Careers in Family Medicine: Value-Based Care

We are continuing our blog series, Careers in Family Medicine. Each week over the next 3-4 months, I will highlight a family physician and their career paths. Each one will share their pearls. Last week, we highlighted an example of Rural Practice. This week we will take a look at an expanding Value-Based Care (VBC) model by highlighting Dr. Erica Swegler, former AAFP Board Member. A VBC model is an Alternative Payment Method (APM, payment model) that can be delivered through various set-ups (delivery models), including Accountable Care Organizations, Centers for Excellence, and Patient-Centered Medical Homes in which care-coordination and team-based approaches are emphasized. These have been growing into the private sector and span the range of how much value-based care is relied upon. (Some of the newer ones in the private sector are backed by private equity and venture capitalists.) (To do a deeper dive into understanding the APM Framework, here is the white paper). The great news for family medicine is that many of these organizations have primary care as their anchor. 

Erica, please tell the readers about your vast and various experiences and expertise as a family physician over the past few decades. 

Note how different this is from setting up your shingle and remaining in the same place for 30 to 40 years, which I thought I'd always do.

I began my career in Denison, Texas. It was a solo practice doing full scope, including obstetrics and all my own hospital work. This was a very busy and challenging time for me, but very rewarding. However, hospital politics and lack of support for family medicine led me to decide that I should accept that I had a "sunk cost" and leave the community.

I moved back to Dallas-Fort Worth and became an employee with a large group (predominately family medicine) that was consolidating in the face of managed care becoming big in the marketplace. After two years, we parted ways as this one was not the right fit in that the expectation of patients per hour exceeded what I felt I could reasonably do to provide high-quality care.

I joined a small, independent family medicine group in Dallas-Fort Worth with two locations and 6 APPs. I was a partner there for 14 years. As I felt it necessary to prove value, I became NCQA recognized in chronic care for diabetes, heart disease, and stroke and lead the group in becoming recognized as a level-three medical home. Unfortunately, this did not lead to improved payment and recognition by payers of the value we brought to the marketplace. It became harder and harder to convince my partners that value-based care was what we should be providing. For a multitude of additional reasons, I resigned in 2012.

For the following 20 months, I worked as a locum tenens physician, doing urgent care, occupational health, and family medicine. I became licensed in two additional states. The situation that fit my practice style wonderfully was in Colorado, where the group was involved in value-based care as part of the Medicare demonstration project in around 2010.

To allow me to fulfill my personal goal within organized medicine of serving on the AAFP Board of Directors, I moved to Austin, Texas, and joined a small independent group. Unexpectedly after one year, the owner of the group closed his practice. I then transitioned back into independent practice in Austin. The economic hardship of Covid in 2020 was devastating. It further highlighted the need to be paid in a way other than fee-for-service. 

Fortunately, at the end of 2020, a large value-based group from Houston was expanding into the Austin area and was willing to purchase my practice. I have been in that environment since.

What were the key lessons you learned while owning your own practice?

It is critical to have sound business practices. No matter how much you empathize with patients, you must collect as much as possible when they're in the office, bill them for everything they are responsible for, and pursue collecting it. This must be done on a monthly basis.

Believing strongly in a team-based model that would include APP's, do not add them too early in your practice's growth and development or expand too early. In many environments, APP's are at best cost neutral.

Be extremely cautious about any venture capital investment in your practice or as a source of loans/capital.

I had seen a group providing point-of-care laboratory services that included CBCs, CMPs, lipid panels and a troponin panel. I chose to adopt this in my independent practice, which was a huge investment that I would not advise early on. The benefits of saving staff time regarding communicating lab results and preventing unnecessary urgent care or hospital ER visits were never realized.

What led you to the value-based care model?

It was obvious to me, even in the late 80s in my very first practice, that the care I provided could not be valued appropriately under the fee-for-service system. Essentially being paid for addressing two concerns during an office visit when especially if one has complex patients and with studies showing the average family physician addresses 2.7 complaints in an office visit, much less might be addressing a family member's need for a refill or having a form completed, one would not be appropriately paid.

Value-based care also pays you for your outcomes, which studies suggest is directly proportional to the time you spend with the patient, as it takes time to incentivize people to follow their care plan and make behavior changes. Fee-for-service only pays for volume. It seemed problematic that under the fee-for-service system, you are paid equally whether you provided excellent or substandard care. 

What have been your positive experiences within your office?

Financial security is absolutely the number one benefit. The salary I am drawing now, after the end of my “guarantee,” is greater than what I would expect to be able to receive on my own in a traditional fee-for-service environment, given the style of medicine I practice. Additionally, I should hopefully get my third meaningful value base payment in the next month. By meaningful, I mean in the thousands of dollars versus the hundreds.

Another positive is giving up managing the office and running the staff on the business side of things.

I have the freedom within my environment to practice my full scope in the office.

In the last several years finding and retaining staff has been increasingly difficult, and now that is not something I need to worry about directly, although the lack of staff does affect me.

Can you tell us about any current problems with value-based care models you are aware of?

I would preface these comments by saying that my hope is that every value-based care payment scenario out there can succeed so that they may help continue to change the market.

The biggest problem with value-based care is that payment is limited only to Medicare Advantage plans in our organization and many other organizations. It must be adopted in the commercial markets. The sooner that happens, the better. When over 50% of Medicare recipients choose Medicare Advantage plans, one might see some commercial market movement. If you practice in the community like I do, which has a small Medicare population, approximately 10 to 12%, it is extremely difficult to change payment to physicians based upon value-based payment substantially. One still practices in a predominantly fee-for-service environment, and the tension of everything associated with that still exists. 

The model in which I practice highlights the pharmacist's increasingly important role in the care model. While I agree they are a valued team member and can contribute in multiple ways, I urge caution and encourage carefully reading the associated language.

What other tips do you have that you think will be helpful for the readers to consider who are looking at the best ways to enjoy their chosen careers and all of life?

Multiple years ago, I heard a lecture that talked about the requirements to have a rewarding career, and it included only three things: that your job was intellectually challenging, that one had a sense one was helping people/had a purpose, and number three, that it was fun. Physicians are truly blessed in that every day when we go to work with nearly every patient, we have the first two things. And then I think it's up to us to make our environment enjoyable and fun to be in.

Thank you for sharing your wisdom!

Such great insights and wisdom that is shared here. I'd love to hear from you what you found helpful.

As you explore opportunities, it would be helpful to gain insight into how much of the practice revenue is from value-based care vs. fee-for-service, whether the practice/group/system is backed by private equity or venture capitalists and to what degree, their ability to influence decisions that impact your ability to care for patients in the way that you desire; and whether the value-based care plans are only upside or if there are downside risks (i.e. penalty paid by you/group for missing metrics). And, inquire from those who've been practicing there for a while about both the impact of those investor influences on the practice and how often, if ever, the downside risks are realized by those who practice similarly to you.  

Next week, we'll dive into being a family physician in Academic Medicine with Dr. Grace Shih. Don't miss any in this series; sign up to have them delivered to your inbox. 

Until then, have a joy-filled week! Tonya