Re: payment reform

June 4, 2010

Hi

We are actually considering this if we

decide to opt out of Medicare. We would probably charge $375 per person

per year or $500 per couple per year. It would definitely make my life

easier. I’d love to do it for all of our patients, but we have a

relatively young, healthy population that balks at paying their $20 copay to

come in once/year. So for them, it doesn’t make sense. But

for our Medicare patients when no one else is accepting Medicare because SGR

hasn’t been fixed, it may be worth trying. I have a friend that has

no insurance that has switched to Steve and would probably pay that too, as she’s

paid almost $200 in the last 2 months for multiple visits and needs regular

follow-up.

Downsides for the payors are for the

young, healthy population. Why should they pay you $375 if the patient

never comes in or only comes in once/year? They are then losing

money. Of course, they are paying less for the older, sicker population,

so I think long term, the insurers would save money. Another downside –

more unemployment because there would need to be way fewer people working at

the insurance companies because they don’t need to adjudicate individual

claims and fewer people working in physician offices because they don’t

need billers/coders any more.

These are just my random (or

not-so-random) speculations about it.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of

Sent: Friday, June 04, 2010 7:14

AM

To:

Subject:

payment reform

Serious

question

There has been a proposal to pay primary care at a bundled rate of a

dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then

you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many

ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take

care of people in varying ways - email phone etc and reduce or

eliminate the hassle of billing/coding( some records would need to be

kept of course)

and could improve primary care's bottom line, working

conditions, abiltiy to function, and thereby increase access and

hopefully quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised

by payors or policy wonks etc , / or what have any of you

encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne

and am preparing for possible objections)

--

PATIENTS-please remember that email may not be entirely secure, and that

Email is part of the medical record and is placed into your chart (

be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

June 4, 2010

One issue that would have to be addressed in that model is the question of what is that $1 a day actually paying for? Does it include procedures in the office like shave biopsies, endometrial biopsies, IUD insertions, lac repairs? If so, can they assure that one primary care practice provides essentially the same types of services as the others. What if practice A refers out all basic skin biopsies and simple lacs, endometrial biopsies and such while practice B just stops short of providing appendectomies.How to account for different patient panel characteristics. What happens when 60% or more of our patients are 70+ (or in my case 60% or more could carry a diagnosis of anxiety which means every visit is longer than average in both cases). Factoring in the overhead

issue- if this were nationwide, the cost of living issue in regard to location and salaries for staff. What about me, the NP with my lower malpractice costs? Do I even get to play?I would want it designed to anticipate the many ways providers or payors could take advantage of the system. One provider could hire 10 RNs and take on 8000 patients managing them via telephone? Will there be some kind of guidelines? I would envision that a system like this would encourage physicians to hire the least expensive care providers possible- so would a doc prefer to hire 2 NPs and expand their patient panel by perhaps twice what hiring a more expensive doc (and I'm not saying either choice is preferable from a care perspective). How is quality evaluated? If the care delivery model changes significantly from what we have now and patients are more likely going to be "pushed" to use phone, email and such (seems

inevitable), will the same measures used currently (or those being developed in P4P etc) adequately measure the quality? I would think that the HYH type measurement would be even more germaine to this model. HYH components including Patient satisfaction and involvement in care and knowing who is the captain of their ship would be such a simple approach with perhaps the added parameters of utilization of urgent/ED/hospital services.Jean- you are amazing! We are cheering you on.CarlaTo:

< >Sent: Fri, June 4, 2010 8:13:55 AMSubject: payment reform

Serious question There has been a proposal to pay primary care at a bundled rate of a dollar a day for all the office care we can doso say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many ways without the fee for service structure) It has been calcuated that this would allow docs freedom to take care of people in varying ways - email phone etc and reduce or eliminate the hassle of billing/coding( some records would need to be kept of course)

and could improve primary care's bottom line, working conditions, abiltiy to function, and thereby increase access and hopefully quality in many way for patients So my question-- what are the possible downsides or what objections might be raised by payors or policy wonks etc , / or what have any of you encountered in pursing or thinking about such a model?

thanks( am asked to propose something here in MAIne and am preparing for possible objections)--

PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax

impcenter.org

June 4, 2010

this is very helpful- I would guess that there would be some guidelines about panel size no one doc can take care of 8000 patietns well, so

you might say panel size would have to be at least X and no more than Y per provider AS you say various practitioners do varying jobs-this impacts the panel size( all hiv patietns smaller panel size all young healthy families bigger size)

-however this payment system equalizes out the biopsies and the hand holding ,the higher level cognitive and the iud insertion the counselling , and etc right? Under the scope of primary care.

you could define quality a number of ways- preventable hospitalizations , er use, drug cost,all measurable by payors, and then the PROM stuff patient reported measures as a standardized thing hyh or equivalent how's that?

