As hospital wards filled with COVID-19 patients, the exam rooms at Dr. Mark Collins’ office in Elk Grove Village, Illinois, sat empty.
“We were not seeing patients in the office except on rare occasions,” the family medicine physician with AMITA Health Medical Group says. “A few doctors saw patients in the office with full PPE.”
Across the country, patient visits to ambulatory care practices fell about 60% by early April due to stay-at-home orders put in place to flatten the curve. In May, visits were still about one-third lower than pre-pandemic.
“Utilization fell off a cliff,” says Salma Khaleq, vice president of network management and contracting with Blue Cross and Blue Shield of Illinois. “Clinicians lost an immediate source of revenue.”
Primary care practices are on track to lose more than $67,000 in revenue per physician this year. That’s because most are still paid in a fee-for-service environment, getting paid for each patient they see.
Disruptions in cash flow could force practices to close or push doctors into early retirement — making it more difficult for people to access the care they need to get and stay healthy.
"Utilization fell off a cliff."
But value-based payment structures — where insurers pay doctors not for the quantity of visits but the quality of those visits — are serving as a life raft for the physicians that participate in them.
Steady revenue streams
BCBSIL’s value-based contracts with in-network providers have given participating doctors like Collins a constant stream of revenue even as exam rooms sit empty.
Some contracts pay doctors for work that isn’t directly caring for patients but is making the patient experience better, like a care coordination fee. Other contracts, like the HMO, pay doctors a set amount of money each month for taking care of its members — an arrangement known as capitation. About 600,000 members are part of the BCBSIL HMO model.
“Patients are guaranteed access to care and clinicians are guaranteed pay regardless of patients being able to come into the office,” Collins says of value-based payment systems.
Between March and June this year, BCBSIL has paid providers a total of $260 million through these value-based contracts — on par with what it paid out in that time period last year.
Not all value-based contracts pay doctors a flat rate per member. In a pay-for-performance contract, doctors can earn bonuses for hitting goals like reducing infections or making sure patients get screenings like mammograms.
The pandemic has made it hard for practices to meet those benchmarks. “It became readily apparent members were not going to get the preventive screenings and other things we measure as a result of the pandemic,” Khaleq says.
So BCBSIL actively worked with providers across its value-based care contracts to extend and change the quality metrics to make sure doctors have the best chance to succeed.
“[Changing] quality metrics put the physicians and groups in the best position to succeed through the end of the year,” Collins says.
In-person patient visits are starting to rebound at Collins’ office.
“Patients have gone from not wanting to come into the office to insisting on coming in,” he says. “So we put on the mask and gloves and goggles and we see them.”
In addition to extra PPE, his practice made other changes to reduce the risk of spreading COVID-19. They now have patients wait in the car before their appointment and have a designated time slot early in the day for elderly or at-risk individuals.
But one thing that’s not changing is the practice’s commitment to participating in value-based care contracts with BCBSIL.
“It would be counterintuitive to go back to the old school fee-for-service,” he says. “We’re valued by patients in terms of what we do for them, and it’s important we get paid for the value we bring in taking care of them.”