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PRESIDENT’S
MESSAGE
Redesigning primary care
is the first step
By Dr. Jayesh Shah, 2016 BCMS President
Last week, the Centers for Medicare & Medicaid Services
(CMS) announced the final rule for MACRA (Medicare Access
and CHIP Reauthorization Act). It replaces the old and flawed
sustainable growth rate formula for physician pay with a new
method meant to shift patients away from the fee-for-service
model to a value-based payment system, so physicians will get
paid by either a merit-based incentive payment system (MIPS)
or advanced alternative payment models. In MIPS, physicians’
pay is based on four performance categories including quality,
resource use, clinical practice improvement and advancing care
information.
CMS is actively making efforts to nudge physicians towards
value-based care. The final rule developed some more exemptions
which include exemptions for physicians who have less than
$30,000 in Medicare charges or physicians seeing less than 100
unique Medicare patients per year. CMS also pledged $100 mil-
lion in technical assistance to clinicians participating in MIPS
who are in small practices, rural areas, and/or in areas with a
shortage of health professionals.
In spite of this hurricane effort by CMS to change the direc-
tion of health care towards value-based care, the majority of
physicians working in the trenches are skeptical that this effort
will increase value or decrease cost. Some solo practitioners feel
that this will be a last nail in the coffin for their practices and cause many of the chronic diseases will be managed better when
will force them to close their practices.
I recently read an article by well-known business strategist and
Harvard Business School Professor Michael Porter about, “How
primary care needs to be redesigned.”
Porter and his colleagues define “value” as patient outcomes
achieved relative to the amount of money spent. I like his prac-
8 San Antonio Medicine • November 2016
tical approach of redefining and deconstructing the primary care
practices and grouping the patients into subgroups. Chronic dis-
eases account for 75 percent of our health care costs. If we sub-
group all chronic disease management patients into subgroups
under primary care practices, such as end stage renal disease sub-
group, coronary artery disease subgroup, diabetes mellitus sub-
group, etc. and then connect these subgroup teams with
telemedicine, it would definitely decrease cost and increase value.
I agree with Porter and his colleagues that by dividing and or-
ganizing teams and providing specialty care around patients’ sub-
groups will most likely make the provision of holistic and
integrative care more efficient.
I also like his idea of creating an umbrella structure for small
primary care practices so that they can redesign themselves. The
article suggests that the payment to the primary care practices
should be in the form of monthly fees based on the complexity
of patients, i.e. more monthly payments if a patient has more
chronic diseases like diabetes mellitus, hypertension, hypercho-
lesterolemia and renal disease. This model also allows paying for
episodic care if necessary, and gives incentives to physicians to
take care of complex patients in a value-based scenario.
Behavioral health care should not be considered separately.
Rather, it should be a part of chronic disease management be-
these patients get treatment of their co-existing mental illness si-
multaneously.
Redesigning primary care is necessary before any of the pay-
ment models will make a meaningful difference in health care
reform.