I would envision this for primary care and so you'd have to say well is that psych , peds and int med and primary care and well how do you include obgyn?do you?I am not the decider of that I am just thinking the basics fp int med peds folks I am just thinking what would be the hard questions to get a pilot started

there are lots of specilaist who are non procedural also, rheum and neuro ,who may make less... let s not zoom over my head I am working on a pilot idea of how you could reform primary care payment no fair asking very very very hard questions!

I have no idea what to say about midlevels There is both a justifciation that much of the work of primary care can be done by them but then not all .And docs do have more trianing and higher overhead becasue of that. I n some regions there may beonly midlevels available and no doc will work there- I do not know answers about that Proably some similar sort of capitaiton at a lower level.

I suspect that if you designed a pilot project partly you would earn from it HOW to expand to the situations you describe becasue those questions would come up and the working folks in the he pilot might know how to address once they trialed such a sys tem

This i s helpful thank you very much I fail t o see why I am amazing but thank you Remember this idea came from Egly! If you were paying any attention at all you would be saying what is wrong w ith you why did not you do this or say that and why are you so weird or calling OTHER things that begin with " a. " ....but thank you.

One issue that would have to be addressed in that model is the question of what is that $1 a day actually paying for? Does it include procedures in the office like shave biopsies, endometrial biopsies, IUD insertions, lac repairs? If so, can they assure that one primary care practice provides essentially the same types of services as the others. What if practice A refers out all basic skin biopsies and simple lacs, endometrial biopsies and such while practice B just stops short of providing appendectomies.

How to account for different patient panel characteristics. What happens when 60% or more of our patients are 70+ (or in my case 60% or more could carry a diagnosis of anxiety which means every visit is longer than average in both cases).

Factoring in the overhead

issue- if this were nationwide, the cost of living issue in regard to location and salaries for staff. What about me, the NP with my lower malpractice costs? Do I even get to play?I would want it designed to anticipate the many ways providers or payors could take advantage of the system. One provider could hire 10 RNs and take on 8000 patients managing them via telephone? Will there be some kind of guidelines? I would envision that a system like this would encourage physicians to hire the least expensive care providers possible- so would a doc prefer to hire 2 NPs and expand their patient panel by perhaps twice what hiring a more expensive doc (and I'm not saying either choice is preferable from a care perspective).

How is quality evaluated? If the care delivery model changes significantly from what we have now and patients are more likely going to be " pushed " to use phone, email and such (seems

inevitable), will the same measures used currently (or those being developed in P4P etc) adequately measure the quality? I would think that the HYH type measurement would be even more germaine to this model. HYH components including Patient satisfaction and involvement in care and knowing who is the captain of their ship would be such a simple approach with perhaps the added parameters of utilization of urgent/ED/hospital services.

Jean- you are amazing! We are cheering you on.Carla

To:

< >Sent: Fri, June 4, 2010 8:13:55 AM

Subject: payment reform

Serious question There has been a proposal to pay primary care at a bundled rate of a dollar a day for all the office care we can doso say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many ways without the fee for service structure) It has been calcuated that this would allow docs freedom to take care of people in varying ways - email phone etc and reduce or eliminate the hassle of billing/coding( some records would need to be kept of course)

and could improve primary care's bottom line, working conditions, abiltiy to function, and thereby increase access and hopefully quality in many way for patients So my question-- what are the possible downsides or what objections might be raised by payors or policy wonks etc , / or what have any of you encountered in pursing or thinking about such a model?

thanks( am asked to propose something here in MAIne and am preparing for possible objections)--

PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax

impcenter.org

-- PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)

Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD

ph fax impcenter.org

June 4, 2010

This idea is very much like the "direct care" approach. There, the patient pays a certain amount per month and sees the provider whenever they need to be seen. I've looked at several plans on various provider websites, and the one I'm going to use assesses a $75 joining fee, then allows a well visit every year (a few more for infants, per the recommended schedule) and up to six total visits annually. After the sixth visit, the patient is assessed a $10 copay per visit. This offsets some of the additional cost for those patients who either "want" to be seen more often (anxiety?) or "need" to be seen more often. My monthly cost will be $30/patient, maximum of $120 per family, so it looks like I'm right there with what's being proposed. Patients will pay discounted prices for their labs and radiology above those amounts.

