Value based payment vs Fee for service

[Shikima]

Can anyone help me understand this better and what it means for psychiatry? What are some examples of actual numbers (a comparison would help) - what financially does this translate into?

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[NickNaylor]

Value-based payments essentially describe models that focus on outcomes (whatever they are determined to be) and cost-savings rather than reimbursement for a provided service - regardless of the outcome or efficacy of treatment - as in FFS. They are payment models that are designed to incentivize cost savings and quality improvements. Often outcomes and measurement-based care go hand-in-hand (e.g., tying reimbursement for patients with diabetes to HbA1c values or patients with lipid abnormalities to lipid panel results). In psychiatry this would likely rely on symptom scales, e.g., improvement in PHQ-9 scores for depressed patients, improvements in GAD-7 for anxiety disorders, etc.. Demonstrating that you’re screening for substance use disorders and referring appropriately and reducing days of hospitalization are other potential quality measures. Most value-based payment systems typically base outcomes (and, thus, payments) on diagnoses, as the outcomes being measured will obviously be different from diagnosis to diagnosis.

Most models like this utilize capitated payments. You receive $x for an “episode of care” (whatever the hell this means) and, in return for positive outcomes and cost-effective care, you get to pocket the difference that does not go to actually providing patient care.

In terms of how this would shake out pragmatically, it is fairly unknown. Alternative payment models (APMs) are a hot policy topic currently, and the APA is actually drafting a letter in response to CMS request for comments regarding APMs generally and how to deploy them in mental health specifically. There are essentially no APMs currently in use for psychiatry for a variety of reasons which are outside the scope of this post but which might you be able to predict in trying to apply the basic concepts above to psychiatric care.

The most widely deployed VBP/APM-like model currently being used is the integrate care model, where psychiatrists are embedded in PCP settings and provide psychiatric care in that setting. It is still unclear who gets payment from these services if they were deployed in the private setting - for example, would the PCP receive additional payment and then remit that to the psychiatrist? Would the psychiatrist just be paid on the side? TBD.

I don’t think there are any clear answers to your questions because this is very much on the “breaking edge” of policy. Obviously as it’s being pushed by the government, the long-term goal is likely to reduce costs. This is obviously of concern for psychiatrists, who generally feel that psychiatric services already aren’t reimbursed sufficiently and further decreases are going to be entirely unwelcome. But the ultimate impact is pretty unknown.

I actually have a few documents reviewing VBPs/APMs as they stand currently and can share them when I’m back at home.

 

[Shikima]

I learned of this a few days afterwards where it'll more than likely keep on a fee for service as a specialist but PCPs will be hit hard as well as hospitalists/surgeons.

 

[Psychotic]

All cash PP is sounding better and better...

 

[futuredo32]

All cash PP is sounding better and better...

But how do ya do that? The million dollar question.

 

[Candidate2017]

Merely another way for insurance execs and politicians to control you and reduce your pay. Look no further than the specialty most heavily covered by "value" payments: family med/primary care. Tobacco cessation, glucose control, blood pressure targets, vaccinations, screening tests, random target goals, and 10 other stupid boxes must be clicked in 12 minutes, on EMR that you are required to pay for, lest you forfeit your $65 fee. We already have enough insurance companies injecting "value" into psychiatry and telling us our patients need to be kicked out of the hospital after 5 days.

 

[Candidate2017]

But how do ya do that? The million dollar question.

Take a risk, rent an office, go out and meet docs and market yourself. Like any other business person. Or old school doc. PM me, I'll let you know where to send my check.

 

[Shikima]

But how do ya do that? The million dollar question.

Find a cheap office, make friends with PCPs and therapists, let them know you're accepting new patients at whatever rate you choose and wait for the phone call. Just need a chart and a script pad. They'll come. Screen for addicts unless you don't care.

Taken from @nitemagi :
1. Get a PT gig so your bills are paid. 1-2 days a week. Always good if they have additional per diem work if you need it.
2. Start the practice, get all your logistics set up, including billing, office, phone, fax, and make a list of referral sources.
3. Start getting the word out and accepting patients.

 

[futuredo32]

Find a cheap office, make friends with PCPs and therapists, let them know you're accepting new patients at whatever rate you choose and wait for the phone call. Just need a chart and a script pad. They'll come. Screen for addicts unless you don't care.

Taken from @nitemagi :
1. Get a PT gig so your bills are paid. 1-2 days a week. Always good if they have additional per diem work if you need it.
2. Start the practice, get all your logistics set up, including billing, office, phone, fax, and make a list of referral sources.
3. Start getting the word out and accepting patients.

Ive done this and take insurance and cant fill. I get most referrals from existing patients, so they feel like I help them I am guessing. I don't see couples separately unless it's med management only, but other family members/friends as long as all parties agree and understand HIPPA. I know this is a grey line but I haven't had problems. I work in a city where some psychiatrists make 275 for 45 min. Getting the word out would consist of what? I work near Ann Arbor, saturated with psychiatrists. They are mostly U-M grads and know each other.

