Rates of physician burnout are at an all-time high. Physician suicides are estimated to be double that of the U.S. population. The practice of medicine has always been hard, but it seems to have become harder than it needs to be. Regulators, who frame and sometimes constrain physicians’ ability to provide seamless, high-quality care, have an obligation to respond. The rollout of MACRA over the next few years is just one regulatory requirement that will demand enormous change from physician practices. Regulators must keep pace, and also anticipate the support that health care providers will need in the future.
Atrius Health employs 750 physicians and over 1,000 other clinicians, who care for 675,000 adult and pediatric patients in 29 medical practices and home health and hospice services across eastern Massachusetts. Atrius Health has embraced the CMS roadmap for change; we are in our fifth year as a Medicare Pioneer ACO, and more than three-quarters of our revenue comes from global risk contracts.
The Triple and Quadruple Aims — ensuring the well-being of our staff in addition to improving the care experience of individuals managing the health of populations, and reducing cost of care — frame Atrius Health’s strategic plan. What do physician practices need from regulators to achieve these essential goals?
Five Legislative and Regulatory Changes
First, since it appears fee-for-service billing will continue to underlie value-based care payment methodology, CMS should reform the fee-for-service payment system to align with value-based care. Relative Value Units, which originated under the fee-for-service system, continue to be central to physician payment. Health care reform calls for primary care clinicians to oversee and coordinate patient care (relying on a team to support primary care clinicians), and will increasingly emphasize many forms of clinical collaboration. RVUs must place more value on cognitive processes, and fund currently non-reimbursable positions such as case managers, clinical pharmacists, population health managers, and community health workers. If the accounting that supports total payments is not aligned to the actual work done, value-based payment may ultimately be unsustainable.
Second, regulators can help plan for the health care workforce that will be needed in the future, through expansion of training programs and increased funding for areas of shortage. This includes creating and funding a larger number of slots in medical schools and residency programs, particularly in primary care. According to the Association of American Medical Colleges, the United States could face a shortage of between 61,700 and 94,700 physicians by 2025. Funding of new and expanded ambulatory training programs based in practices like Atrius Health would encourage physicians to go into primary care. Compounding the physician shortage problem, a shortage of as many as 260,000 nurses is predicted by 2025. At a time when aging and obesity are driving up health needs, the workforce must be ready.
We would like to see national coordination and standardization of quality and safety metrics and other national standards that streamline administrative processes. The sheer number and variation among quality measures and reporting requirements requires physician practices like ours to devote significant resources to developing an administrative infrastructure for establishing multiple tracking mechanisms, educating clinicians, and monitoring and reporting results. This means that clinicians, analysts, and administrative staff must attempt to identify which measures and activities should be prioritized, as it is sometimes impossible to achieve all goals simultaneously. Other areas for national standards are in credentialing and licensing to support use of telemedicine across state lines, more rapid start-up for new and relocating clinicians, and greater visibility for malpractice or licensing issues.
Fourth, seamless interoperability, for both clinical content and semantic interoperability, will ensure the highest quality of care for all patients, regardless of where they seek care. This means developing and achieving the semantic interoperability that is required for more robust standardized quality and safety metrics that can be applied uniformly and accurately across multiple EMR vendors to all parts of the care continuum, and then requiring that providers exchange at least a minimal set of data in every interaction across settings of care. We applaud ONC for including interoperability on their HIT timeline, and encourage CMS to join in leading toward this goal. These changes will require significant coordination among the various federal and state agencies that regulate these efforts, including updating and streamlining regulations to reflect the future state of practice and technology. Adopting standards to enable easy access to EMRs would go a long way toward improving care coordination and cost reduction. Protecting patient confidentiality is a high priority, which should be done through medical licensure provisions. Access to EMRs to improve care coordination and reduce costs should be done by adopting a national consent process that allows clinicians to view EMR data via a patient “opt-out” process, rather than an “opt-in” process (that is, separate consent required for each event).
Finally, the federal government should commit to seeking lower pharmaceutical costs, particularly for Medicare and Medicaid patients. CMS must be given the ability to negotiate for pharmaceuticals so that Americans do not face the highest drug costs in the world.
With fewer barriers to the practice of value-based medicine, clinicians will realize that the movement from volume to value makes sense and is achievable. Changes that reduce administrative barriers will free up clinicians’ time to spend in critical areas like improving patient access to care and bettering population health, wellness, and prevention. These changes support our vision at Atrius Health of “transforming care to improve lives.”
Disclosure: Marci Sindell is a registered lobbyist for Atrius Health.