I think it will appeal to those with high-deductible accounts.

Deanna, FNP

Beth's right, having a set fee per month would be low risk for larger practices (our small traditional group has around 8000 patients). These larger populations will tend towards the mean in use of services and their costs can be predicted fairly accurately. However, a solo IMP could be bankrupted quickly if his or her several hundred patients tend to be sicker or needier than average.Again, a copay system would reduce this risk for the very small practice by sharing the risk of increased costs with the patient. The alternatives, forcing small IMP practices to take on a large financial risk or forcing them into larger practices are much worse.BP

Beth - I do not understand why?I am not that birght.. In a country where you have X millions of patietns and all of them have their primary care paid for why does it matter where they seek care? Y number of docs are needed to take care of X people CAn't those docs be in any setting?then folks will seek care in any style practice They all need care/all pratices are paid equally to see them.NOW ,the smaller practices are undercut by hospitlas' offering slding fees and becasue smaller practices are forced to financially cherry pick payers to stay alive.This idea puts small practices on a solid footing woudn't it So brian and Tim think there would have to be some pooling o f patients or weighting of patietns illnesses Hmm This immediaitely begins to drive us back a system of complex rules; geographical sitribution of people would be invovled--eg IHAVE to see older and sicker as that who lives here...how can you keep this simple? Forcing copays on sicker patietns does not sit well with me.... is saying if I wan t to make more money then I only take the well patietns so I can take more of them and have less work so make more dollars.What measures could you take about that? How likely is that to be a widespread problem?Could looking at quality measures help you in some way??thanks for the disussion you guys help me a lot. keep talking...

On Fri, Jun 4, 2010 at 2:41 PM, Beth Sullivan, DO <bethdo97windstream (DOT) net> wrote:

This system almost assures the death of the small imp micro practice. Not something I would support.

Beth Sullivan, DO

Ridgeway Family Practice

Commerce, GA 30529

From: [mailto: ] On Behalf Of Sent: Friday, June 04, 2010 10:14 AM To: Subject: payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a dollar a day for all the office care we can doso say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract out overhead, hiring a care coordaintior etc whatever grealty improves income and allows freedom to provide car e in many ways without the fee for service structure) It has been calcuated that this would allow docs freedom to take care of people in varying ways - email phone etc and reduce or eliminate the hassle of billing/coding( some records would need to be kept of course) and could improve primary care's bottom line, working conditions, abiltiy to function, and thereby increase access and hopefully quality in many way for patients So my question-- what are the possible downsides or what objections might be raised by payors or policy wonks etc , / or what have any of you encountered in pursing or thinking about such a model?thanks( am asked to propose something here in MAIne and am preparing for possible objections)

-- PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

June 4, 2010

Basing some of our pay on a per patient per month fee

would be an improvement our current fee for service system. However, I

would not want to base all of our pay on monthly fees. That would

penalize the docs who take sicker patients and encourage dumping of

high maintenance patients.

A monthly or yearly fee plus a copay per visit or procedure would be

ideal.

this is very helpful

- I would guess that there would be some guidelines about panel size

no one doc can take care of 8000 patietns well, so

you might say panel size would have to be at least X and no more than

Y per provider

AS you say various practitioners do varying jobs-this impacts the panel

size( all hiv patietns smaller panel size all young healthy families

bigger size)

-however this payment system equalizes out the biopsies and the hand

holding ,the higher level cognitive and the iud insertion the

counselling , and etc right? Under the scope of primary care.

you could define quality a number of ways- preventable

hospitalizations , er use, drug cost,all measurable by payors, and

then the PROM stuff patient reported measures as a standardized thing

hyh or equivalent how's that?

I would envision this for primary care and so you'd have to say well

is that psych , peds and int med and primary care and well how do

you include obgyn?do you?