 

[Shikima]

Ive done this and take insurance and cant fill. I get most referrals from existing patients, so they feel like I help them I am guessing. I don't see couples separately unless it's med management only, but other family members/friends as long as all parties agree and understand HIPPA. I know this is a grey line but I haven't had problems. I work in a city where some psychiatrists make 275 for 45 min. Getting the word out would consist of what? I work near Ann Arbor, saturated with psychiatrists. They are mostly U-M grads and know each other.

What about opening up shop in Fenton? Need to think outside the box, not the safety confines of the meager existence. No reward without the risk.

 

[hamstergang]

I don't see couples separately unless it's med management only, but other family members/friends as long as all parties agree and understand HIPPA. I know this is a grey line but I haven't had problems.

The way I'm reading this makes it sound like you'll do joint sessions for people who are friends and family of each other instead of giving each their own individual therapy. It sounds weird and sounds like a bad idea if you need some more slots filled. Am I misunderstanding?

 

[Shikima]

The way I'm reading this makes it sound like you'll do joint sessions for people who are friends and family of each other instead of giving each their own individual therapy. It sounds weird and sounds like a bad idea if you need some more slots filled. Am I misunderstanding?

You are. Referrals are said to be slim and counts only on word of mouth.
The missing piece is established relationships and marketing choice.

 

[Merely]

If you take insurance and psychiatrist arenin demand, shouldn't he be overflowing with patients? How the hell can he not even fill his practice? Is it that he's in a super saturated market and needs to move elsewhere?

 

[zolof]

Even with insurance it seems it may take a while to fill if it is a saturated area. It also depends on which insurance, maybe they are only taking some insurance panels. It really is regional. I had opened up part time earlier in the year, and was getting way full in over an area hour away from where i live. I could not stand the commute so a few months ago , I recently moved the office within the city where I live which is very saturated no doubt but wanted to be very close to home, and cannot get full even with insurance. Luckily I am doing it only part time.

 

[futuredo32]

The way I'm reading this makes it sound like you'll do joint sessions for people who are friends and family of each other instead of giving each their own individual therapy. It sounds weird and sounds like a bad idea if you need some more slots filled. Am I misunderstanding?

Sorry, I wasn't clear. No they are not joint sessions. I see each one individually. I don't do family therapy. I did couples counseling and each had their own therapist as well. I am NOT doing joint sessions. Lucky for me my patients have a positive transference and they tell their family members about me and their family members or friends come to see me during their own appointments. The only thing I do is make sure it is ok with all family members that they are seeing the same psychiatrist, get written permission and let them know they can talk about their relatives seeing me but I can't comment on anything their friends or relatives have said. I'm in analysis myself and he is awesome and I would NOT be ok with a friend or relative seeing him. I don't share his name and he is pretty far away so the likelihood of them seeing him is almost nil. I agree unless it was family therapy it would be weird.

 

[futuredo32]

If you take insurance and psychiatrist arenin demand, shouldn't he be overflowing with patients? How the hell can he not even fill his practice? Is it that he's in a super saturated market and needs to move elsewhere?

I need to get on 2 more insurance panels and reach out to PCPs and therapists. I had planned to apply to FP this year and didn't volunteer or do anything so that went away. I am a she btw I have never made the effort to get more patients because I was doing locums. I went to that area because I was sharing a suite with a former attending who promised the moon and the stars and said he wasn't taking new patients but could fill me in a few months. But word had gotten out that he wasn't taking new patients. He got me like two. I need to make the effort to contact PCPs and therapists in the area. I have patients and the county I am practicing in has much lower malpractice rates than other areas. I have an awesome office with great furniture and I am actually good at what I do. I would hate to start all over. The area is supersaturated but most nearby with patients who are insured are.

 

[Merely]

Hmm I hope most areas aren't saturated, I thought psych was supposed to be a "open up anywhere and get flooded with patients" type of situation...maybe you guys are in highly sought after locations?

 

[zolof]

Curious, has anyone used a billing service for their insurance? I am curious about the verification of insurance and how if they use someone, they are charged for it?

 

[WingedOx]

What about opening up shop in Fenton? Need to think outside the box, not the safety confines of the meager existence. No reward without the risk.

I may or may not have lived in Fenton once a upon a time (with a commute to a job in Ann Arbor). It's a doable commute but not the most pleasurable experience in the world.

I can't imagine it's at all saturated with psychiatrists though. And if lakeside living is your thing, there's that.

 

[futuredo32]

Curious, has anyone used a billing service for their insurance? I am curious about the verification of insurance and how if they use someone, they are charged for it?

I use the billing company my attending or former attending used. 8% she gets. She sucks.

 

[finalpsychyear]

I use the billing company my attending or former attending used. 8% she gets. She sucks.

