Patient-Centered Primary Care Programs

Accustomed to getting paid for each procedure they perform, many primary care physicians may soon be compensated based on their ability to keep costs down and meet quality standards. In recent months, major health insurers have announced plans to change the fee structure for primary care physicians, holding them accountable for meeting certain requirements. In return, they can share in any savings. WellPoint, Inc revealed in late January that it would launch a patient-centered medical home (PCMH) initiative in the third quarter of this year and hopes to have a nationwide program in place by 2014. Physicians who maintain or exceed certain standards could earn 30% to 50% more than they do today, according to the company. WellPoint already has a few pilot PCMH programs, but this one is much more ambitious. By 2015, WellPoint wants to reduce medical costs by as much as 20% for its 34 million members in its health plans and the 65 million people it serves through subsidiaries. “Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we’re committed to helping them achieve these quality and cost goals,” Dr. Harlan Levine, WellPoint’s executive vice president for comprehensive health solutions, said in a news release. “Primary care is the foundation of medicine, and it can and should be the foundation of our members’ health.” The PCMH is not a new idea. The American Academy of Pediatrics (AAP) introduced the first medical home concept in 1967, and other organizations followed. In 2007, the American Academy of Family Physicians, American College of Physicians, American Osteopathic Association, and AAP formed a coalition and developed an overview of PCMH characteristics. According to the guidelines, a PCMH is led by a personal physician who is responsible for caring for patients on all healthcare needs throughout their lives. The physician either provides the care or is in charge of arranging care with other physicians. The PCMH is focused on providing quality, safe care, and values coordination among providers. The Agency for Healthcare Research and Quality (AHRQ), a government organization, is attempting to promote more widespread use of the PCMH as a way to transform primary care. In 2010 it awarded $8.2 million in grants over a 2-year period to help primary care practices transition into a PCMH. AHRQ defines a PCMH as having 5 requirements: comprehensive care (a team of providers working on a patient’s physical and mental health needs); patient-centered (communicating clearly and meeting a patient’s needs); coordinated care (working with hospitals, specialty care centers, and others in the health system); accessible services (through extended hours, minimizing wait times, and providing access to providers on the telephone or via e-mail); and quality and safe care. There have also been state-based PCMH models working with private insurers, Medicare, and Medicaid. The shift toward a PCMH model comes at a pivotal time as primary care practices endure challenges. According to an AHRQ analysis, there were 490 million visits to primary care physicians in 2008, more than half of all physician visits. However, only approximately one-third of physicians are in primary care and <25% of medical school graduates specialize in primary care. The research noted primary care physicians have increased demands while also facing economic hardships. Practices are becoming more expensive to run, and reimbursement is not keeping up with the higher costs. The Wall Street Journal reported WellPoint’s plan will cost $1 billion, but the company believes it will lead to fewer emergency department visits and hospital stays. WellPoint has a network of approximately 100,000 primary care physicians. “This will fundamentally change our relationship with primary care physicians,” Dr. Levine said. Soon after WellPoint’s announcement, other insurers followed by disclosing their own plans. Aetna launched a PCMH program beginning in New Jersey and Connecticut that will expand nationwide later this year. Eligible participants must be certified as a PCMH by the National Committee for Quality Assurance. If they meet certain requirements, they will receive quarterly payments. Anthem Blue Cross and Blue Shield’s PCMH program in Connecticut has comparable goals of providing physicians with incentives to keep costs down and coordinate care to help patients. Anthem began pilot PCMH programs last year. The company said it hoped to further its efforts by applying for the Centers for Medicare & Medicaid Services (CMS) primary care initiative. In July, CMS will choose 5 to 7 sites comprised of 75 practices to participate in the PCMH program. “This is an important step in advancing quality healthcare and ultimately improving the coordination of care while promoting a more accessible and efficient experience for our members,” David R. Fusco, Anthem’s president in Connecticut, said in a news release. UnitedHealthcare intends on extending its new payment system to hospitals and physician groups as well as primary care physicians, according to documents the insurer sent to employer clients that were reviewed by the Wall Street Journal. By 2015, 50% to 70% of UnitedHealthcare’s commercially insured members may be affected by value-based contracts, up from the current 1% to 2%. The report said most higher volume hospitals and medical groups would eventually be included in the program. Primary care physicians could earn bonuses of $1 to $3 per member per month, while accountable care organizations may earn an additional $1 to $5 per member per month if they meet certain goals. “This is not just an exercise or a pilot,” Sam Ho, United Healthcare’s chief clinical officer, told the Wall Street Journal. “It represents a significant change in the architecture of our compensation models for doctors and hospitals.”—Tim Casey