I am not the decider of that I am just thinking the basics fp int med

peds folks I am just thinking what would be the hard questions to get

a pilot started

there are lots of specilaist who are non procedural also, rheum and

neuro ,who may make less... let s not zoom over my head I am working

on a pilot idea of how you could reform primary care payment no fair

asking very very very hard questions!

I have no idea what to say about midlevels There is both a

justifciation that much of the work of primary care can be done by them

but then not all .And docs do have more trianing and higher overhead

becasue of that. I n some regions there may beonly midlevels available

and no doc will work there- I do not know answers about that Proably

some similar sort of capitaiton at a lower level.

I suspect that if you designed a pilot project partly you would earn

from it HOW to expand to the situations you describe becasue those

questions would come up and the working folks in the he pilot might

know how to address once they trialed such a sys tem

This i s helpful thank you very much

I fail t o see why I am amazing but thank you Remember this idea came

from Egly!

If you were paying any attention at all you would be saying what is

wrong w ith you why did not you do this or say that and why are you

so weird or calling OTHER things that begin with "a."....but thank you.

On Fri, Jun 4, 2010 at 11:59 AM, Carla

Gibson <carlygold>

wrote:

One

issue that would have to be addressed in that model is the question of

what is that $1 a day actually paying for? Does it include procedures

in the office like shave biopsies, endometrial biopsies, IUD

insertions, lac repairs? If so, can they assure that one primary care

practice provides essentially the same types of services as the

others. What if practice A refers out all basic skin biopsies and

simple lacs, endometrial biopsies and such while practice B just stops

short of providing appendectomies.

How to account for different patient panel characteristics. What

happens when 60% or more of our patients are 70+ (or in my case 60% or

more could carry a diagnosis of anxiety which means every visit is

longer than average in both cases).

Factoring in the overhead issue- if this were nationwide, the cost of

living issue in regard to location and salaries for staff. What about

me, the NP with my lower malpractice costs? Do I even get to play?

I would want it designed to anticipate the many ways providers or

payors could take advantage of the system. One provider could hire 10

RNs and take on 8000 patients managing them via telephone? Will there

be some kind of guidelines? I would envision that a system like this

would encourage physicians to hire the least expensive care providers

possible- so would a doc prefer to hire 2 NPs and expand their patient

panel by perhaps twice what hiring a more expensive doc (and I'm not

saying either choice is preferable from a care perspective).

How is quality evaluated? If the care delivery model changes

significantly from what we have now and patients are more likely going

to be "pushed" to use phone, email and such (seems inevitable), will

the same measures used currently (or those being developed in P4P etc)

adequately measure the quality? I would think that the HYH type

measurement would be even more germaine to this model. HYH components

including Patient satisfaction and involvement in care and knowing who

is the captain of their ship would be such a simple approach with

perhaps the added parameters of utilization of urgent/ED/hospital

services.

Jean- you are amazing! We are cheering you on.

Carla

From:

To:

< >

Sent: Fri, June 4,

2010 8:13:55 AM

Subject:

payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a

dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then you

can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many

ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take care

of people in varying ways - email phone etc and reduce or eliminate

the hassle of billing/coding( some records would need to be kept of

course)

and could improve primary care's bottom line, working conditions,

abiltiy to function, and thereby increase access and hopefully

quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised

by payors or policy wonks etc , / or what have any of you

encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for

possible objections)

--

PATIENTS-please remember that email may not be entirely secure, and

that Email is part of the medical record and is placed into your

chart ( be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

--

PATIENTS-please remember that email may not be entirely secure, and

that Email is part of the medical record and is placed into your

chart ( be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

June 4, 2010

The idea of $365/yr/patient only works if all the patients are pooled, like a

" community rating. " Then the work is averaged out for some younger and low

maintenance patients with the older and high maintenance. The idea works as a

general idea so the billing silliness can be removed from the equation.

Could imagine a tiered design too. For example, some age groups $200, others

$350, and other $500, so it generally averages out as $365/yr/pt. But if one has

a panel of 20-somethings then honestly it will generally be easier load, and you

can carry more patients, than if working with many 60-somethings.

Finally, the insurances could track data of outside referrals and billings very

easily, and then check on the main outlier docs if they are taking the monies

but costing the system by not offering the care and only sending folks to other

docs. But hopefully they could be out of the hairs of most docs who are doing

generally the right thing.

I'd love the idea!