I learned to do my own billing and honestly if you have an emr with billing a lot of them are free. Now i only do a few days of pp so maybe this becomes not really feasible if your doing 5 days of PP but Im a bit OCD about my money collection and actually have collected 99% which is better than any billing company my peers have said. No one will care about your money as much as you will. I pay like 30-50 bucks a month for my emr which comes with free clearinghouse and billing. Its simply 2 clicks in my emr once i have done the note and literally i have submitted the claim.If your not using an emr to do billing and doing paper claims then you probably need someone. I worked with a private prac doc in my 4th year who showed me extensively how to do it with and without emr. Honestly everyone should learn how to do it through an EMR if they have the function. Also, 8% seems high. Get a company if you must have someone and u can probably get it for 4-5%.

 

[zolof]

I use the billing company my attending or former attending used. 8% she gets. She sucks.

Maybe we have the same person haha.

 

[zolof]

I learned to do my own billing and honestly if you have an emr with billing a lot of them are free. Now i only do a few days of pp so maybe this becomes not really feasible if your doing 5 days of PP but Im a bit OCD about my money collection and actually have collected 99% which is better than any billing company my peers have said. No one will care about your money as much as you will. I pay like 30-50 bucks a month for my emr which comes with free clearinghouse and billing. Its simply 2 clicks in my emr once i have done the note and literally i have submitted the claim.If your not using an emr to do billing and doing paper claims then you probably need someone. I worked with a private prac doc in my 4th year who showed me extensively how to do it with and without emr. Honestly everyone should learn how to do it through an EMR if they have the function. Also, 8% seems high. Get a company if you must have someone and u can probably get it for 4-5%.

I am planning on learning this, I use EMR and it seems easy enough so far to submit, but how do you not lose track to follow up and aging and all that. What about verification of insurance, do you have time to do that before seeing new patients? this 7 percent person who wants my business says she also does verification for 13 dollars a new client! I am glad this is very part time for me. I would like to add more hours in the future though. 99 percent for collections is better than what these people are getting. impressive.

 

[nitemagi]

Ive done this and take insurance and cant fill. I get most referrals from existing patients, so they feel like I help them I am guessing. I don't see couples separately unless it's med management only, but other family members/friends as long as all parties agree and understand HIPPA. I know this is a grey line but I haven't had problems. I work in a city where some psychiatrists make 275 for 45 min. Getting the word out would consist of what? I work near Ann Arbor, saturated with psychiatrists. They are mostly U-M grads and know each other.

I can't speak about other markets, but I've found success through diversifying referral sources. Take ppl out for coffee and make contacts. Especially therapists, primary care docs, and other physicians (including specialists). And make sure you're offering the highest quality care you can, and unique services/niches that others don't.

 

[PikminOC]

I learned to do my own billing and honestly if you have an emr with billing a lot of them are free. Now i only do a few days of pp so maybe this becomes not really feasible if your doing 5 days of PP but Im a bit OCD about my money collection and actually have collected 99% which is better than any billing company my peers have said. No one will care about your money as much as you will. I pay like 30-50 bucks a month for my emr which comes with free clearinghouse and billing. Its simply 2 clicks in my emr once i have done the note and literally i have submitted the claim.If your not using an emr to do billing and doing paper claims then you probably need someone. I worked with a private prac doc in my 4th year who showed me extensively how to do it with and without emr. Honestly everyone should learn how to do it through an EMR if they have the function. Also, 8% seems high. Get a company if you must have someone and u can probably get it for 4-5%.

Which emr?

 

[futuredo32]

You all have a private practice and can afford EMR?

 

[Shikima]

You all have a private practice and can afford EMR?

Of course! There are many platforms to use. Not all are equal in function and pricing.

 

[SeniorWrangler]

I have read about psychiatric accountable care organizations (ACO) where the payment is based on the number of covered lives and meeting quality benchmarks like decreased depression scores and access to new patient appointments. A big part of the ACO model is getting the health care provider to accept a lot of downside risk, and nobody really knows how that will work out.

 

[futuredo32]

Of course! There are many platforms to use. Not all are equal in function and pricing.

I heard they were 30k to buy and 15k to upgrade yearly.

 

[Shikima]

I heard they were 30k to buy and 15k to upgrade yearly.

Not at all. A lot of misinformation - also your experience is with health systems, not the office. I saw a particular product which has an annual fee that includes billing and e-rx (controlled too) and a monthly fee of $250/user

 

[WisNeuro]

I heard they were 30k to buy and 15k to upgrade yearly.

Maybe like 15 years ago. Many of my PP colleagues get by with systems that are <1k a year, many that are far cheaper, depending on what kind of functionality you need.

 

[MrWonderful]

Which EMRs are most popular for private practice psychiatrists? This is something I've been looking into recently

 

[finalpsychyear]

I heard they were 30k to buy and 15k to upgrade yearly.

Practice fusion is free and has E-prescribe but not controlled unless you pay extra i believe.

 

[futuredo32]

Practice fusion is free and has E-prescribe but not controlled unless you pay extra i believe.

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