Health Plans Beginning to Recognize Importance of Paying for PCMH Model

The AAFP's persistence is beginning to pay off.

You might not be aware that AAFP leaders and staff members meet with the nation's largest health plans annually to discuss payment issues and improving care coordination and quality. Now our ongoing dialogue with these health plans has resulted in a significant increase in one health plan's investment in primary care.

WellPoint Inc. recently announced that it plans to increase its base fee schedule by 10 percent, start paying for electronic visits and other previously uncompensated services, and offer practices shared savings payments. And according to Samuel Nussbaum, M.D., WellPoint's chief medical officer and EVP for clinical health policy, the Academy's input was critical to the development of its new primary care program.

"This is about strong and enduring collaboration with the AAFP," said Nussbaum in an interview with AAFP News Now. "It is really the strong working relationship we have with so many of the leaders of the AAFP that has helped us advance this program. In fact, go back and look at the patient-centered medical home (PCMH) and the meetings we've had with the AAFP. The AAFP was instrumental in designing those models."

In the eight years since the Future of Family Medicine report called for changes in the U.S. health care system, including ensuring that every American has a personal medical home, the Academy has actively championed the PCMH model. The AAFP has held ongoing meetings with private payers and legislators. In addition, the AAFP created TransforMED in 2005 to test the PCMH model and to help family physicians transform their practices.

And as part of an ongoing commitment to help members meet the challenges of a changing health care system, the Academy recently expanded member access to TransforMED's clinical and practice management experts via its Delta-Exchange network.

Additionally, in 2006, the AAFP played a key role in forming the Patient-Centered Primary Care Collaborative (PCPCC). The collaborative, which includes members from a variety of physician groups, health plans, employers, consumer groups, hospitals, labor unions and patient organizations, was formed to create a more effective and efficient model of health care delivery and improve patient-physician relations. The PCPCC serves as a forum where stakeholders can communicate about the nation's health care system. It also educates legislators, other government officials and physicians about the PCHM model.

Although some Academy members have questioned the wisdom of allowing insurance companies to sit on the executive committee of the PCPCC, involving private payers in the coalition has helped maintain an open dialogue with the health plans. And they have heard our message, as is demonstrated by WellPoint's recent announcement.

WellPoint said it will offer physicians who meet certain standards -- such as National Committee for Quality Assurance (NCQA) recognition -- a number of opportunities to earn more revenue through its patient-centered primary care program.

WellPoint estimates that physicians could increase their revenue by 30 percent or more by participating in the shared savings program. The health plan intends to begin implementing the program in the third quarter of this year in select markets, with a national rollout anticipated by the end of 2014.

In addition, Aetna has launched a PCMH program in Connecticut and New Jersey that company officials expect to be nationwide by the end of the year. Practices that achieve NCQA Level 1 or 2 PCMH recognition will receive a $2 per-member, per-month care coordination fee, while practices that achieve NCQA Level 3 recognition will receive a $3 per-member, per-month fee.

Although it is great news that Aetna is beginning to recognize the importance of paying for the type of care coordination offered by family physicians, we know from other such PCMH pilots that $2 or $3 a month simply isn't enough to cover the investments in electronic health records and other aspects of practice transformation that physicians need to make to participate in these programs.

In comparison, the Comprehensive Primary Care Initiative, which was announced last fall by CMS, is expected to pay physicians a per-member, per-month care coordination fee ranging from $8 to $40.

The gap between the $2-$3 that Aetna and others are offering and the $8-$40 being offered by CMS is one that must be addressed. Aetna's program most likely will be on the agenda when AAFP leaders and staff meet with representatives from the health plan next month.

An Aetna representative told the AAFP this week that the company believes in the PCMH model. That's encouraging to hear, but clearly there is more work to be done.

The Academy will continue to engage these insurance companies and will continue to encourage them and other health plans to properly pay us for our time, service and expertise. Health plans that value primary care appropriately will see that patient outcomes improve and costs are saved when we are encouraged and compensated to provide the full range of care that our extensive training and experience allows.