Looking ahead to 2020—Seeking clarity in a cloud of change and disruption

By Tom Banning

Momentum continues to grow for value-based payment initiatives and other alternative payment models to fee for service. According to a report from the Health Care Payment Learning and Action Network, 34% of all U.S. health care payments in 2017 were tied to the value of care delivered, up from 23% in 2015.

The Centers for Medicare and Medicaid Services has led the charge toward value-based payment models, through various programs that design, pilot, and reward providers’ participation in them–pay for performance, Medicare Shared Savings ACOs, bundled payments, etc. Additionally, Medicare Advantage participation continues to grow and flourish. Commercial insurers are also beginning to aggressively drive payment models away from fee for service toward total cost of care, capitation, and value-based payments through exclusive provider or narrow networks.

Despite an accelerating trend toward alternative payment models, many physicians are not completely on board with the shift to value-based payment models. A recent survey of payers and providers found physicians are feeling varying levels of reluctance. Concerns include the belief that quality measures are too complex to achieve, and that physicians do not have all the information they need about their patients to improve outcomes. Some payers also believe that physicians lack tools necessary to succeed in a value-based payment model.

According to Lisa Bielamowicz, MD, of Gist Healthcare, “Physicians’ concerns are understandable; realizing clinical and financial success in a value-based payment model requires innovative business models and great skill in population health management that many providers have not yet developed. However, shrinking margins due to an older, sicker U.S. population and ever more sophisticated and costly treatments, combined with payers’ pressure to deliver a better return on the care dollars they invest may push providers toward value-based payment despite their concerns.”

The reluctance of physicians to adapt to these changes has created a void that corporate America and venture-capital-financed disruptors are exploiting by building radically different care models that depend very little on doctors. Texas has become a testing ground for disruptors looking to refine their consumer-focused care offerings.

Payers, retailers, hospitals, and third-party telemedicine providers are seeking to disintermediate physicians from their patients. For example:

  • Blue Cross Blue Shield of Texas, announced a partnership with global health care firm Sanitas to launch 10 primary care clinics in Houston and Dallas next year. They intend to expand to Austin and El Paso. The clinics will provide health and wellness services in addition to primary care, imaging, and lab services.
  • Texas is also the test market for CVS-Aetna’s HealthHUB pilot stores, which opened in Houston in February.
  • Walmart will launch a new standalone primary care clinic, offering a comprehensive array of services including behavioral health, audiology, dental, and vision care. The new clinic is branded Walmart Health, and they are differentiated from the retailer’s Care Clinics, which offer a range of health care services inside 20 Walmart Stores in Georgia, Texas, and South Carolina.
  • Amazon has agreed to acquire a new health care platform, Health Navigator, an online symptom checker and virtual triage service. The company works with a range of telemedicine, EHR, and call center companies, providing clinical content and a diagnosis engine that enables virtual triage of patients based on symptoms using a natural language processing tool to capture patient complaints and match them to clinical conditions.

TAFP physician leadership and staff have been sounding the alarms with AAFP, TMA, and our individual members on these market developments. TAFP succeeded in passing a resolution through TMA to conduct a comprehensive study of these market developments and develop a data-driven strategy to assure fair business practices and enforceable protections from predatory behavior and adverse patient consequences that empowers physicians to compete and thrive in Texas’ health care markets.

These changing market dynamics underscore the need for doctors to work together to create lower cost, consumer-friendly care models. No matter what size or type your practice may be, three questions face us all. How shall we prepare for these changes? How can we best compete in this new environment? And how should we rightly define patient or consumer value?

We’d like to hear from you. What are you doing to prepare for these market changes and how can TAFP assist you in those efforts? Email Jonathan Nelson at jnelson@tafp.org and let us know.

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