In the mid-2010s, Longview internist Brenda Vozza, MD, was in the market for an alternative payment model (APM).
Traditional fee for service, which remunerates physicians for the quantity of services provided, left her wanting. Nor was she eager to adopt Medicare’s alternative to APMs: the Merit-Based Incentive Payment System, or MIPS. Meanwhile, she felt increasing pressure from Medicare’s stated goal of shifting all patients to value-based arrangements by 2030, with private payers following suit.
An accountable care organization (ACO) seemed the right kind of APM for her practice: a voluntary group of physicians and other health care professionals who share accountability for the quality and cost of care for a Medicare patient population.
But she struggled to find one in her East Texas community.
“Initially, I didn’t have any options at all,” she told Texas Medicine.
After five years of asking around, Dr. Vozza was approached by an ACO. Despite having reservations about the contract, she joined for lack of other options – and later struggled to access the data and support she needed to improve patient outcomes and reap any financial benefits.
“I had to understand how the system worked, and no one teaches you that in residency,” she said.
This learning curve is becoming less steep, thanks to trailblazers like Dr. Vozza, who served on TMA’s inaugural APM task force convened in May 2022.
Fee-for-service payment still dominates the U.S. health care system. But economic headwinds – including rising inflation, declining physician payment, and rampant industry consolidation – are pushing some practices across settings and specialties to seek supplementary revenue, according to recent surveys. (See “Taking the Value-Based Care Pulse,” page 32.)
Some payers are also putting forth a variety of APMs and, in the case of Medicare, spurring voluntary and sometimes mandatory participation with its looming 2030 deadline. Lawmakers are paying attention as well, with the Texas Legislature eyeing APMs’ potential for costs savings most recently during the 2023 regular and 2024 interim sessions.
“As with any successful health care payment model, sufficient guardrails are essential to help balance the inherent tensions between cost savings and high-quality, patient-centered care,” Zeke Silva III, MD, chair of TMA’s Council on Legislation, testified to the Senate Health and Human Services Committee in a May hearing on health care coverage (tma.tips/HHSTestimonyMay).
To help physicians navigate this landscape, the TMA House of Delegates in May approved the formation of a standing Committee on APMs, which will replace its predecessor task force and report to the Council on Socioeconomics. The goal: to educate physicians regarding the different types of APMs and develop related legislative and regulatory recommendations (tma.tips/APMCommitteeReport).
Gary Sheppard, MD, an internist in Houston and chair of TMA’s Council on Socioeconomics, submitted written testimony on behalf of the council in support of the new committee at TexMed. He cited Medicare’s push toward value-based care and its catalyzing influence on private payers.
“Whether physicians support or oppose these payment models, there is no denying that our members are aware of this movement and will look to their TMA for information and education,” he wrote to the Reference Committee on Financial and Organizational Affairs.
Dr. Vozza says the formal committee will continue its work to develop resources for the value-based-care curious. She would have benefited from such support and is now eager to share her learnings with other Texas physicians.
For instance, she recently switched to a physician-led ACO, where she found more practice support to enable follow-up care.
“It actually saves me work, and it doesn’t take that much [staff] time to call patients,” Dr. Vozza said. “And the patients are happier. They say, ‘Oh, your staff is so great. They called me after I went to the ER.’”
Dr. Vozza says her patients are more forthcoming in the exam room, leading to higher-quality care and lower costs. As a result, her solo practice was able to reap additional profits and pour them back into office infrastructure.
“It’s nice to be able to spend it on things that make us happy as a physician,” she said.
Net positive
Susan Escudier, MD, an oncologist in Houston and vice president of value-based care and quality programs for Texas Oncology, is another early adopter. Despite some challenges, participating in APMs so far has benefited the large multispecialty practice.
Dr. Escudier traces her interest in value-based care back to its predecessors, including managed care plans and quality programs, and to concerns about the viability of fee-for-service payment systems.
In 2016, Texas Oncology began participating in its first APM: Medicare’s now-defunct Oncology Care Model. Since then, the practice has expanded its portfolio to include that model’s shared-savings successor, the Enhancing Oncology Model, along with bundled and pay-for-performance models, for instance.
