The Journal of the Arkansas Medical Society Issue 11 Vol 114 | Page 7

indicate that there will always be losers. If we are
“If you are going to hold providers account-
measured relative to our peers and split into quar- able on the tail-end (threat of reduced reimburse-
tiles, there will always be relatively low performers, ment if not performing well re: cost and quality) then
thus there will always be penalties, no matter the the reasonable trade-off should be removal of the
level at which the entire pack is performing. If the onerous process of prior authorization on the front-
goal is to increase overall quality, why not decide on end. Failure to do so is the health care analogy of
a reasonable standard to which the program might double-jeopardy: requiring us to deal with adminis-
aspire to raise the quality bar, and reward all pro- trative headaches and paying someone in our offices
viders who perform above the mark? As planned, if to jump through hoops on the front end, then being
there were a theoretical situation in which all provid- penalized on the tail end with lower reimbursement.”
ers were providing a high level of
Threat to Primary Care. “Val-
care, there would still be providers
ue-based programs should bolster
who would be penalized despite
primary care, not present a threat to
their collectively high level of per-
them.  The threat of narrowing the
formance. I would suggest that set-
already thin margins under which
ting a mark of acceptable perfor-
many of our rural primary care phy-
mance (above which there would
sicians operate does not incentivize
be no penalty) would be a way to
improvement as much as it presents
raise quality while allowing for the
a threat to practice viability. I be-
(albeit unlikely) scenario in which
lieve that the constantly rising cost
all providers could avoid penalty
issues being faced by BCBS ARE
if meeting an acceptable level of
NOT significantly impacted by the
Lonnie Robinson, MD,
performance. This approach has
habits of primary care providers …
FAAFP
already been utilized successfully
we are not the ‘big spenders’ in this
with the pattern seen in APII, both for the Episodes situation. And yet my colleagues feel this initiative
of Care and PCMH programs, in which BCBS al- is targeting the physicians who bring more value to
ready participates. It is my understanding that the the table than any other specialty. As you probably
only way to continue to receive the traditional/his- know, despite all its short-comings, FFS income
toric rate of reimbursement from BCBS is to be a top continues to be the ‘bread and butter’ of primary
performer. This is quite concerning, since the costs care practices, since we are charged with providing
involved in clinical practice for all providers have not E/M-dependent care to our populations, rather than
decreased and are, in fact, rising.”
procedures and surgeries. 
No Relief of Administrative Burden (Prior
Authorization). “As you present VBCI as a way for
BCBS to gain control of rising costs, the administra-
tive burden on practices continues to rise as well. We
have already had discussions about removal of prior
authorization and other utilization-management
strategies employed by payers that present an ex-
cessive administrative burden for practices as we
move increasingly away from FFS, and I have heard
the argument by BCBS that studies demonstrate a
rise in utilization with removal of the PA process. I
would argue that none of those studies took place in
an environment in which providers were ultimately
held accountable for both quality (adherence to
Choosing Wisely and other guidelines) and cost. 
“The AAFP agrees with me … in their Prin-
ciples for Administrative Simplification, they
state:  ‘Physicians strive to deliver high-quality
medical care in an efficient manner. The frequent
phone calls, faxes, and forms physicians and their
staff must manage to obtain prior authorizations
(PAs) … impede this goal.’ and ‘PA for imaging
services should be eliminated for physicians with
aligned financial incentives (e.g. shared savings,
etc.) and proven successful stewardship.’ ”
“As Kent Moore, senior strategy analyst for
the AAFP recently said, ‘While payment is mov-
ing toward value-based care, fee-for-service (FFS)
remains the dominant method of payment. Family
physicians provide high quality, cost-effective care
but are financially dependent on the thin margins
associated with current FFS payments to pay for
the increased administrative and clinical personnel
needed to transition to and be successful in value
based contracts. To reduce payment in any amount
for the services done by primary care physicians is
detrimental to their ability to provide high-quality,
low-cost care in the current FFS care environment.’ 
An initiative that seeks to decrease reimbursement
in such a manner (i.e., there will always be losers)
is a threat to primary care practice viability. Unfor-
tunately, those who are most vulnerable are going
to be those in small practices in rural parts of our
state, and this represents a significant portion of the
Arkansas primary care workforce.”
Alignment. “We are bombarded with new pro-
grams and new ways in which we are measured. We
have literally dozens of disparate quality metrics by
which we are evaluated. What reassurance do we
have that there will be near-perfect alignment with
On a quarterly basis, 100
percent of the value pool
funds will be distributed to
providers based upon a set
of value-based performance
metrics using the most recent
and available 12-month
performance period, which will
roll forward every quarter.
existing programs (CPC+, PCMH, MIPS, etc.)?  All of
the programs have some measures in common, but
there are always some/many that are different.  This
too, creates additional administrative burden the
practice must bear [while] at the same time figur-
ing out a way to staff adequately despite declining
reimbursement. 
“According to the AAFP Principles for Admin-
istrative Simplification, ‘Quality measures have
proliferated in the past 15 years, leading to a sig-
nificant compliance burden for physicians. Most
of the measures are disease-specific process
measures, rather than more meaningful evidence-
based outcomes measures. With many family phy-
sicians submitting claims to more than 10 payers,
the adoption of a single set of quality measures
across all public and private payers is critical,’ and
similarly, ‘All payers … should implement the core
measure sets developed by the multi-stakeholder
Core Quality Measures Collaborative to ensure par-
simony, alignment, harmonization, and the avoid-
ance of competing quality measures.’ ”
Data. “Every program in which we participate
has a secure website at which we may obtain ac-
cess to our performance data. Every one of those
sites requires a secure password and often asks us
to change that quarterly. The CMS CPC+ portal takes
me at least five minutes to login and get to the in-
formation I need. The AHIN site makes me change
my password often, I typically don’t have ready ac-
cess when I need it. Same story with the Arkansas
PDMP. I know that there will be a similar process
for this program, one that presents data in the way
YOU want me to see it, not necessarily in the way I
need to have it. I don’t really need another login. If we
are being asked (forced?) to participate in a program
such as VBCI, real data access and transparency is
a must. Additionally, we need the opportunity and a
reasonable period of time in which to review and
validate the data by which we are being measured
before the financial implications are applied. I have
NUMBER 11
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