work group will soon disseminate a toolkit of resources to help providers and plans to develop those bundles. The group is also working on care coordination/management fees for primary care patient-centered medical homes.
We need more physician engagement and participation in this work. CIVHC is using a deliberate approach that seeks broad participation and feedback on bundling and care coordination payments, as they are “way stations” toward global payments. CIVHC is also using the latest literature and data, and once it gets the All Payer Claims Database up and running later this year there will be even better information to drive change. Commercial health plans are already rolling out alternative payment models and through this work CIVHC is attempting to focus attention and drive consistency across payers. For example, by 2013 CIVHC intends to secure agreements from major payers representing 50 percent of covered lives in Colorado to implement specified bundled payments or limited global payments.
These new approaches are exciting because they can advance health care quality, shared decision-making, integration of evidence-based practices, prevention initiatives and care coordination. However, care must be taken so that quality of care is not sacrificed in the drive to cut costs. The metrics of quality must be relevant and actionable (non-intrusive to clinical workflow). Again, a lack of physician engagement creates a void when a strong and deft hand is required on the wheel.
Get into gear
This is the time to get it into gear. Payment reform is not going away and now is your chance to exert your professional muscle and be part of the change. Check out the details of CIVHC’s work at www.civhc.org, meet with your colleagues, your component and/or specialty society and CMS to vet these proposals and help build a high-performance health care system. It is our responsibility to be good stewards of our patients’ health and our society’s fiscal health.