1. Physician leadership. Physician leadership
is seen as essential for the implementation of new payment reform
models. Strong leadership from primary care and specialty care
physicians in both the administrative structure of accountable care
organizations (ACOs) and other payment reform models, as well as in
policy development, cost containment and clinical decision-making
processes, is key.
2. One size will not fit all. One single
payment model will not be successful in all types of practice
settings. Many physician groups will have a great deal of
difficulty making a transition due to their geographic location,
patient mix, specialty, technical and organizational readiness, and
other factors.
3. Deliberate and careful. Efforts must be
undertaken to guard against the risk of negative unintended
consequences in any introduction of a new payment system.
4. Fee-for-service payments still have a
role. While a global payment model could encourage
collaboration among providers, care coordination, and a more
holistic approach to a patient's care, fee-for-service payments
will likely should be a component of subset of any global payment
system.
5. Infrastructure support. Sufficient resources
for a comprehensive health information technology infrastructure
and hiring an appropriate team of physician assistants, nurse
practitioners, and other relevant staff are essential across all
payment reform models.
6. Proper risk adjustment. In order to take on
a bundled, global payment or other related payment models, funding
must be adequate, and adequate risk adjustment for patient panel
sickness, socioeconomic status, and other factors is needed.
Current risk adjustment tools have limitations, and payers must
include physician input as tools evolve and provide enough
flexibility regarding resources in order to ensure responsible
approaches are implemented. In addition, ACOs and like entities
must have the infrastructure in place and individuals with the
skills to understand and manage risk.
7. Transparency. There must be transparency
across all aspects of administrative, legal, measurement, and
payment policies across payers regarding ACO structures and new
payment models. There must also be transparency in the financing of
physicians across specialties. Trust is a necessary ingredient of a
successful ACO or other payment reform model. The negotiations
between specialists, primary care physicians, and payers will be a
determining factor in establishing this trust.
8. Proper measurements and good data.
Comprehensive and actionable data from payers regarding the true
risks of patients is key to any payment reform model. Without
meaningful, comprehensive data, it becomes impractical to take on
risk. Nationally accepted, reliable, and validated clinical
measures must be used to both measure quality performance and
efficiency and evaluate patient experience. Data must be accurate,
timely, and made available to physicians for both trending and the
ability to implement quality improvement and cost effective care.
The ability to correct inaccurate data is also important.
9. Patient expectations. Patient expectations
need to be realigned to support the more realistic understanding of
benefits and risks of tests and clinical services or procedures
when considering new payment reform models. Physicians and payers
must work together to provide a public health educational campaign,
with an opportunity for patients to provide input as appropriate
and engage in relevant processes.
10. Patient incentives. Patient accountability
coupled with physician accountability will be an effective element
for success with payment reform. An important aspect of benefit
design by payers is to exclude cost sharing for preventive care and
other selected services.
11. Benefit design. Benefit designs should be
fluid and innovative. Any contemplation of regulation and
legislation with regard to benefit design should balance mandating
minimum benefits, administrative simplification, with sufficient
freedom to create positive transparent incentives for both patients
and physicians to maximize quality and value.
12. Professional liability reform. Defensive
medicine is not in the patient's best interest and increases the
cost of healthcare. In an environment where physicians have the
incentive to do less, but patients request more, physicians view
litigation as an inevitable outcome unless there is effective
professional liability reform.
13. Antitrust reform. As large provider
entities, ACO definitions and behavior may collide with anti-trust
laws. The state legislature may be the adjudicator of antitrust
issues. Accountable care organizations and other relevant payment
reform models should be adequately protected from existing
antitrust, gain-sharing, and similar laws that currently restrict
the ability of providers to coordinate care and collaborate on
payment models.
14. Administrative simplification. Physicians
and others who participate in new payment models, including ACOs,
should work with payers to reduce administrative processes and
complexities and related burdens that interfere with delivering
care. Physicians should be protected from undue administrative
burden, or should be appropriately compensated for it.
15. The incentives to transition. In order to
transition to a new model, incentives must be predominantly
positive.
16. Planning must be flexible. Accommodations
must be made to take into account the highly variable readiness of
practices to move to a new system.
17. Primary care physician. All patients should
be encouraged to have a primary care physician with whom they can
build a trusted relationship and from whom they can receive care
coordination.
18. Patient access. Health care reform must
enable patient choice in access to physicians, hospitals and other
services, while recognizing economic realities.
Adopted by the MMS House of
Delegates, May 21, 2011
