By Jeff Keeling
The Tennessee Medical Association (TMA) supports increased access to medical care for Tennesseans, its president, Kingsport gastroenterologist Dr. Doug Springer, told the Business Journal Jan. 23. That fact, though, didn’t keep the state’s largest professional organization for physicians from initially balking at endorsing Gov. Bill Haslam’s now-dead plan to extend Medicaid (TennCare) coverage to an estimated 280,000 uninsured Tennesseans. The reason? Those newly insured folks would enter a TennCare system that for two years has been experimenting with significant payment reform, and those experiments have doctors worried the state is a long way from getting things right.
“We are extremely concerned about the implementation of payment reform,” Springer said. The primary complaint is a perceived lack of input from physicians – the very people who have to adapt to a sea change in medicine, and whose own financial viability is on the line.
Talking with Springer and Dr. Nelson Gwaltney, a Bristol surgeon and president of 1,000-provider-strong Highlands Physicians, Inc., an independent physicians association, it quickly becomes clear that for doctors, the shift to a “population health” approach that aims to pay providers for keeping people well and doing it in a cost-effective manner will impact medicine far more in the long run than Medicaid expansion.
“This payment reform is going forward with or without Insure Tennessee,” Springer said.
What it is
In essence, payment reform transitions health care reimbursement models from fee-for-service to “value-based” payment systems. To stem continually rising health care costs – always a concern to the Tennessee legislature, where health care represents a large and growing portion of the state budget – the reforms flip care toward population health. In theory, “population-based models” such as patient-centered medical homes will reward provider teams who care for patients on an ongoing basis, promote prevention, treat chronic conditions and coordinate care over time. When it comes to acute events – surgeries and the like – the aim is to reward providers for delivering high-quality and efficient care.
According to language related to a $65 million “State Innovation Model” federal grant recently awarded to Tennessee by the Centers for Medicare and Medicaid Services (CMS), “providers will be rewarded for delivering high-quality, evidence-informed, coordinated and efficient care. Payers will reward outcomes rather than volume of services.” The federal money is supposed to help Tennessee implement a structure that makes that model work.
Tennessee’s government, in the same document, anticipates “cost-avoidance” of around $1.1 billion through three years, compared to baseline projections. Extending to 2020, the state projects $7.7 billion in savings over baseline projections, including savings back to the federal government (Medicaid and Medicare) of just more than $700 million.
“That’s the basis for the money that’s going to be used for changing the way medicine is paid for in Tennessee,” Springer said. He added that he has no beef with the need for reforms, or the theories behind gaining savings through population health.
“The current status quo is poor, fragmented care, and the TMA believes in reducing silos and team kind of care. We agree that however it can be done, we have to increase quality and reduce costs to the system. The state can’t afford things to continue in the direction they’ve been going.”
Gwaltney agreed. “Our physicians are more than willing to work with anyone, be it the government or insurance providers, hospitals, to come up with real solutions and not just politic. We want to sit down at the table and figure out really what’s going to make a difference.
“However you want to look at it,” Gwaltney added, “bundled payments, pay for performance, gain sharing, all those kinds of things are ways that you get the providers at the table to try to figure out what it’s going to take to make the process better. And better usually means higher quality and less expensive.”
Why doctors aren’t impressed so far
Springer said moving from theory to practice won’t be easy. Providers, he said, will be paid for outcomes based on various “episodes of care,” with teams that include everyone from primary care and specialty providers to hospitals and vendors. If a team delivers high quality and efficient care for an acute health care event, rewards are supposed to follow. The changes are supposed to “bend the cost curve,” the rising cost of health care as a percentage of GDP that some blame on fragmented care in a fee for service system.
The state rolled out episode of care experiments in asthma, joint replacement and perinatal care last year, Springer said, and has added gall bladder removal, colonoscopy, stent placement and a few others this year. Plans call for a rollout of five or six every six months, a measurement period of up to a year, and then full implementation of reports, rewards and penalties.
The process is occurring too fast and without adequate input from providers, Springer and Gwaltney both argue.
“We believe if you can work on three or four initiatives you’re doing well,” Gwaltney said. “You can’t work on 300 and do any of them well. If you work on a few and figure out what to do there, then you can move on to the next problem.”
In the month after Haslam’s Insure Tennessee announcement, Springer met with the governor, as well as with Brooks Daverman with Tennessee’s division of health care finance and administration. Daverman is responsible for implementing the payment reform initiative. TennCare’s chief medical officer, Wendy Long, was also in on discussions. Springer told them their work so far on developing technical advisory groups for episodes of care, and coming up with realistic cost and reimbursement models for the new payment methods, was falling short. Providers weren’t being given adequate data, and with multiple TennCare managed care organizations – major players in this whole thing – each sticking with its own proprietary data, there was no uniformity.
“That’s what I think was a shock to the TennCare bureau,” Springer said. “We said, ‘you’re making us responsible for trying to improve quality and bend the cost curve, and you’re not giving us information that we can actually act on.’”
Physicians need more information and more input, Springer said.
“There was almost no effort by the government to educate anybody on this. So we said, ‘educate everybody on what you want done. Then, when you develop these technical advisory groups, you’ve got everything together and you’re just about to roll it out, revisit the whole thing and make sure that’s exactly what you want. Test it a little bit.’”
The TennCare MCOs’ proprietary data is a problem as well, he said.
“It ought to be transparent, the metrics ought to all look the same, the actionable data all ought to look the same and the reports ought to look the same. The only thing that ought to look different at the top of the report ought to be the name of the MCO.”
Springer also said penalizing physicians based on the payment reforms shouldn’t occur until they’ve had at least a year to adjust. A grace period would assure greater physician buy-in.
“It’s a system that’s kind of living on a thread anyway, but you’ve got to make it as good as you can to make it as attractive as possible, and the least annoying, to the people that are trying to do the work. They haven’t done that yet.”
Springer was cautiously optimistic coming out of those meetings, he said.
“We’ve forwarded our concerns about the way we are responsible for the actionable data,” he said. “We can’t make a difference if there’s not actionable data. We’re concerned about the reports, the stuff that’s in the reports, and we’re concerned about how we can make a difference, and I think it’s being listened to by the government. All I can do is hope that they continue on this line of good communication and responsiveness to the concerns of TMA.”
Springer also said the SIM grant would allow for funding of an ombudsman position, a person who can act as a conduit between the government and physicians to help interpret reports and provide feedback. “The governor agreed to that,” he said.
Gwaltney agreed that actionable data is key, and said physicians and patients, more than government workers and the programs they represent, are the only ones who can make the transition from fee-for-service medicine work.
“You have to ask people to commit a significant amount of time to think through the process, get data to see if you can really make good decisions and then create a plan,” he said. “Then, convince the broader physician community and the patients that these new plans are really going to help them. If you just throw something out, the patients are going to push back because they don’t like being told what to do, and the physicians are the same way.
“If you can come up with a good idea, explain to the patients and physicians why it works and then move forward, you’ve got lots of opportunity.”