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Effects of Health Care Payment Models on Physician Practice in the United States

Core Content

This report, sponsored by the American Medical Association (AMA), examines the effects of alternative health care payment models on physicians and their practices in the United States. It analyzes six geographically defined health care markets, with 34 physician practices serving as case studies. The models studied include capitation, episode-based and bundled payment, shared savings, pay for performance (PFP), and retainer-based practice. Accountable care organizations (ACOs) and medical homes, which integrate these models, are also considered.

The report explores how these models influence organizational structure, practice operations, data management, physician incentives, work-life balance, and the broader healthcare ecosystem. It highlights both challenges and opportunities for physicians, practices, health plans, hospitals, EHR vendors, and regulators.

Main Findings

Organizational Level Effects

• Changes in Organizational Structure: Practices are increasingly affiliating or merging with other practices or hospitals to adapt to alternative payment models. These changes are driven by the need to make capital investments (especially in data infrastructure), negotiate contracts with payers, and gain stability.
• Practice Stability and Financial Impact: Alternative payment models had neutral to positive effects on practice stability and financial health. Retainer-based practices, in particular, reported escaping market pressures through conversion to this model.
• Shift in Care Delivery Models: There is a growing emphasis on team-based care, with allied health professionals playing a more prominent role. This is especially evident in primary care settings where care managers are used to support patient management.

Practice Operations

• Team-Based Care: Alternative payment models encouraged the development of team-based approaches, allowing physicians to focus on higher-value tasks.
• Expanded Access Options: Practices reported increasing options for after-hours care and community-based in-person care to meet cost-containment goals.
• Primary Care and Subspecialist Relationships: These models shifted the focus toward primary care, altering referral patterns and creating both collaborative and competitive dynamics.

Data and Data Analysis

• Data Management Investments: Practices made significant investments in data infrastructure, including EHR systems and data entry processes.
• Data Challenges: Issues with data integrity, timeliness, and the mismatch between internal EHR data and claims data were common. Practices generally trusted internal data more.
• Price Data Limitations: Accurate price data for services and commodities (e.g., specialty drugs) were difficult to obtain, limiting cost-containment efforts.

Payment Program Interactions and Regulations

• Administrative Burden: Multiple payment programs and regulations created a complex administrative environment, particularly for smaller practices.
• Spillover Effects: EHR upgrades and installations under meaningful-use incentives had both positive and negative impacts on practices' ability to meet performance targets.
• Conflicting Incentives: Practices facing both fee-for-service (FFS) and risk-based contracts experienced tensions between increasing volume and reducing costs.

Individual Physician Level Effects

• Financial Incentives: Financial incentives from payment models were not directly passed to individual physicians, except in FFS. Instead, practices converted these into nonfinancial incentives like performance feedback and coaching.
• Work Intensity: The overall quantity and intensity of physician work increased, contributing to potential burnout. Practices encouraged delegation of lower-intensity tasks to allied professionals.
• Professional Satisfaction: While some physicians were optimistic, many in non-leadership roles expressed apprehension, particularly about documentation requirements.

Key Limitations in Implementation

• Data Integrity and Timeliness: Practices faced issues with data accuracy, performance measure specification, and patient attribution, especially in new models.
• Performance Measure Complexity: The multitude of performance measures across payers created confusion and operational challenges.
• Uncontrollable Events: High-cost events like the introduction of specialty drugs could undermine the effectiveness of shared savings and capitation models.
• Lack of Clarity: Some physicians found it difficult to understand the intended behaviors for performance-based programs, even after clarification.

Conclusion and Implications

• Need for Support and Guidance: Physician practices require support to optimize work under alternative payment models, which can lead to more satisfying and efficient care.
• Improving Program Effectiveness: Addressing operational details, ensuring clear communication of performance goals, and conducting dry runs can enhance the effectiveness of payment models.
• Data Infrastructure: Investment in data management and greater transparency in pricing data are critical for successful implementation.
• Harmonization of Models: Aligning payment models and performance measures across payers can reduce the burden on practices and improve their ability to adapt.

Challenges and Opportunities

• For Physicians and Practices: Increased workload, unclear incentives, and administrative complexity pose challenges, but opportunities exist for better care delivery and professional satisfaction.
• For Health Plans: They need to simplify and clarify payment programs to support practices effectively.
• For Hospitals: Ownership of physician practices can create conflicting incentives between cost reduction and revenue generation.
• For EHR Vendors: They should support practices with robust data systems and interoperability.
• For Regulators: Harmonizing regulations with alternative payment models can reduce confusion and improve outcomes.

Recommendations

• Provide guidance and support for practices to adapt to new payment models.
• Improve the clarity and understandability of performance incentives.
• Invest in data infrastructure and pricing transparency.
• Harmonize performance measures and payment models across payers and regulations.

Acknowledgments

The report acknowledges the contributions of numerous stakeholders, including physician leaders, medical societies, health plans, hospitals, and researchers. It also thanks individuals who provided input on the study design and methodology.