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INSPIRATIONAL
proven Independent Physician Association (IPA). Yet others are still
independent. Seldom does the marketplace agree with one model
over another, which is why there are many substitutes designed to
accommodate the needs of a wide group of physicians and their re-
spective philosophies in the practice of medicine. The regulatory en-
vironment will never go away; however, the market will allow many
options for physicians as to how and with whom they want to align
with to manage the maze of regulations.
Physicians should adapt to the increasing payment systems that
continue to change. Now many physicians should pay attention to
the outcome of patient services to be appropriately reimbursed in-
stead of volume of services provided to patients. This new payment
system, as part of the ACA, can be the silver lining of the ACA.
Under the Medicare Advantage program, the health plans are paid
based on the previous claims experience of the patients that have se-
lected the doctor as their Primary Care Physician (PCP). The patient
is assigned a Risk Adjustment Processing System (RAPS) score.
Thus, each patient has a dollar amount that correlates to the RAPS
score. A patient that is “healthy” has a lower dollar amount assigned
to the patient. A “sick” patient has a higher dollar amount assigned
to the patient. A patient that does not have a lot of health problems
or has health problems and has not seen a physician in a while will
have a low “risk adjustment score” which will equate to a lower pay-
ment to the health plan from Center of Medicare and Medicaid
Services (CMS).
The health plans often enter into various reimbursements with
physicians in one of three broad categories. Physicians that are cap-
itated by the health plans often see an adjustment in their capitation adopt accordingly. In this one narrow space of the ACA, both the
payment correlated to the RAP scores. A physician that receive FFS
are largely unaffected on the front end on RAP scores since they are
paid on a FFS basis. Physicians that enter into risk arrangements
can be affected by the RAP scores. Physicians that accept risk from
a health plan can be have their upside bonus money at risk for many
factors including satisfaction levels of the patient. For Physicians
that are passionate in providing the right level of care with a high
level of service will ultimately receive, over time, increasing higher with the value based payment system. Of course, no reimbursement
reimbursements for their patients when they enter into risk arrange-
ments with health plans directly or via an IPA. The administration
of this population based model is indeed complex; however, there
are many companies and IPAs that have been created to assist inde-
pendent physicians with managing the maze so physicians can do
what they love; practice medicine and improve the outcomes of their
patients.
The silver lining in this value based model is that most Primary
Care Physicians (PCPs) can continue practicing medicine. They can
treat the patient for co-morbidities if needed, follow-up on the
progress of the patient’s care, and provide a high level of customer
service. In other words, physicians can be rewarded for doing what
they have been trained to do all along: treat the entirety of the pa-
tient and get appropriately paid for the services provided. Some of
the IPAs create a model that works so well to incentivize physicians
to spend more quality time with each patient and to participate in
MEDICINE
the coordination of care for patients. Of course, the doctor must
be in the right IPA model and in a risk sharing IPA to see upside fi-
nancial potential in such a model.
The emphasis going forward will be on population based man-
agement, which is simply making sure that the patients under the
care of a doctor are receiving appropriate outcomes and follow-up
and that the interventions are indeed working. Yes, this will require
additional management of the patients in a different manner than
many physicians have been accustomed to managing. Nevertheless,
the marketplace has responded to assisting the physician in the man-
agement of this population. There are many Accountable Care Or-
ganizations (ACOs) that can assist, though some ACOs do not have
a proven track record. There are also various IPAs that have assisted
physicians to receive up to 200 percent of the FFS Medicare equiv-
alent when the PCPs perform the care that they were trained and
motivated to perform.
It is true that the ACA has dramatically changed the way physi-
cians must approach the practice of patients to keep their practice
viable. And the ACA has created many unintended consequences
for many physicians that have not been very positive. Nevertheless,
they do not have to go it alone since the marketplace has adopted
many delivery systems to help the physician manage the new regu-
latory environment. Medical Societies are one of the advocates for
physicians in managing the new regulatory environment. Inde-
pendent Practice Associations (IPAs) are yet another, that advocate
for physicians. Physicians can select a “business” model that suits
their practice, lifestyle, and philosophy and many will earn more in-
come because of the ACA if they pay attention to the changes and
doctor and the regulators want the same thing; improved outcomes
for patients and higher reimbursements for Physicians!
Seldom is regulation all good or bad. And there are times when it
can be difficult to see any good of some regulation. In the case of
the ACA, paying physicians for creating a good outcome for a pa-
tient is appropriate. Physicians can be rewarded for their passion
system is perfect and though there can be rewards to the physician,
there can also be pitfalls, which is why it can be helpful to seek as-
sistance from organizations that can help the physician navigate
through the maze of an increasing and hostile regulatory framework.
Finding the silver lining of a regulation is not easy; however, there
are times when it does exist.
Alan Preston, MHA, Sc.D., is the Executive Director of
IntegraNet Health, an IPA that helps physicians navigate
through the difficult regulatory framework and helps them
achieve higher reimbursements from insurance companies.
His experience has been divided between running HMOs, large physi-
cian practices, and academia. He earned both his Master’s and his Doc-
torate at Tulane’s School of Public Health and Tropical Medicine in
Health Services Research and Epidemiology
visit us at www.bcms.org 25