Internists tasked with implementing the triple aim

The year 2019 will be here sooner than you think, and that is important for 2 reasons. First, the Centers for Medicare & Medicaid Services (CMS) will transition from the present quality-based Physician Quality Reporting System (PQRS), Value-Based Payment (VBP), and Meaningful Use (MU) programs to the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APMs). Second, 2017 is the first measurement year for 2019 payments.

The overarching theme of these programs is the triple aim of health care: better patient experience, improved population health, and higher quality at lower cost. General internal medicine and family medicine have been tasked with being the stewards of this initiative to improve the practice of American medicine.

For many of us, the decision to participate has arrived. The first decision is whether to accept health insurance or not. Nationally, about 5% to 6% of internists have decided to practice concierge or direct-pay medicine. ACP recently published a paper on issues to consider in this model of practice, “Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians,” which appeared in the Dec. 15, 2015, Annals of Internal Medicine.

Internists who decide to accept insurance will have to choose between the MIPS and APM programs. To be successful in either MIPS or APM, physicians will need to have a practice with a vision and goals to provide high-quality and low-cost care in a team-based approach. The patient-centered medical home (PCMH) model of care seems to align with the above goals. My practice of 8 physicians in southern Rhode Island has been a level 3 PCMH in a multi-stakeholder initiative for 5 years. Here is what we have learned:

• Patients need to be an important member of the team with consideration of their expectations and values in shared decision making;
• Staff needs to feel important (through education and training) in fulfilling the vision and goals;
• Clinicians need to provide high-value care with judicious use of laboratory testing, imaging, generic prescribing, and appropriate specialty referrals;
• Practice access is extremely important, with consistent evening and weekend hours, same-day appointments, and walk-in capabilities;
• The office team needs to have close collaboration and coordination with specialists and follow through on emergency department visits and hospital admissions; and
• The office team needs to perform accurate and complete clinical data entry, retrieval, and reporting for quality and cost measures.

The development and maintenance of our PCMH model were funded by a statewide multi-stakeholder collaborative of health plans and CMS. The funds support clinical nurse managers, infrastructure development, and maintenance with monthly dollars per member payments.

A recent study by Magill and colleagues in the September/October 2015 Annals of Family Medicine quotes a cost of approximately $100,000 per year per physician to practice this model of care. Our experience is consistent with this study. It is clear that present fee-for-service reimbursement based on evaluation and management codes cannot support this model of care.

The MIPS program adjusts payment up or down up to 4% in the first year, escalating to 9% in the fifth year. PCMH will give you an option to enter into an APM such as an accountable care organization (ACO) or remain a PCMH and receive an additional 5% per year. ACO participation does require assuming some downside risk with possible additional gains.

It remains unclear how internists will perform in the MIPS or ACO programs. We know from the initial 353 organizations that participated in the CMS demonstration project of ACOs (Shared Savings and Pioneer) that only about 30% had savings and returned a payment.

I think much of the transition to quality- and cost-based payment remains a morass. It is still not clear that the vast majority of practices will be able to meet these ambitious goals to move the needle on health care costs and quality. It is also not clear if the savings and quality improvements are sustainable over the long horizon and not a function of picking the “low-hanging fruit.”

Finally, the holy grail remains funding sources. Small, medium, and to some degree large practices cannot develop the complex information technology and employ personnel to achieve the triple aim of health care on fee-for-service payments. Supple-mental payments in the form of monthly member payments, pay-for-performance payments, enhanced fee-for-service, or population-based global payment are essential to success.

Having said that, there are successes around the country, and if you plan on practicing more than 5 years, I would suggest that you need to do the following:

• Merge if needed to create an office of at least 6 to 8 internists;
• Develop a PCMH team-based approach to care;
• Secure external funding through a multi-stakeholder health plan initiative; and
• Choose between MIPS and APM.

If you do decide to stay on the grid of health insurance participation, I think it is essential that you choose one of the new options. ACP has several resources to help with your decision and management of your office. The transformation to quality-based payment is one of the most important changes in health care of the last 50 years. Let us see if this will achieve the triple aim of health care.

I look forward to hearing from you in person or by e-mail in my year as your President.