Dr. Escudier says there are pros and cons to this approach.
Each model provides treatment guidance that supports consistent, high-quality care, with room for physician input, and hassle-free payment. Instead of chasing prior authorization approvals, the practice can invest in support services, such as social workers and care management, that improve patient outcomes.
But participation in multiple payment models, including fee-for-service, requires a dedicated staff to comply with constantly changing regulatory requirements, track inconsistent quality measures, and calculate physician compensation.
“It’s like having your foot in two different rowboats,” Dr. Escudier said, adding that additional staff for such tasks often is out of reach for small and solo practices.
She also cites the challenge of physician buy-in. Texas Oncology focuses on educating staff physicians about the APMs in which it participates. But “it’s constant reinforcement,” she said.
For these reasons, Dr. Escudier, who served on the APM task force, stresses the importance of cultivating physician discernment toward value-based care and of advocating for fair payer policies, including transparency around quality measures and patient attribution.
Patient choice
Sugar Land internist Elizabeth Torres, MD, has more mixed feelings about value-based care.
The member of the Texas Delegation to the American Medical Association belongs to three ACOs and operates a partial concierge practice. This patchwork affords her patients maximum choice. If they wish to access in-network care via their local health care system, she belongs to their ACO. If her patients can afford the monthly concierge fee, she will conduct home visits and accommodate appointments outside of office hours. If they can’t, her solo practice accepts other health plans.
But there is a cost. She laments “the bugaboo” of rigorous documentation requirements and care coordination with her patients’ other health care professionals, which add to her pajama time.
“We don’t always get credit for the work we have done, and we get penalized if patients don’t get their exams done. We do a lot of shared decision-making discussions with our patients and if they decide not to have their preventive exams done, we have to respect that decision,” she said. “You get compensated if you meet the goals, but you have to jump through a lot of hoops to get there.”
The patchwork of financing – with its mix of membership dues, delayed lump-sum payments, and other revenue – hardly guarantees her practice’s solvency, especially in the wake of the COVID-19 pandemic, from which it is still recovering.
“That fragmentation does hurt us as it does make it more difficult to focus on patient care,” she said, and leaves her uncertain about how to make value-based care more functional for her practice.
For instance, since 2016, she has helped grow one of her ACOs from six doctors caring for roughly 1,000 patients to 25 physician groups with a shared patient population of more than 80,000. She attributes its success to its physician leadership, which allows for more flexibility.
During this same period, she has since learned that ACOs are difficult to leave, namely because she worries about the impact on her patients and her practice.
“There’s always going to be a gap where [their care and] your payment is going to get interrupted,” she said.
Meeting physician needs
Recognizing the fast growth in value-based care payment models, there’s more advocacy to be done to ensure these models add value for practices like Dr. Torres’ and to engage non-participants, says David Fleeger, MD. The past TMA president, a colon and rectal surgeon in Austin, co-chaired the APM task force.
“This is something that’s going to happen and happen in the immediate future, so we need to get everybody educated,” he told Texas Medicine.
As this article went to press, TMA leaders were in the process of appointing participants to the nine-member body with regional representation of varying practice sizes, types, and specialties.
As the task force transitions to a standing committee, its members will:
- Research, develop, and recommend TMA policy relating to APMs;
- Identify and develop related regulatory, legislative, and budget recommendations; and
- Promote CME and other resources, including information focused on the financial aspects of value-based care.
Dr. Fleeger also acknowledges physician concerns about APMs, citing a dearth of options for specialists and payers’ prioritization of cost savings, sometimes at the expense of patient care. But he says the committee will work toward resolving them.
“We need to accumulate the knowledge and experience of those actively participating in [value-based care] to make sure that our doctors and our patients are not taken advantage of by federal, state, or private payer policy,” Dr. Fleeger testified at TexMed in May. “Given these needs and those to come, we are confident that the [committee] will serve our association well and hopefully raise all boats.”