Benefits Clear but Questions Remain

The Group Practice Without Walls is an interesting concept, and one that logically flows from the recognition that instead of pay for service, the focus has been shifting to paying for quality and value. The National Commission on Physician Payment Reform, convened by the Society of General Internal Medicine, provided a number of recommendations regarding changes in physician payment, and there was recognition that fee-for-service payment is a significant driver of high healthcare utilization [https://www.nejm.org/doi/full/10.1056/NEJMsb1302322?query=featured_home. The commission's report is available at https://physicianpaymentcommission.org/report/].

Dr. Matera and the nephrologists correctly view new payment structures and incentives, such as pay for performance, as having a more important role in the future, although it is unlikely that fee for service care will disappear anytime soon [Ginsburg PB. Fee-for-service will remain a feature of major payment reforms, requiring more changes In Medicare physician payment. Health Aff (Millwood) 2012;31:1977-1983]. The evidence of the effectiveness of pay for performance systems on quality measures is mixed, but some programs have shown positive results.

By forming a practice organization, the 29 nephrologists will be able to more effectively work with payers as it will be a single large practice group within the region. I am not sure what percentage of nephrologists this may represent within the area encompassing the different practices, and whether it will form into the dominant nephrology practice organization in the region. However, it is an approach that enables small practices, which represent the majority of how care is currently delivered [Isaacs SL, Jellinek PS, Ray WL. The independent physician -- going, going. . . . N Engl J Med 2009;360:655-657], to form management structures which offer advantages in terms of bargaining power, potential development and collaboration with other practice organizations, centralized health information management, data analysis, quality improvement, patient and physician education, and more, as well as “back office” functions including billing and other practice management needs, which have become more time consuming and costly for small practices. More and more physicians are leaving small practices, and an increasing number of practices, especially in some areas, are being purchased by hospitals and health systems. The ability of independent physicians to consolidate within a larger physician and practice management group may be appealing to many.

I am familiar with other structures involving primary care and other physician groups here in CT that share some similar features, and which may be expanding given the increasing concern among physicians in single or small practices that they will be “left out” of emerging practice structures. Some small practices are joining or merging with hospital practice organizations or networks.

Whether in this Group Practice there will be uniform electronic medical records and how the group will be organized together is unclear, as Dr. Matera indicates.

Other unanswered questions remain at this point: How will the group manage physicians whose quality data is not in keeping with others within the group—and which will drive down group performance— and how tightly are the group members connected—among themselves and with other professionals, patients and their families, and their communities—to deliver higher quality and potentially more financially rewarding outcomes? How can virtual connections with other physicians and with patients (including telemonitoring) be optimized? How will the group share in any risk bearing arrangements?  How will preexisting individual physician arrangements and/or contracts with other organizations or professionals be managed within this new administrative structure? Will “Group” nurses and/or other professional staff serve patients from each of the 29 individual practices or be hired by and dedicated to individual physician practices? What credentialing or other inclusion characteristics identify the members of the group? How will the Group Practice function when approached by hospitals, health systems, or others to join an accountable care organization or to participate in other potential payment reform systems, such as bundled care, capitation, or patient-centered medical homes?

Another question concerns the planned loose organization (easy in/easy out) and focus on practice management functions; this structure makes it seem more like that of many practice management organizations rather than a unified practice group, in which the physicians within it share common care approaches, resources for patient care, professional needs, and finances.

As the Group Practice takes shape it will be instructive to learn how the group approaches many of the medical organization issues, including governance, confronting it.

Dr. Barney Spivack, a medical director with experience in geriatric medicine, long-term care, care coordination, and managed Medicare, is currently working with a leading health insurer.