New payment models in health care Who should lead the change?

I had a small skin problem that (I thought) called for seeing a dermatologist. At my health plan, one still needs to get a referral to see a specialist, and it took me a while to get to see my doctor. Once I got to the appointment, however, the doctor did an eloquent job of convincing me that I didn’t need medical treatment. He shared tools with me to help me understand what kinds of problems I should follow up on and what was benign.

I was slightly annoyed at having wasted my time to go in, but he charmed me into a good mood by telling me about the change he’d made in his career. He had retired from private practice to work for a large health system on a salary. He told me how much he enjoyed convincing people not to get unnecessary care rather than finding a reason to provide more treatment, which, in his old practice, helped maintain his income. I think my dermatologist is unusual in seeking out a new approach to medicine.

I’ve reflected on that conversation several times as I looked at the results of Deloitte’s 2014 survey of US physicians.¹ Respondents expressed concern about shifting to value-based payment approaches, which is what public and private purchasers are calling for and most of which create bonuses or penalties based on total cost of care for a patient and quality of results. Surveyed physicians are—in essence—concerned that they will be penalized for factors outside their control. This concern is clearly present in the responses despite the other interesting finding—that physicians predict 50 percent of their incomes will be through these new payment systems within 10 years. So, physicians see the change coming but are worried about it.

A number of different stakeholders are pushing for change; some are more influential and trusted than others. Payers—not traditionally popular with many physicians—are pushing hard. Health plans and health systems adopting value-based care models like Accountable Care Organizations are leading the charge. So is Medicare, with its goals for transforming the traditional part of the program. Medicare also recently announced funding for private organizations to help support change.²

Could and should physician membership organizations or boards,too, lead this change? Or should they react with the same caution as many of their members? On the one hand, such organizations have great access to their members, and their leadership usually works hard to keep members’ interests front of mind. Some examples include the American Academy of Cardiology’s work on quality measure development and the Society of Thoracic Surgeons’ registry intended to help surgeons benchmark their performance to others’.

Another is the work of the American Board of Internal Medicine’s (ABIM) foundation around the Choosing Wisely campaign. With other stakeholders, the foundation is asking physician groups to identify services that are overused or should be used more thoughtfully. Organizations moving on to value-based care might target these services to watch more closely and educate physicians to be more parsimonious in their use.

On the other hand, if organizations get ahead of their membership, they may risk rebellion.

A recent kerfuffle illustrates the risks of leading change as a membership organization. Several articles have revealed strong discontent among internists with the ABIM’s approach to influencing physician performance.

ABIM requires internal medicine specialists to demonstrate that their knowledge is up to date by taking regular tests in its Maintenance of Certification (MOC) program. This program, involving a periodic test of a physician’s knowledge, has “raised the bar” by adding more content and requirements over time. More physicians are failing the tests.

One school of thought would say that the ABIM has been visionary in trying to improve value in health care with initiatives like these. The other school of thought, articulated in the article, The ugly civil war in American medicine, takes aim at the MOC program.³ It says ABIM has been forcing this change for its own financial betterment. Physicians pay to take these tests, and if more physicians fail, they need to pay more to retake the tests. These critics also say that “raising the bar” has been achieved by adding questions to the test that are unfair—one of the big concerns we heard in our physician survey.

It is too soon to tell what ABIM will decide to do in response to the criticism—I will watch with interest. The organization may have a public relations challenge on its hands and should consider how to re-engage with internists. I hope they are able to preserve the best parts of their strategy while keeping their members on board.

Should physician member organizations lead charge? My answer is yes, if they are careful to get a buy-in from critical members and make sure that the strategy is as good in execution as it is in concept.