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Under Healthcare Reform, Where Do Practicing Physicians Go From Here?

June 30, 2015
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Physicians in all settings in U.S. healthcare—private practice, medical group management, and association leadership—are living through the inevitably messy transition to the new healthcare

It’s a fascinating time these days in healthcare, on so many levels. And discussions in the past week—mine and others’—have only underscored that fact.

First, there was my breakfast and interview with Scott Weingarten, M.D., the senior vice president and chief clinical transformation officer at Cedars-Sinai Health System in Los Angeles. Reconnecting with Scott Weingarten reminded me once again of what a vortex we’ve been flying into and through, lately in our industry. Southern California is one of the more advanced managed care markets in the U.S., and yet even there, change has proven to be challenging for physicians. And if anyone is in a position to know just how challenging all this is, it is Dr. Weingarten. As he told me a week-and-a-half ago, when asked what the key to helping physicians move forward to optimize care is, “It’s a combination of things. I think physicians want to do the right thing. They went to med school to help patients; they’re trained in the scientific method. And they need to know that what they’re doing is scientifically valid. If you can’t convince physicians that something is the right thing to do for patients, they’re not going to do it.”

Weingarten, who practiced for years as an internist before he went into administration at Cedars, then co-founded Zynx Health (which provides evidence-based guidelines), and then came back to Cedars two-and-a-half years ago,  told me this: “ I used to be a practicing physician; and if someone couldn’t convince me something was right for my patients, I wouldn’t do it, either. So they need to understand that all of this is good for their patients; and they need to understand all the changes taking place at the national and local level; and also to understand how change will help them better take care of their patients.”

Weingarten believes that the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law that eliminated the SGR (sustainable growth rate) problems under Medicare, and which mandates either participation in the new Merit-based Incentive Payment Program, or MIPS, or participation in alternative payment models, which push practicing physicians forward quickly, once they figure out their options. “We provide them with those resources to help them, because it’s very hard for physicians in small practices,” he noted, of his organization’s clinical transformation and performance improvement work at Cedars-Sinai, because “with MIPS—in 2019, physicians will either need to participate in alternative payment models, or in MIPS. Beginning 2019, they’ll get a 5-percent annual bonus for participating, whereas there could be up to a 9-percent downside under MIPS in Medicare reimbursement over time, and that could be very difficult for the physicians.” And of course, “A lot of physicians are trying to figure out what alternative payment models mean for them,” he noted, “so we try to explain to them what’s going on and what it means.”

Not every physician is practicing in an integrated health system like that of Cedars-Sinai, where senior executives are working assiduously towards clinical transformation—and even have a senior vice president for clinical transformation, in Scott Weingarten. Joseph Valenti, M.D., an obstetrician-gynecologist who practices at the Denton, Texas-based Caring for Women practice, recently told HCI Associate Editor Rajiv Leventhal, that physicians like himself are becoming stressed by some aspects of healthcare reform. Asked why he believes that some doctors are wary of joining accountable care organizations, Dr. Valenti said, “I think that a lot of physicians are not completely convinced that the data is out there to demonstrate that they could potentially develop the savings necessary, and prevent hospital admissions and readmissions. Much of the healthcare spending that is extreme right now is in hospitals, not clinician offices,” he said, “so the concern is, can you keep this person out of the hospital? Also in terms of Medicare ACOs, you’re going to be assigned 5,000 patients at least, and they could be the sickest patients out there, so there is no guarantee that you can make them well enough and be assured that they don’t need to come back to the hospital. So maybe you can’t demonstrate shared savings. And the ACO stats prove this; one-third of them are working, one-third are breaking even; and one-third are leaving the program. “