Tim

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use or

disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the intended

recipient, please contact the sender immediately by reply email and destroy all

copies of the original message, including attachments.

payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a dollar a

day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract

out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many ways without

the fee for service structure)

It has been calcuated that this would allow docs freedom to take care of people

in varying ways - email phone etc and reduce or eliminate the hassle of

billing/coding( some records would need to be kept of course)

and could improve primary care's bottom line, working conditions, abiltiy to

function, and thereby increase access and hopefully quality in many way for

patients

So my question--

what are the possible downsides or what objections might be raised by payors or

policy wonks etc , / or what have any of you encountered in pursing or thinking

about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for possible

objections)

Jean

--

PATIENTS-please remember that email may not be entirely secure, and that Email

is part of the medical record and is placed into your chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more

urgent .

MD

ph fax

impcenter.org

--

PATIENTS-please remember that email may not be entirely secure, and that Email

is part of the medical record and is placed into your chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more

urgent .

MD

ph fax

impcenter.org

June 4, 2010

I posted some thoughts separately. But I'll add that I agree with you on the

balance of some, perhaps " most " payment from set fee, then a copay for a visit.

The challenge then is balancing the work of visits and non-visit care ... " but

doc, can't we just deal with this without a visit so I can skip the copay? I

already paid the $250 fee for this care you are offering by phone/email/etc.

.... "

But, again, I'd prefer that system over current hassles of billing.

Tim

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

-- Confidentiality Notice --

This email message, including all the attachments, is for the sole use of the

intended recipient(s) and contains confidential information. Unauthorized use or

disclosure is prohibited. If you are not the intended recipient, you may not

use, disclose, copy or disseminate this information. If you are not the intended

recipient, please contact the sender immediately by reply email and destroy all

copies of the original message, including attachments.

payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a dollar a

day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract

out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many ways without

the fee for service structure)

It has been calcuated that this would allow docs freedom to take care of people

in varying ways - email phone etc and reduce or eliminate the hassle of

billing/coding( some records would need to be kept of course)

and could improve primary care's bottom line, working conditions, abiltiy to

function, and thereby increase access and hopefully quality in many way for

patients

So my question--

what are the possible downsides or what objections might be raised by payors or

policy wonks etc , / or what have any of you encountered in pursing or thinking

about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for possible

objections)

Jean

--

PATIENTS-please remember that email may not be entirely secure, and that Email

is part of the medical record and is placed into your chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more

urgent .

MD

ph fax

impcenter.org

--

PATIENTS-please remember that email may not be entirely secure, and that Email

is part of the medical record and is placed into your chart ( be careful what

you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more

urgent .

MD

ph fax

impcenter.org

June 4, 2010

This system almost assures the death of the small imp micro practice.

Not something I would support.

Beth Sullivan, DO

Ridgeway Family Practice

Commerce, GA 30529

From:

[mailto: ] On Behalf Of Jean

Antonucci

Sent: Friday, June 04, 2010 10:14 AM

To:

Subject: payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a

dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then

you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many

ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take

care of people in varying ways - email phone etc and reduce or

eliminate the hassle of billing/coding( some records would need to be

kept of course)

and could improve primary care's bottom line, working

conditions, abiltiy to function, and thereby increase access and

hopefully quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised

by payors or policy wonks etc , / or what have any of you

encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for

possible objections)

--

PATIENTS-please remember that email may not be entirely secure, and that

Email is part of the medical record and is placed into your chart (

be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

June 4, 2010

Beth - I do not understand why?I am not that birght.. In a country where you have X millions of patietns and all of them have their primary care paid for why does it matter where they seek care? Y number of docs are needed to take care of X people CAn't those docs be in any setting?then folks will seek care in any style practice They all need care/all pratices are paid equally to see them.

NOW ,the smaller practices are undercut by hospitlas' offering slding fees and becasue smaller practices are forced to financially cherry pick payers to stay alive.This idea puts small practices on a solid footing woudn't it

So brian and Tim think there would have to be some pooling o f patients or weighting of patietns illnesses Hmm This immediaitely begins to drive us back a system of complex rules; geographical sitribution of people would be invovled--eg IHAVE to see older and sicker as that who lives here...how can you keep this simple? Forcing copays on sicker patietns does not sit well with me....

is saying if I wan t to make more money then I only take the well patietns so I can take more of them and have less work so make more dollars.What measures could you take about that? How likely is that to be a widespread problem?

