Physician Payment and Reimbursement

Few Physicians Support Value-Based Models: Survey

February 1, 2018 9:31 am

Organizations have found physicians can be successfully engaged in value-based payment models if they use certain approaches.

Jan. 31—Most physicians are unconvinced that high-profile value-based payment models will either control costs or improve patient health outcomes, according to a recent survey

Only one-fifth of physicians thought either bundled payments or hospital-led accountable care organizations (ACOs) would contain healthcare costs, according to a Leavitt Partners survey of 621 physicians. Similarly, few thought patient health improvements likely would result from bundled payments (19 percent), ACOs (29 percent), or episode-based payments (29 percent). 

The lack of physician belief in emerging value-based payment models likely stems from unfamiliarity with their specific efforts, goals and results, said David Muhlestein, PhD, chief research officer for Leavitt. Although a large number of hospitals, health systems, and practices are involved in ACOs and bundled payments, for example, few frontline physicians are aware of what those organizations are doing to participate and to improve results.  

“We’re capturing that a lot of physicians don’t have valid experience to really assess that,” Muhlestein said about payment model efficacy. Pluralities of physicians were uncertain about the patient health benefits of ACOs (46 percent), bundled payments (48 percent), capitated payments (45 percent), and patient-centered medical homes (46 percent). And majorities were uncertain about the health benefits of integrated delivery networks (56 percent), episode-based payments (55 percent), and global payments (58 percent).

Additionally, some physicians were aware that their employer is participating in value-based payment models but saw such participation in a negative light because it is different, affects how they are paid, and is of questionable value to them. 

“There is an opportunity for [employers] to educate their physicians and clinicians and help them at least be aware of the changes that are happening and how they are intended to help the patient,” Muhlestein said in an interview.

More likely to improve outcomes, according to physicians in the survey, are physician pay for performance (40 percent) and patient-centered medical homes (40 percent). More likely to contain costs are an increased focus on wellness and prevention (60 percent), improved management of mental health (56 percent), and better management of heavy utilizers of care (52 percent). 

Indicating another challenge related to new payments models, only 41 percent of physicians were at least somewhat familiar with the requirements of the Medicare Access and CHIP Reauthorization Act (MACRA). 

“We didn’t ask their opinion about MACRA and whether it would make a difference, but I imagine it would be similar where a lot of them simply don’t know because they don’t know enough about the models to have an opinion yet,” Muhlestein said.

The survey did not find marked differences in physician views based on whether they were participating in value-based payment models. 

“A lot of this goes back to there being a lot of uncertainty,” Muhlestein said. “As a society we’re in the same bucket. We like to think we’re working toward the Triple Aim, but we really don’t know if it is going to work yet.”

Muhlestein was a little surprised about the strongly negative views of some payment models, such as capitated payments, with 37 percent of physicians saying they negatively impact patient health outcomes.  

“It’s hard to look at an ACO and say that there’s enough information to say for sure that it’s not going to work, but a quarter of physicians claim that they are going to be negative,” Muhlestein said.

Previous conversations by Leavitt advisers have found that frontline physicians are frequently uninformed about the practical effects of payment models or MACRA. Such unfamiliarity usually stems from an inability of organizations that operate such models to see the value in educating participating physicians about the benefits, and a lack of time on the part of physicians to receive such education. 

MACRA Impact

One reason why relatively few physicians appear focused on MACRA or the payment models it encourages is the two-year lag between physician performance and the resulting impact on Medicare payment. For that reason, Muhlestein expects that physicians won’t focus on the Medicare payment program until 2020.

“That’s when there will be a compelling business case or a financial dissatisfaction that could relate to the change,” Muhlestein said. “Right now, if you’re a small physician group and you are generally aware of MACRA and you are reporting on that, but you don’t have much of an opinion about ACOs and you don’t know what it takes to get there, you don’t have any incentive to move right now.” 

Engaging Physicians

In the case of ACOs, the lack of physician support generally is not due to a lack of efforts of those entities to engage them. 

Such buy-in is critical to the success of ACOs, leaders of such organizations told Muhlestein. 

Effective approaches to physician engagement include reaching out to all physicians—especially at smaller organizations—through a retreat or other type of group meeting. Such outreach allows organization leaders to discuss the reasons for participating in the model, the needed changes, and the potential benefits with their physicians before the payment model even has launched.  

“When you do that up front, you get a lot of people who say, ‘I don’t know if it is going to work, but it might be important,’” Muhlestein said. 

Such an approach usually instills at least a grudging willingness to experiment and eliminates outright negative attitudes. 

Another effective approach to engagement has focused on starting the model with a subset of clinicians who the organization believes are most amenable to moving toward value-based arrangements. That initial group would be included for the first few years, with the organization then publicizing the results and incorporating more physicians.

“There’s a million different approaches you can take, but it is hard,” Muhlestein said. “That’s the consensus that we hear. It’s difficult no matter which approach you use. It’s hard to get people to change their beliefs and opinions after they have been part of an organization for a long time and they have certain expectations.” 

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare 


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