New Financing Model Could Reward Primary Care

The medical home may be the future of primary care, but finding a way to pay for it needs to happen now. The good news is that this goal can be achieved -- and quickly.

That's the contention of a white paper recently released by the Bridges to Excellence coalition. The authors of the paper, "Prometheus: Paying for Excellence," (PDF file: 48 pages / 298 KB. More about PDFs.) hope to light a fire under the health care industry to provide fair pay for good care.

“When you look at the total cost of care … for patients with conditions like diabetes or heart disease, you find exactly the same thing: Patients who are taken care of well cost less,” said Francois de Brantes, to an audience of health policy experts at a June 22 forum sponsored by the Robert Graham Center. De Brantes is one of the paper's authors and national coordinator for the Bridges to Excellence program, a non-profit coalition established by employers, physicians, health care services researchers and other industry stakeholders to encourage and reward advances leading to improved health care quality.

Although it often falls to primary care physicians to provide that comprehensive care, the current financing system fails to recognize these physicians are doing so. According to de Brantes, under a system called Prometheus, family physicians would get justly rewarded for saving money by keeping patients healthier.

De Brantes and his colleagues argue that by using the Prometheus system, in which care for various diseases or conditions is paid for according to standardized case rates, physicians who provide good quality care will receive a predictable amount of profit, while those who provide exemplary care will reap higher rewards.

High-quality, efficient care produces savings, mainly because of reduced visits to specialists and reduced hospital time, said de Brantes, adding that under the Prometheus case rate system, the medical home would keep the savings generated. "It's just as simple as that," said de Brantes.”

The plan also would give physicians the freedom to practice without the constraints of health plan micromanagement, said de Brantes. “No prior authorization, no formularies, none of the review that goes on -- which is really just a waste of everyone’s time, but is the only way today, in a fee-for-service system, plans have to pretend that they can try to figure out or control a little bit what is going on.”

Although the use of case rates -- also are known as global fees -- is not a new concept, according to the report, the Prometheus system includes several differences. Those differences include

Although physicians would be eligible for performance rewards in the Prometheus system, they also would be taking on some risk if their costs ran above the case rate, according to de Brantes. Additionally, physicians' performances would be judged in part on the performance of other physicians in their practices whom their patients might see.

“The amount that is actually at risk, which is 10 percent to 20 percent (of the total case rate amount), is a small fraction of the total compensation that’s at risk for what other providers are doing. But it’s a market signal. And it is an important one that says, 'we really want physicians to collaborate around the treatment of the patients.' That is what the medical home is about,” said de Brantes.

The Prometheus group is in the process of convincing key players, mainly large health plans, of the value of the proposal. And, recent trends work in their favor.

“When you consider the big push toward consumer-directed health plans, the one big struggle that everyone and every consumer in those plans has is, 'How do I anticipate the cost of care?'” de Brantes noted.

“If you are a consumer and you can look at a case rate, you can fully anticipate what the cost of your care is going to be,” he added.

Although the proposal is not simple, and the transition won’t be easy, it can be done and done quickly, said de Brantes. “It is going to require a lot of real leadership. There are a lot of people over the past 30 years in health care who have been 'talking the talk,' and now we’re going to give them the opportunity to 'walk the walk.'”