• Patients, Physicians, Payer Benefit From Primary Care Investment

    "Secret, secret, I've Got a Secret."  

    Some of you may recognize these lyrics from the 1983 Styx mega-hit "Mr. Roboto," but most of you probably are pondering its application to the AAFP and family medicine. My secret is this: the key to improved quality and reduced health care costs is -- wait for it -- primary care. I realize that few of you are shocked by this statement, but there are plenty of people in health care that are just now waking to this reality.  

    A couple of weeks ago, I had the opportunity to meet with the president and CEO of CareFirst BlueCross BlueShield, about that organization's patient-centered medical home program. CareFirst, which operates in Maryland, the District of Columbia, and northern Virginia, launched its PCMH program in 2011 with more than 2,000 primary care physicians and providers participating. Today, 80 percent of primary care physicians and providers in this service area participate in the program, and collectively they provide care to more than 1 million patients. Seventy-five percent of participating physician practices are solo, small and medium-sized physician practices.

    The design of the CareFirst program is quite simple. Physicians are asked to align themselves with other primary care physicians to form panels that range in size from five to 15. CareFirst provides two forms of upfront financial support -- a 12 percent participation fee and a $250 payment for each care plan developed. In addition, CareFirst provides three types of administrative support -- care managers; data and analytics; and technical assistance via program consultants.

    CareFirst does not require that the practices achieve third-party PCMH recognition, nor do they require that the panels form new legal entities to work together towards achieving shared savings. Physicians can partner with others in a virtual or cooperative way rather than through contractual alignment. In return, CareFirst asks each panel to assume responsibility for the total cost of care for their attributed patients by focusing on five key areas:

    • cost effectiveness of referral patterns;
    • engagement in care coordination programs;
    • medication management;
    • reducing gaps in care and quality deficits; and 
    • physician engagement and performance improvement.

    If the primary care panels control total costs of care as compared to their benchmark, they get to share in the savings. I know what you are thinking, the benchmark lowers annually, thus making it impossible to achieve continuous savings in the program. Well, that would be wrong. CareFirst does not lower the benchmark to reflect annual or cumulative net savings. It only adjusts the benchmark based upon the risk stratification of the patients attributed to the panel.

    So, has it worked? In short, yes.  

    Since 2011, CareFirst has reduced its expected costs of care and slowed spending growth by an estimated $609 million. Additionally, CareFirst slowed its rate of growth from 7.5 percent in 2011 to 3.5 percent in 2014. In four years, the CareFirst PCMH program has contributed to a 19 percent reduction in hospital admissions, 15 percent fewer hospital days, 20 percent fewer hospital readmissions, and 5 percent fewer outpatient health facility visits. As a result, participating physicians who met quality and savings targets earned, on average, $41,000 in shared savings.

    Physician participation and engagement in the program is high and holding. Since 2011, only 13 percent of physicians have left the program. Of that 13 percent, 82 percent retired. The remaining 18 percent were asked to leave due to a lack of participation, but 7 percent of those physicians subsequently returned.  

    Since 2011, 38 percent of the primary care panels have secured savings in all four years, and 32 percent have secured savings in three of the four years, debunking the so-called process bias theory that suggests savings are not sustainable over long periods. In fact, only eight panels, or 2 percent, have failed to secure savings at some point.

    Following my conversation with CareFirst, I came away with five key points about the future of advanced primary care practices and the medical home:

    • Empowering primary care should be a central tenant for payers and purchasers, not a passing ambition. The value of primary care has become widely accepted. Now payers and purchasers need to increase their investment in primary care. Primary care accounts for approximately 5 percent of the total spend for any health care payer or purchaser, but primary care has tremendous influence over the remaining 95 percent of spending. Investments in primary care can come in the form of resources (care managers, data dashboards, cost/quality reports on specialists and hospitals), financial (engagement bonuses, care management fees, increased payment for performance), or both. This investment should be upfront, meaningful and independent of undue administrative complexity.
    • Independent does not mean isolated. Primary care physicians in any practice type and size need to embrace alignment. This alignment can be virtual or contractual. More than 75 percent of physicians participating in the CareFirst program are not employed by an academic or large health system, and many of these physicians are in solo or small practices.
    • Teams matter. Teams come in various shapes and sizes, but they are important to patients and physicians alike. This can be teams of physicians or physicians working with other health care providers in a coordinated manner, but the key is moving away from the concepts of individual, independent and isolated care delivery models. Care managers, who are embedded in a practice, seem to be an important and essential element of highly functioning and successful advanced primary care practices.
    • Data is key. If purchasers and payers truly want primary care physicians to accept responsibility for the total cost of care, they must provide the primary care physicians timely and accurate data on the cost and quality of all physicians, hospitals and outpatient care facilities in their community or service area. 
    • PCMH recognition by a third party may not be necessary. Evaluating performance remains an important component of advanced primary care practices, but securing recognition of your practice as a medical home may not be essential. The more important recognition is a physician’s performance against a set of core functions in his or her practice.

    I realize that this posting could facilitate some interesting comments, and I look forward to hearing your thoughts. I also realize that there are likely some shortcomings in the CareFirst program. However, the successes of the CareFirst program and others like it are becoming far more prevalent. This leads me to believe that the core functions of an advanced primary care practice are becoming more identifiable and replicable and are being paid differently and better.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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