Could looking at quality measures help you in some way??

thanks for the disussion you guys help me a lot. keep talking...

This system almost assures the death of the small imp micro practice.

Not something I would support.

Beth Sullivan, DO

Ridgeway Family Practice

Commerce, GA 30529

From:

[mailto: ] On Behalf Of Jean

Antonucci

Sent: Friday, June 04, 2010 10:14 AM

To:

Subject: payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a

dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then

you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many

ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take

care of people in varying ways - email phone etc and reduce or

eliminate the hassle of billing/coding( some records would need to be

kept of course)

and could improve primary care's bottom line, working

conditions, abiltiy to function, and thereby increase access and

hopefully quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised

by payors or policy wonks etc , / or what have any of you

encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for

possible objections)

--

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ph fax impcenter.org

June 4, 2010

along time ago I figured it as 1.00 /day for birth- age 2 then ages 50 up, with a rate of 50- 75 cents/day in between. You could have outlier very i ll 34 yr olds but less likely.Jean

The idea of $365/yr/patient only works if all the patients are pooled, like a " community rating. " Then the work is averaged out for some younger and low maintenance patients with the older and high maintenance. The idea works as a general idea so the billing silliness can be removed from the equation.

Could imagine a tiered design too. For example, some age groups $200, others $350, and other $500, so it generally averages out as $365/yr/pt. But if one has a panel of 20-somethings then honestly it will generally be easier load, and you can carry more patients, than if working with many 60-somethings.

Finally, the insurances could track data of outside referrals and billings very easily, and then check on the main outlier docs if they are taking the monies but costing the system by not offering the care and only sending folks to other docs. But hopefully they could be out of the hairs of most docs who are doing generally the right thing.

I'd love the idea!

Tim

Malia, MD

(phone / fax)

www.MaliaFamilyMedicine.com

www.SkinSenseLaser.com

Malia Family Medicine & Skin Sense Laser

6720 Pittsford-Palmyra Rd.

Perinton Square Mall

Fairport, NY 14450

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payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take care of people in varying ways - email phone etc and reduce or eliminate the hassle of billing/coding( some records would need to be kept of course)

and could improve primary care's bottom line, working conditions, abiltiy to function, and thereby increase access and hopefully quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised by payors or policy wonks etc , / or what have any of you encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for possible objections)

--

PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent .

MD

ph fax

impcenter.org

--

PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent .

MD

ph fax

impcenter.org

-- PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)

Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD

ph fax impcenter.org

June 4, 2010

This is basically like the capitation we tried with the HMO's. So, what went wrong there?

1. The biggest problem, I think: capitation ended up being too low for services provided (I know for some patients, we were getting less than $10/month for primary care services).

2. Incentives to get rid of sick patients (don't take good care of your cancer patients and pretty soon word gets around to not sign up with that group or doctor if you are sick, and boom, that doctor gets a bonus the next year because of lower utilization (no bone marrow transplants at all). Advertise for sports medicine, urgent care stuff and get lots of men in their 20's and 30's and either you become rich or have a lot of free time compared to taking care of Carla's anxiety patients (how DID you end up with 60%?), menopausal women, or other higher need people.

3. Friction between specialists (if they are also capitated): ortho back guy thinks PCP's should take care of back pain; PCP thinks ortho should since both get paid no more to do it.

4. Need to figure out how to incentivize good care: probably need some additional payment for visit, but not so much that things that can be handled well by phone or email or class get turned into individual office visits just for the money (like happens now under fee for service).

5. Definitely have to have some type of quality measures, lots based on patient satisfaction, but probably some others also. For example, a doctor who sees 50 people a day giving them prescriptions for unneeded antibiotics may have a lots of satisfied customers, but is he really doing the right thing?

I'm sure there were others I'm not thinking of right now.

Things I LOVE about it:

1. I would love to have capitated specialists that I could email or call about how to manage a patient without feeling like I was taking advantage of them or " owed " them some good referrals.

2. Incentivizes keeping people healthy.

3. Returns focus of health care system to primary care, which is where it should be, both for cost control, patient satisfaction, and long term outcomes.

