SGR Fix: APMs threaten physician burnout (RAND)

RAND Corporation
March 19, 2015
Effects of Health Care Payment Models on Physician Practice in the
United States
By Mark W. Friedberg, Peggy G. Chen, Chapin White, Olivia Jung, Laura
Raaen, Samuel Hirshman, Emily Hoch, Clare Stevens, Paul B. Ginsburg,
Lawrence P. Casalino, Michael Tutty, Carol Vargo, Lisa Lipinski

The project reported here, sponsored by the American Medical Association
(AMA), aimed to describe the effects that alternative health care
payment models (i.e., models other than fee-for-service payment) have on
physicians and physician practices in the United States. These payment
models included capitation, episode-based and bundled payment, shared
savings, pay for performance, and retainer-based practice. Accountable
care organizations and medical homes, which are two recently expanding
practice and organization models that feature combinations of these
alternative payment models, were also included. Project findings are
intended to help guide efforts by the AMA and other stakeholders to make
improvements to current and future alternative payment programs and help
physician practices succeed in these new payment models.

Physician Incentives and Compensation

Practice leaders described transforming certain practice-level financial
incentives (especially those concerning cost containment) into internal
nonfinancial incentives for individual physicians, choosing instead to
appeal to physicians' sense of professionalism, competitiveness, and
desire to improve patient care. Common nonfinancial incentives included
performance feedback and selectively retaining or terminating their
physicians based on quality or efficiency performance.

Generally speaking, alternative payment models had negligible effects on
the aggregate income of individual physicians within our sample.

Physician Work and Professional Satisfaction

Within our sample, alternative payment models had not substantially
changed how physicians delivered face-to-face patient care. However, the
overall quantity and intensity of physician work had increased because
of growing patient volume expectations and ongoing pressure for
physicians to practice at the "top of license" (e.g., by delegating less
intense patient encounters to allied health professionals), which was
described as a potential contributor to burnout because lower-intensity
patients could be an important source of respite for busy physicians.

Additional nonclinical work, particularly documentation requirements,
created significant discontent. Physicians recognized the value of
documentation tasks that were directly related to improvements in
patient care, such as identifying patients with diabetes to facilitate
better management of all patients with this condition, but they disliked
the extra burden generated when documentation requirements were
perceived as irrelevant to patient care.

Most physicians in practice leadership positions were optimistic and
enthusiastic about alternative payment models, while most physicians not
in leadership roles expressed at least some level of apprehension,
particularly with regard to the documentation requirements of new
payment models. Overall, even these physicians seemed to believe that
major changes in payment methods would continue and acknowledged that
some changes were useful. Nevertheless, their attitude was frequently
one of resignation, rather than enthusiasm, because their day-to-day
work life was more difficult and included burdens they did not believe
would improve patient care.

Factors Limiting the Effectiveness of New Payment Models as Implemented

Physicians and practice leaders described encountering three general
types of operational problems in new payment programs that limited their
effectiveness and sapped physicians' enthusiasm for them.

First, physicians and practice leaders participating in a variety of
alternative payment models described encountering errors in data
integrity and timeliness, performance measure specification, and patient
attribution (the process by which patients are assigned to a specific
physician or practice). These payment models shared characteristics that
might have made errors more likely: They were administratively more
complex than FFS payment; some required payers to develop new
measurement systems; and some were deployed for the first time quite
quickly, without a "dress rehearsal" in which errors could be corrected
before payments were on the line.

Second, physicians had a variety of concerns about the implementation of
performance and risk-adjustment measures underlying PFP, shared savings,
and capitation programs. Broadly speaking, these concerns stemmed from a
sense that the multiplicity of measures within and across programs could
distract physician practices from making the changes to patient care
that were actually the ultimate goal of many payment programs.

Third, the influence of uncontrollable, game-changing events in shared
savings and capitation programs (e.g., the introduction of very
high-cost specialty drugs) sapped physician practices' enthusiasm for
these payment models. Finally, some physicians reported that they could
not understand exactly what behaviors were being encouraged or
discouraged by certain performance-based payment programs—even after
seeking clarification from payers.

Increased Stress and Time Pressure

New nonclinical work for physicians was almost universally disliked,
especially when there was no clear link to better patient care. For
example, frustration was common when physicians believed they were being
asked to spend more time on documentation solely to get credit for care
they had provided already. Overall, increased stress on physicians might
directly harm the quality of patient care and might also serve as a
marker that physicians are concerned about the quality of care they are
able to provide.

Full report (142 pages):
http://www.rand.org/content/dam/rand/pubs/research_reports/RR800/RR869/RAND_RR869.pdf

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Comment by Don McCanne

HR 1470, which Congress is scheduled to approve in only two days (March
26), would replace the flawed Sustainable Growth Rate (SGR) method of
determining Medicare payments with a new Merit-based Incentive Payment
System (MIPS). MIPS introduces considerable administrative complexity
which would be a great burden to physicians, but the legislation allows
physicians to opt out of MIPS by joining Alternative Payment Models
(APMs) such as Accountable Care Organizations (ACOs) or Patient Centered
Medical Homes (PCMHs). This RAND study of APMs reveals that physician
members of APMs are at very high risk of BURNOUT.

Some believe that the onerous structure of MIPS was designed
specifically to drive physicians into APMs, especially ACOs. But is
moving from burnout to burnout really progress?

From the report: "(physicians') day-to-day work life was more difficult
and included burdens they did not believe would improve patient care."
Further: "Overall, increased stress on physicians might directly harm
the quality of patient care and might also serve as a marker that
physicians are concerned about the quality of care they are able to
provide."

This legislation will require physicians to submit to MIPS requirements
or join an APM, in either case incurring a high risk of burnout. But
health care should really be about the patient. Well, this does affect
patients, but in a bad way. Stressed-out physicians unintentionally
provide lower quality care. This is the exact opposite of the intent of
this legislation, assuming that higher value is intended to represent
higher quality.

Supporters say that getting rid of SGR is not only worth the legislative
compromise, but that the new MIPS provides the additional benefit of
improving quality, not to mention some CHIP funding being thrown in as
well. As we have seen, quality will likely be worse instead because of
the inevitable burnout. But now the supporters are responding with the
usual: "perfect being the enemy of the good," "art of legislative
compromise," "bipartisan support," "making sausage," and "must move on
to other priorities."

It's tempting to tell them what to do with their sausage, but, above
all, we should speak out loudly on behalf of our patients. This
legislation will make health care worse. With only two days left and the
steamroller in full momentum, can we do anything to prevent this
injustice about to be inflicted on patients and their health care
professionals?