While payment reform efforts are proliferating, we still have a lot to learn about which health care payment and delivery reform programs result in more affordable care, with better outcomes for patients. But one thing we see often is a mismatch between the incentives offered to health care providers and those offered to their patients, who may not be driven to seek care from practices that have restructured to provide higher value care.
This disconnect causes difficulties for providers who spend time and money restructuring to improve patient care, sometimes at financial risk. To succeed under payment reforms, providers often need patient volume, which may only materialize if those shaping health plan offerings design programs that thoughtfully interweave the right benefit and network designs.
In 2016, Catalyst for Payment Reform (CPR) and the Urban Institute explored these issues in a series of papers examining how payments to providers offering new care delivery models can be supported by what we identify as “high-value benefit designs.” We examined how these benefit designs can support accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and “focused factories” (a qualified group of specialists who provide care for a procedure or condition and related services in an efficient, high-quality way).
High-Value Benefit Designs Are Needed to Support Success
Recent reports find potential evidence to support our assumptions in a real-world test of a model by CareFirst BlueCross BlueShield of Maryland, known as the CareFirst Patient-Centered Medical Home Program (the “PCMH” or the “Program”). The Program’s primary intention is to “reinforce the role of the Primary Care Physician (PCP) in helping members to understand and manage their health risks as well as guide their care when they experience major illness, especially involving chronic disease.”
The Program is built around more than 400 self-selected and voluntarily organized groups of PCPs (called medical panels), which are given financial incentives to meet cost and quality objectives. PCPs that join the CareFirst PCMH first receive a 12 percent increase in their current fee schedule for professional services. In addition, they receive a professional service fee of $200 for developing care plans for patients with certain chronic conditions or multiple chronic conditions; they also receive recurring payments of $100 for monitoring care plan progress. Supported by teams of nurses, known as “local care coordinators,” the PCPs have assistance in establishing and implementing care plans for the sickest patients. CareFirst also supports the medical panels with online information, on-site hospital care coordinators, pharmacists, data analysts, and other staff.
The medical panels vary in size from five to 15 PCPs. Similar to an accountable care organization (ACO), each medical panel has a target budget based on historic expenditures of their attributed members. If, in a given year, the medical panel beats its target budget (e.g., the expenditures for the attributed members are less than the target budget) the PCPs can earn shared savings, called “Outcomes Incentive Awards,” which typically range from 30-40 percent of the PCP’s normal income, depending on the medical panel’s quality performance.
In addition to strong financial incentives for PCPs to manage the cost and quality of their patients’ care, CareFirst offers lower premiums to customers whose members choose PCPs in high-performing medical panels. Furthermore, the Program offers other financial incentives, in the form of co-pays, deductibles, and medical card credits, to the CareFirst commercial beneficiaries who are attributed to participating PCPs and who rely on these PCPs for care coordination and referrals to high-value hospitals and specialists.
First, CareFirst encourages its members to select a PCP from a “high-performing” panel by waiving a portion of their deductible or giving them a credit on their medical expense debit card. Second, the Program uses financial incentives to encourage members to use services economically, such as seeking care from a lower-cost setting. For example, a patient member’s cost-share at an emergency department is $200 versus $50 at an urgent care center. These types of incentives help the PCPs control the costs their patients incur when receiving health care services.
The Program also offers incentives to CareFirst’s beneficiaries who have major health care problems and chronic illnesses. Specifically, members with chronic conditions who agree to work with their PCP to establish and follow a care plan are eligible to have their co-pays and deductibles reduced or eliminated. These changes in the CareFirst benefit structure introduce patient incentives that align with those of the PCPs and medical panels to manage and coordinate their patients’ care and to perform well on the quality metrics that serve as a factor in their total payment.
Results
Two external studies examining the performance of the PCMH in its first three years have been recently released with somewhat similar, although not definitive, findings.
The first study found that, by the third year, annual adjusted total claims payments per attributed member were $109, or 2.8 percent lower than they were before the Program began. Total three-year savings were $297 per attributed member, relative to the control group. These savings were achieved on a “net” basis—i.e., after accounting for all additional direct care management support costs and Outcome Incentive Awards paid to PCPs. Forty-two percent of this savings was explained, according to the study’s authors, by lower utilization of inpatient care, emergency care, and prescription drug spending. These results have been questioned by some experts, who have suggested that the study might have found a better control group—a challenge for many studies.
The second study released this month in Health Affairs, found only minor differences between the CareFirst PCMH enrollees and non-enrollees. The authors concluded that the Program needs more time to produce visible and significant differences, similar to the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, which did not generate meaningful savings until year four. Qualitative interviews revealed that participating PCPs supported the program but, in many cases, had not yet changed their behavior as a result of it. Those who had changed their behavior focused more on improving quality than reducing costs.
CareFirst’s own analysis of the Program’s impact found improvements in patient satisfaction as well as quality, with 19 percent fewer admissions, 15 percent fewer days in the hospital, and 20 percent fewer all-cause hospital readmissions since the Program’s inception. Additionally, in the first six months of 2016, high-performing panels of PCPs increased their market share. Because the PCPs in those panels had been channeling their referrals towards high-performing specialists and hospitals, the market shares of those providers also went up.
In 2012, CareFirst extended the Program to 40,000 fee-for-service Medicare beneficiaries through a three-year Health Care Innovation Award from the Center for Medicare and Medicaid Innovation (CMMI).
Conclusion
The CareFirst PCMH Program provides an example of how aligning patient incentives with those of health care providers could produce better, more affordable care. Although the Program’s early results are mixed, it may produce greater costs-savings as consumers become more aware of their financial incentives to seek care from less expensive sites or from lower-cost, higher-quality providers (due to out-of-pocket differentials). Providers and patients may be more successful in lowering the use of unnecessary services and procedures and increasing utilization of needed care if they work toward the same goal.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2o64adw
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