4. Can you imagine how much more fun our list serve would be to read if we had no billing or coding questions?? (Not that it isn't great fun now.)

you are a goddess for trying to change the system and not burying your head in the sand.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com

June 4, 2010

Beth's right, having a set fee per month would be low risk for larger

practices (our small traditional group has around 8000 patients).

These larger populations will tend towards the mean in use of services

and their costs can be predicted fairly accurately. However, a solo

IMP could be bankrupted quickly if his or her several hundred patients

tend to be sicker or needier than average.

Again, a copay system would reduce this risk for the very small

practice by sharing the risk of increased costs with the patient.

The alternatives, forcing small IMP practices to take on a large

financial risk or forcing them into larger practices are much worse.

BP

Beth - I do not understand why?I am not that birght.. In a

country where you have X millions of patietns and all of them have

their primary care paid for why does it matter where they seek

care? Y number of docs are needed to take care of X people CAn't

those docs be in any setting?then folks will seek care in any style

practice They all need care/all pratices are paid equally to see them.

NOW ,the smaller practices are undercut by hospitlas' offering slding

fees and becasue smaller practices are forced to financially cherry

pick payers to stay alive.This idea puts small practices on a solid

footing woudn't it

So brian and Tim think there would have to be some pooling o f

patients or weighting of patietns illnesses Hmm This immediaitely

begins to drive us back a system of complex rules; geographical

sitribution of people would be invovled--eg IHAVE to see older and

sicker as that who lives here...how can you keep this simple? Forcing

copays on sicker patietns does not sit well with me....

is saying if I wan t to make more money then I only take the

well patietns so I can take more of them and have less work so make

more dollars.

What measures could you take about that? How likely is that to be a

widespread problem?

Could looking at quality measures help you in some way??

thanks for the disussion you guys help me a lot.

keep talking...

On Fri, Jun 4, 2010 at 2:41 PM, Beth

Sullivan, DO <bethdo97windstream (DOT) net>

wrote:

This system almost

assures the death of the small imp micro practice.

Not something I would support.

Beth Sullivan, DO

Ridgeway Family

Practice

Commerce, GA 30529

From:

[mailto: ]

On Behalf Of Jean

Antonucci

Sent: Friday, June 04, 2010 10:14 AM

To:

Subject: payment reform

Serious question

There has been a proposal to pay primary care at a bundled rate of a

dollar a day for all the office care we can do

so say you had a panel of 1000 patietns-->$ 365,000 gross then

you can subtract out overhead, hiring a care coordaintior etc whatever

grealty improves income and allows freedom to provide car e in many

ways without the fee for service structure)

It has been calcuated that this would allow docs freedom to take

care of people in varying ways - email phone etc and reduce or

eliminate the hassle of billing/coding( some records would need to be

kept of course)

and could improve primary care's bottom line, working

conditions, abiltiy to function, and thereby increase access and

hopefully quality in many way for patients

So my question--

what are the possible downsides or what objections might be raised

by payors or policy wonks etc , / or what have any of you

encountered in pursing or thinking about such a model?

thanks

( am asked to propose something here in MAIne and am preparing for

possible objections)

--

PATIENTS-please remember that email may not be entirely secure, and

that

Email is part of the medical record and is placed into your chart (

be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

--

PATIENTS-please remember that email may not be entirely secure, and

that Email is part of the medical record and is placed into your

chart ( be careful what you say!)

Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the

matter is more urgent .

MD

ph fax

impcenter.org

June 5, 2010

I do not understand what risk are you talking about?There is no responsibility of physicians for keeping costs down as it impacts their payment-- in my hypothetical model here no mention of this How is small practice at risk? In my hypothesis I have not linked payment to expenditures or to quality - -- we have payment now that is without link to any quality ,after all.

if all physicans in primary c are were paid the same certainly without some controls docs could game the system by accepting lots of excess patients to get income but would not able to provide care to all of them ..

In a pilot to reform payment the hypothesis is that is we reduce the burden of billing and coding and most importnalty get away from fee for service, so then we reduce costs actually as docs can take care of more people for less cost- as -patietns do not need ot come in to the office( for expensive visits) to get care

- quality might be improved becasue of guaranteed fair income independent of visit volume In a pilot if you measured quality you would see if this works and decide to extend it. i do not myslef think specialist should be paid the same way- at least procedures But that digresses I am only exploring how else you could pay PCPs.

by fair payment you support small practices' sustainability yes? sorry if I am not that bright:)