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Title: Bob%20Doherty
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Designing new payment models for Medical Care
Version 2009 (PCMH) Presentation toThe
Medical Home Summit
- Bob Doherty
- Senior Vice President, Governmental Affairs and
Public Policy - American College of Physicians
- March 3, 2009
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Traditional FFS Medical Care Version 1965
- Based on the way that care was provided 40 years
agonot way it delivered today - patients treated only when sick (acute condition)
- little or no emphasis on prevention and
coordination - care based on doctors best judgment as informed
by CME and journals but not on evidence-based
guidelines - specific visit or procedure code
- individuals not teams
- usual, customary, reasonable (UCR)
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RBRVS-FFSMedical care Version 1989
- Same as 1965 version but
- Instead of UCR, based on RBRVS
- Relative values based on time, mental and
physical effort, and iatrogenic risk - Initial pay shift to primary care, eroded over
time
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Traditional capitationMedical Care Version
1995
- Per patient per month
- Not risk-adjusted
- Transfer of insurance risk to physicians
- Incentive do as little as possible, for as few
as possible keep people out of the office dont
take on higher risk/higher use patients
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Wanted! New pay models forMedical Care Version
2009
- Medical care today
- prevention/management of illness rather than just
treating disease - care rendered by coordinated teams of health
professionals - clinical judgment informed by evidence-based
clinical decision support - results matter (not just service rendered)
- systems and processes of care to support better
outcomes
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Getting from here to there
- Here is a payment system that discourages
innovation, care coordination, teams, systems and
better outcomes - There is a payment system that rewards practice
innovation, care coordination, teams, systems and
better outcomes - How do we get from here to there?
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There . . .
- The Patient-Centered Medical Home
- Care coordinated by personal physician
- Responsible for whole person
- Prevention and coordination
- Systems
- Patient-Centeredness
- But a PCMH wont work without a payment model
designed for Medical Care Version 2009
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Payments to a PCMH must
- Be sufficient to recognize the costs, work and
time for a practice to be qualified as a PCMH and
sustain it over time - Recognize the value of physician time and work
that falls outside of a face-to-face visit - Help offset the costs of acquiring HIT and other
systems
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Payments to a PCMH must
- Recognize the increased expense and work
associated with caring for more complex patients - Provide positive incentives for practices take
the first step up the QI ladder . . . with
additional incentives to climb higher
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Payments to a PCMH should not be based solely on
- doing as much as possible for as many as possible
(FFS) - or doing as little as possible for as few as
possible (capitation) - or how well a practice scores on quality measures
(P4P) that may ignore elements of care that are
not being measured
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A better idea combine FFS, monthly care
coordination fees, and performance
- The PCMH payment equation
- Monthly care coordination prospective
payments (tiered levels 1, 2, 3) - x risk adjuster
- Risk-adjusted care coordination fee
- FFS payment for visits
- Total payment w/o performance
- Performance based payments
- Total payment to the PCMH
- could be combined with shared savings model
- Incorporates work outside of visit and costs of
HIT amount could vary depending on practice
capabilities per NCQA scoring
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Patient-Centered Primary Care The Denmark
Example ______
- Blended primary care payment system
- Fee-for-service
- Medical home payment
- Organized off-hours service
- Health information technology
- Reimbursement for email
- Health information exchange common portal
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Denmark leads the way
- 98 of primary care MDs have totally electronic
records and e-RX - Highest public satisfaction with health system
among European countries - Source Commonwealth Fund, 2006
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Why is this a better way to pay?
- Reduces incentives for excess volume
- Creates incentives for physicians to spend time
coordinating care outside a visit - Accelerates adoption of HIT and other best
practices - Assures that physicians will see the most complex
patients - Rewards measurable improvements (quality,
efficiency, satisfaction) and patient-centered
care - Supports value of primary care
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Payment Model for Non-PCMH
- Prospective Payment
- -Structure
- -Care coordination
- -Non face-to-face care
- -Adjusted for complexity of
- population services
- Enhanced RBRVS
- Fee for Service
- Performance
- Fee For Service
- Enhanced RBRVS
- Performance
- A la carte codes for
- -Care Coordination
- -Non face-to-face care
PCMH
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Payment Models for the PCMH
- Prospective Payment
- -Structure
- -Care coordination
- -Non face-to-face care
- -Adjusted for complexity of
- population services
- Enhanced RBRVS
- Fee for Service
- Performance
- Fee For Service
- Enhanced RBRVS
- Add-on codes
- Performance
- Global Payment
- Procedures
- Performance
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MEDICARE MEDICAL HOME DEMONSTRATION
- PER PATIENT PER MONTH PAYMENT RATES, OVERALL AND
BY PATIENT HCC SCORE - PPPM HCC Score lt1.6 1.6
- Tier 1 40.40 27.12 80.25
- Tier 2 51.70 35.48 100.35
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Practice Implications
- Need to understand challenges of transformation
- Initial capital and restructuring costs
- Ongoing support maintenance
- Reporting on quality, cost and satisfaction
- Implementation of HIT coincident with PCMH
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What needs to be done to get there?
- More study needed on costs to practices to become
PCMHs - More work on risk-adjusters and tiers for the
PPPM care coordination fees - Work with payers to overcome technical and
administrative challenges - More work on building in performance-based
compensation and shared savings - Pilot-testing
- Benchmarks for evaluations
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Benchmarks
- Does it provide sufficient support for practice
transformation? - Does it make primary care more competitive and
viable? - Is it administratively feasible for physicians
and payers? - Does it work in smaller practices?
- Does it create incentives for patient-centered
care? - Does it accelerate adoption of the PCMH model?
- Can it be scaled up to a national scale?
- Does it lead to better patient care?
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Summary
- Current pay models do not support the way care is
delivered in 2009 (or the way it should be) - New models are needed to support prevention,
systems, and care coordination in PCMH - Hybrid model (Denmark) holds particular promise
- Model must be viable for practices (including
smaller ones), payers
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Summary
- More work needs to be done on development,
implementation and evaluation - But the promise of the PCMH will not be realized
without a new payment system that works for
patients, physicians and payers
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COMING SOON!
- Physician Payment Version 2009!
