Medical home pilots spur delivery and payment reform

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Patient-centered medical home models have proven that they reduce hospital admission and emergency room use in recent pilots.

WellPoint and other payers were involved in medical home test models in Colorado and New Hampshire that demonstrated not only higher-performing care delivery but an example of payment reform with its incentives for care coordination and improved quality.

WellPoint and other plans paid physician practices a care coordination fee and performance bonus based on quality and utilization measures or costs on top of the typical fee for service, according to Sam Nussbaum, WellPoint executive vice president and chief medical officer.

The outcomes showed increasing improvement in quality measures for chronic conditions, more use of preventive services and cost savings. For example, in the Colorado pilots, hospital admissions decreased by 18 percent, emergency room visits by 15 percent and specialty visits were flat, he reported.

As a result of the findings, WellPoint is spreading the medical home model across its 14-state network, Nussbaum added.

“This is such promising information that we can’t wait to apply and wait for medical homes to come together across the nation. Every one of our primary care physicians is going to be offered an opportunity to be part of a new patient-centered primary care initiative, where we’re starting by paying more,” Nussbaum said at a Sept. 7 payment reform briefing sponsored by Health Affairs.

WellPoint is paying more for the fee-for-service foundation, more for coordination of care, for working on care plans and other non-visit services, he said.

The goal is to “assure more savings and more care coordination that, in fact, is an incentive for the programs for shared savings and other initiatives led by the Centers for Medicare and Medicaid Innovation (CMMI),” he said. Indeed, CMMI selected Colorado as one of the locations of the Comprehensive Primary Care Initiative to align payment reform with practice transformation.

Nussbaum said the company was investing in expanding access through virtual care and offering a continuation of care outside the office; putting more nurse care managers in practices; and establishing information systems to exchange meaningful information.

In the three-year pilots, the payer provided an average care management fee of $4 per patient per month, with more depending on level of recognition practice redesign from the National Committee for Quality Assurance (NCQA).

“Whether it was diabetes measures, blood pressure control, flu shots, aspirin therapy, statin treatment, in each instance you see increasing quality in measures,” Nussbaum said.

The Colorado pilot involved 16 physician practices, representing 60 physicians, while the New Hampshire pilot had nine practices with 75 physicians participating.

The multiple payers and mostly small providers needed a lot of support to build trust and work together, said Marjie Harbrecht, CEO, HealthTeamWorks and assistant clinical professor of family medicine at University of Colorado.

The practices had to deal with multiple payers, so it was critical to find common methods to get data back and forth. “We tried to get shared care managers for multiple practices to use for the really complex patients,” she said.

For payers, because the pilot was voluntary and not convened by a governmental body, legal counsel was involved to minimize antitrust concerns. Payers also had to change their systems to get the data flowing among participants, she said.

[Q&A: Moving from PCMH to a 'medical neighborhood' via Direct.]

This transformation is as much about people and culture change as the payment and delivery model changes.

Payers and providers need incentives to work together to coordinate care and the incentives have to be aligned “or everyone won’t play with each other,” she said.

But it’s also necessary to “change the hearts and minds of health plans, providers, hospitals and employers” to come together in a collaborative effort. That’s what’s going to make the difference “if I am going to game the system or if I have enough invested from the fact that I went into medicine to make this quality happen and do the best for my patients,” Harbrecht said.