When physician leaders at Hattiesburg Clinic began to examine the accountable care organization cost-and-quality data they got from the Centers for Medicare & Medicaid Services (CMS), they did so as a self-assessment exercise. But what they discovered transformed into a national focal point in debates over scope of practice and physician-led team-based care.
Hattiesburg Clinic, the largest private multispecialty clinic in South Mississippi, took the raw data it received from CMS and learned that nonphysician providers were driving up costs by ordering more tests and referring more patients to specialists. Their patients made more emergency department visits as well.
“We were very curious to find out internally where our costs were going for our Medicare ACO patients,” said Bryan Batson, MD, CEO of Hattiesburg Clinic, a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
“Out of curiosity more than anything else,” Dr. Batson said Hattiesburg leaders—on their first pass through the CMS data—looked to see which physicians and nonphysician clinicians had generated the highest costs among its ACO patients.
The 2017–2019 CMS cost data on Medicare patients without end-stage renal disease and who were not in a nursing home showed that per-member, per-month spending was $43 higher for patients whose primary health professional was a nonphysician instead of a doctor.
This could translate to $10.3 million more in spending annually if all patients were followed by nonphysicians, says the analysis. When risk-adjusted for patient complexity, the difference was $119 per member, per month, or $28.5 million annually.
These findings were included in a study entitled “Targeting Value-based Care with Physician-led Care Teams” that was published in the Journal of the Mississippi State Medical Association.
“Naturally, there have been a lot of questions and some angst around some of the findings,” Dr. Batson said during an episode of “AMA Update” in which he discussed the importance of physician-led, team-based care.
“But our purpose remains the same,” he added. “We're going to continue to learn from our examination of ourselves and hopefully continue to improve on the way we deliver care.”
Fighting scope creep is a critical component of the AMA Recovery Plan for America’s Physicians.
Patients deserve care led by physicians—the most educated, trained and skilled health professionals. The AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety.
Valued members of the care team
Four of the top five costliest professionals during the years studied were nonphysician clinicians.
“The one physician who was in that group was a physician who was specifically running a clinic for Medicare highly complex patients in the geriatric age group and those patients who had the highest complexities of care,” Dr. Batson. “Seeing her in that group was not a surprise. But what was a surprise was to see the other four in that group being all” nonphysician clinicians.
Dr. Batson emphasized, however, that nurse practitioners and physician assistants (PAs) are valued members of the Hattiesburg Clinic care team and that their ACO saved Medicare $23 million from 2017 through 2019.
“Our nurse practitioners and PAs have been integral to our journey,” Dr. Batson said.
This journey included having its ACO ranked first in quality in its cohort in 2016 and 2017, among a total of 471 other participants, and recognized by CMS for delivering high-quality care at a low cost.
“Team-based care is crucial,” Dr. Batson said. “We need to make sure we're leveraging everyone's skill set to the best of our ability.”
Acting on the CMS data, Hattiesburg Clinic redesigned its care teams so that—starting Jan. 1, 2021—only a physician would be leading a patient’s care team.
The AMA has policy that defines physician-led team-based care “as the consistent use by a physician of the leadership knowledge, skills and expertise necessary to identify, engage and elicit from each team member the unique set of training, experience and qualifications needed to help patients achieve their care goals, and to supervise the application of these skills.”
AMA policy also recognizes “nonphysician providers as valuable components of the physician-led health care team.”
State and national interest
Since publication of its study, multiple organizations have reached out to Hattiesburg Clinic to compare notes, Dr. Batson said.
In addition to the national attention, state legislators sat down with clinic leaders to examine the data to determine its relevance to bills that are introduced every year to allow nonphysician clinicians to practice independently.
This year, the legislation didn’t make it out of committee.
“This was local data in a health system in Mississippi, and our legislators were willing to take the time to understand what we learned, and what it was telling us and what we were doing in response to it,” Dr. Batson said.
“AMA Update” covers health care topics affecting the lives of physicians and patients. Hear from physicians and experts on public health, advocacy issues, scope of practice and more—because who’s doing the talking matters. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.
