not been made aware of [ such ] a process in the context of VBCI .”
Jason Wilson , CPA , FACMPE , is the chief executive officer of Medical Associates of Northwest Arkansas ( MANA ), an independent physician group with more than 80 physicians . His concerns focus on the impact VBCI may have on groups such as MANA .
When asked what impact he foresees VBCI will have on various patient populations — specifically if it might have any negative effect on the chronically ill patient or those with severe disabilities / conditions — Wilson responds , “ I think this is hard to determine and one that I really hope would not be a concern . There is a concern that it could incent physicians to focus their practice on the healthier patients that are seen less and therefore do not negatively impact the metrics as much . I worry that doctors with older patient populations may score worse than doctors with younger populations . I ’ ve also heard from groups like GI that feel that the metrics could be a deterrent in finding issues during screening exams . For instance , the metrics may incent doctors performing colonoscopies to not have the additional charges that come with finding polyps during a colonoscopy or may reward doctors who have low detection rates vs doctors with higher detection rates . Typically , the Adenoma Detection Rate ( ADR ) is a measure of quality in GI practices for colonoscopy , but this model does not measure that . Instead it measures the number of times the CPT code is used indicating that polyps were detected . I would like to believe that which patients a doctor sees is not influenced by the economics of a model , but it is something to think about . By the way , I have also had this same concern with some of the PCMH measures from Medicaid , ABCBS and others that incent lower total cost of care .”
Jason Wilson , CPA , FACMPE
Wilson also has concerns regarding the various metrics / measures upon which physicians will be scored . “ Some of the metric trees that ABCBS has released contain as many as 35 to 45 different metrics that are being measured in this program ,” he says . “ These individual metrics are then rolled up into subscores and rebalanced , rolled up into another subscore and then rebalanced before ultimately being rolled up into the physician ’ s overall score . Each physician ’ s overall score is then ranked and the physician given a score of 1 to 5 . Even if a physician can determine that one metric is out of line , will the data be detailed enough for the physician to determine how to modify their practice style to influence that metric ( i . e . if the metric for procedures per patient are out of line , will the physician be able to determine which procedures are out of line ?)”
Wilson adds a concern about the depth of control a physician may have over scoring , “ Several of the metrics are based upon referrals or hospital measures . For instance , a referral is defined as any specialist visit occurring within 30 days of a primary care visit . A patient who self refers to a dermatologist within 30 days of an unrelated primary care visit will count as a referral on the primary care physicians score card . Regarding the hospital numbers , some of the scores for ‘ Optimal Hospital ’ are based on ‘ Average Readmission Rate to your Referral Hospitals ’ or ‘ Average Length of Stay of your Referral Hospitals .’ These measures may be controllable if a physician has multiple options of hospitals to refer to , but in many places in Arkansas , the physician does not have this luxury . As an independent medical group , it is important that we receive accurate payment for the services that we provide . Currently , we are able to track the number of visits or services we provide and then ensure that we are paid the correct fee schedule amount for each service . Under the VBCI model , it will be much more difficult , if not impossible , to accurately monitor that payment . In this new model , each payment will be reimbursed at a reduced amount and then we may receive a payment for the difference in the future . Depending on how this quarterly payment is reported , we may or may not be able to audit that back to the withhold amounts that occurred each month . It will be even more difficult to reconcile if the quarterly payment is 50 percent , 150 percent or 200 percent of the withheld amounts .
“ To complicate matters more , ABCBS controls the data that is used to determine how a physician is scored , whereas , in the current model , physicians have all of the information to ensure that they are paid correctly . The measures used are not typically tracked by physicians and even if they were , physicians do not have the comparable data needed to determine whether or not they are being scored correctly when compared to their peers . How transparent will the data be ?”
Will the proposed method fairly measure a physician ’ s performance ? Wilson isn ’ t so sure : “ The VBCI system will be graded on a bell curve . To my knowledge , ABCBS has not released the projected percentages in each of the one-to-five categories ; therefore , it can only be assumed , based on a standard bell curve , that the distributions will something close to the following : 1 ) 0-10 %; 2 ) 10-15 %; 3 ) 65-
75 %; 4 ) 10-15 %; and , 5 ) 0-10 %. Regardless of how poorly the best physician scores or how well the worst physician scores , using a bell-shaped curve methodology , there will always be physicians graded in each of the five categories , and there will always be winners and losers . Even if all physicians were to outperform some national benchmark , there would still be physicians who lose in this system .
“ In addition , this is a moving target . The score a physician receives not only depends on how that physician performs but also on how the physician ’ s peer group performs . A physician who is rated a 5 in one quarter and makes improvements may still be rated a 5 in the next quarter if the entire group of physicians shows improvements . Presumably , all physicians will be trying to improve their numbers and it may be difficult to move from one ranking to the next . To further complicate matters , if physicians who score a 4 or a 5 leave Arkansas or are forced out of business , all remaining physicians will naturally move down the scale with some 3s becoming 4s or 5s OR some 3 scores becoming 4 scores or 5 scores .”
Regarding the timing of payments and cash flow , Wilson shared additional concerns , “ Most independent physician practices in Arkansas practice cash-based accounting . In a cash-based system , revenue is recorded when the payment is received . In the VBCI system , the practice will receive a reduced amount each month and then a settlement at the end of the quarter that could return anywhere from 0-200 % of the withholds from the clinic . Most practices look at financials monthly . With the fluctuations that will occur in monthly cash flow , will these monthly financial statements accurately show how the practice is performing or will that only be determinable on a quarterly basis ?
“ In several years , when the payment reductions from ABCBS reach 25 %, physicians in Arkansas will be receiving monthly payments roughly equal to Arkansas Medicare reimbursement . Arkansas currently has one of the lowest Medicare reimbursement rates in the country . As the payment withholds from ABCBS increase , will practices be able to pay all of their monthly bills on the reduced rates ? Do some of the quarterly payments need to be held and used for overhead payments in future quarters ? What if there are no quarterly payments ?
“ Many practices pay physicians monthly or quarterly based on the practices ’ cash flow . The change to the VBCI payment methodology will cause large fluctuations in monthly cash flow . Practice changes could include the timing of bonuses , holding some of the funds in the months the quarterly bonus pool is received to help in the months that reimbursement is cut , etc .”
248 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 114