Field testing of new models of healthcare delivery and payment often reveal unanticipated challenges and benefits in efforts to achieve targeted outcomes.
The Puget Sound Health Alliance's Patient-Centered Medical Home Multi-payer Reimbursement Model pilot in Washington state, led with the Washington Health Care Authority and Department of Social and Health Services, is one example of the mixed bag pilot participants are finding.
Puget Sound's pilot includes seven health plans and eight medical groups at 12 practice sites. Since 2011, the pilot has rewarded primary care practices for better outcomes through prevention of emergency room use and inpatient hospitalization. Like other pilots, it included extra income for providers - $2.50 per member per month - and access to care management, said Susan Dade, deputy director of the Puget Sound Health Alliance. Over 21 months, practices received $1.2 million for improved patient outcomes and reduced emergency department use.
"What is unique about our pilot is that providers have accepted financial accountability for achieving specific targets. If they do achieve the target, they get to split the savings. But if they fail to achieve the target, they have to pay money back to their health plans," she said during a presentation on the pilot at a recent conference sponsored by AcademyHealth.
One of the difficult aspects was early resistance from the multiple payers to share the data they accumulated during the pilot, which is dependent on complete and accurate information.
"It fell more on the providers to handle differences and inadequate documentation from payers," Dade said.
The work-around added to the complexity of reporting quality and utilization data, which was driving the payment from the health plans to the practices, and potentially from the practices, who did not meet targets, back to the health plans.
Each payer has managed their own measurement and reporting separately and provided Puget Sound, which acted as an aggregator, with "the data that payers wish to give to us," Dade said. "As a multi-payer program, you may not have access to all the information that you may need."
In the mid-Atlantic region, CareFirst BlueCross BlueShield established a voluntary patient-centered medical home with its physicians in an accountable care model. CareFirst introduced a global expected cost of care based on episodes, including hospital, drug, lab, imaging, per person per month and rewards outcomes on a shared savings basis.
Every service a physician provides to a member is debited against the global payment account, said Chester "Chet" Burrell, president and CEO of CareFirst, but physicians carry no risk if they fail to meet the expected cost.
About 3,600, or 85 percent, of the region's primary care physicians participate in the program, grouped in 403 panels in this region serving 1 million people.
In the first full year in 2011, 60 percent of the panels beat their expected cost of care, Burrell said. Forty percent did not. Those that did won an average award of 21 percent on top of their fees.
"If you ever got 21 percent more, you won't soon forget it. And if you didn't get it, you will try what the others did to get it," he said at a recent American Medical Association conference.
After two years, the panels in CareFirst's program performed better versus other physicians on indicators, such as readmissions or outpatient visits, Burrell said.
Physicians now ask more about how their quality compares with other clinicians, and they don't shop for specialists' referrals by price but by quality and outcome. "What we see is behavioral change coming with deeper understanding," he said.
CareFirst's program has been bending the cost curve, he said. "It tells me that it is a better way to go. It puts the decision-making power back in the judgment of physicians."