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Alternatives to Fee-for-Service in Primary Care: Insights from Multi-Payer Efforts and Research OCTOBER 30, 2017 Crystal Gateway Marriott Hotel Arlington, VA

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  • Alternatives to Fee-for-Service in Primary Care: Insights fromMulti-Payer Efforts and Research

    OCTOBER 30, 2017 Crystal Gateway Marriott Hotel Arlington, VA

  • Welcome

    Charles Fazio, MD, MS PAC Chair

    SVP and Medical Director, HealthPartners, Inc.

  • Today's Panel

    Bruce Landon Professor of Health Policy, Harvard Medical School

    Professor of Medicine, Beth Israel Deaconess

    Medical Center (BIDMC)

    Internal Medicine Practitioner, BIDMC

    Christiane LaBonte Payment Policy & Operations

    Lead, Division of Advanced Primary Care

    CMMI

    Alicia Berkemeyer Vice President,

    Enterprise Primary Care and Pharmacy Programs

    Arkansas Blue Cross and Blue Shield

    Dr. Peter Hollmann Chief Medical Officer

    Assistant Clinical Professor of Family Medicine

    University Medicine, Rhode Island

    Eileen Wood Senior Vice President,

    Clinical Integration

    Chief Pharmacy Officer

    Capital District Physicians Health Plan, Albany NY

    3

  • Payment for Primary Care:Implications from a MicrosimulationModel

    Bruce Landon, M.D., M.B.A. Department of Health Care Policy, Harvard Medical School Division of General Medicine and Primary Care, BIDMC

    4

  • Background

    PCMH demonstration programs to date have yielded relatively unimpressive results

    Successful in bringing additional resources to primary care Butlittle change in quality or utilization of services

    5

  • Our microsimulation model suggests that PCMH paymentmodels used in most early evaluations were not sufficientto change practice

    Source: Basu et al. Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model. Ann Fam Med. September/October 2016 vol. 14no. 5 404-414

    6

  • Key Assumption

    It is not rational to expect primary care practices to implement changes that adversely impact their costs or

    revenues

    7

  • Changes in Care Delivery Strategies UnderPCC

    Strategies to leverage physician effort enable time to care for largerpanels Expanded staff to handle lower level visits, telephone care, e-mail, e-visits,

    counseling, etc. Enhanced triage to eliminate wasteful visits Enhanced care coordination capabilities

    Direct costs of above capabilities plus additional proportional overhead related to increased panel size

    8

  • Results

    Scenario Metric

    Payment Strategy

    Traditional FFS

    Capitation (at 110% prior years

    FFS level)

    50% capitation 100% capitation

    Before

    transformation

    Revenue $530181 $556690 $583199

    Costs $451893 $451893 $451893

    Net surplus $78288 $104797 $131306

    After

    transformation

    Revenue $528877 $613641 $698405

    Costs $492987 $492987 $492987

    Net surplus $35890 $120654 $205418

    Change in net surplus ($/full-time

    MD/year) $-42398 $15857 $74112

    9

  • Capitation Threshold

    >63% capitationneeded Varies little by

    changes in: # visitsshifted, panel size,productivity,practice location But reduces with

    shared savings: to56% under 0.6% shared savings

    10

  • Take Home Points

    Success under different payment models requires that PCPs/practices do things differently

    Existing PCMH financing strategies will not be sufficient to motivatefundamental practice transformation

    Moving to PCC is promising, but thresholds are higher than mostpeople thought

    11

  • 12

    Thank you [email protected]

    mailto:[email protected]

  • Three Main Goals Underlie CPC+

    Advance care delivery and payment to allow practices to provide more comprehensive care that meets the needs of all patients, particularly those with complex needs

    Accommodate practices at different levels of transformation readiness through two program tracks, both offered in every region

    Achieve the core objectives of improving the quality and efficiency of primary care

    13

  • CPC+ Program OverviewStructure, Participants, and Launch Dates

    Greater Buffalo Region (NY)

    ND

    NE

    LA

    = Statewide Round 1 Region

    = Statewide Round 2 Region

    = Round 1 region comprising contiguous counties

    = Round 2 region comprising contiguous counties

    Practices

    Over 2,800 practices participating in the model

    Payers

    Round 1 54 payers in 14 regions Round 2 8 payers in 4 new regions + 5 additional payers in Round 1 regions

    5 Years 1/1/2017 Round 1 launch 1/1/2018 Round 2 launch

    Progress monitored quarterly

    14

  • CPC+ Two Tracks

    Track 1

    Pathway for practices ready to build the capabilities to deliver comprehensive primary care.

    Track 2

    Pathway for practices poised to increase comprehensiveness of care through enhanced health IT, improve care of patients with complex needs, and inventory resources and supports to meet patients' psychosocial needs.

    15

  • CPC+ Payment Innovations To support the delivery of comprehensive primary care, CPC+ includes three payment elements:

    16

  • LAN Action Collaboratives

    A LAN Action Collaborative (AC) provides a results-oriented forum for sharing, integrating, and applying new knowledge and tailoring solutions to APM implementation challenges.

    This will support committed participants with a shared aim to take more effective action in their organizations to increase effective implementation of APMs that make a collective impact on the U.S. health care system.

    ACTION COLLABORATIVE

    17

  • 18

    The Role Of The PAC The Intersection of the PAC and CPC+

    REGIONAL

    CPC+ Multi-payer primary care APM designed to support practice-level transformation in 18 regions by encouraging regional payers to align alternative payment model, data sharing, and quality measure approaches

    SHARED MILESTONES

    Seeking solutions that enable better care to multi-payer primary care APM implementation challenges, such as:

    Aggregating multi-payer data Aligning quality measures APM payment issues TCOC considerations

    NATIONAL

    PAC Establishes a national table for regional CPC+ payers to collaboratively identify and

    0implement solutions, share promising practices, and accelerate progress towards successful implementation of APMs in primary care

    Strengthening collaboration and empowering participants to take action to advance APM adoption as part of improving primary care delivery and outcomes

  • Track 2 Alternative to FFS Payment:PAC Work Flow

    Design Practice Engagement Implementation

    Lines of business included

    Providers/practices included

    Services included

    Level of practice risk

    Using fee schedules to calculate payment

    Minimum volume thresholds

    Financial reconciliation

    Risk adjustment

    Data feedback to practices

    Involving practices in model design

    Attribution Timing of rollout and

    first payment

    19

  • LAN Resources https://hcp-lan.org/resources/

    20

    https://hcp-lan.org/resources

  • Exit Survey We want to know what you think!

    Please take a moment to complete the exit survey so we can continue to improve and enrich the LAN. https://www.surveymonkey.com/r/lansummitsession

    https://www.surveymonkey.com/r/lansummitsession

  • Contact Us We want to hear from you!

    www.hcp-lan.org

    @Payment_Network

    [email protected]

    Search: Health Care PaymentLearning and Action Network

    mailto:[email protected]:www.hcp-lan.org

  • OCTOBER 30, 2017 Arlington, VA Crystal Gateway Marriott Hotel

    Thank You!

  • Back Up Slides

    24

  • Team Members Sanjay Basu, MD, PhD

    Stanford University, Prevention Research Center; Institute for Economic Policy Research; Centers for Health Policy, PrimaryCare & Outcomes Research

    Asaf Bitton, MD, MPH Harvard Medical School, Center for Primary Care; Ariadne Labs; Center for Medicare & Medicaid Innovation

    Bruce Landon, MD, MBA, MSc Harvard Medical School, Department of Health Care Policy

    Russ Phillips, MD Harvard Medical School, Center for Primary Care

    Zirui Song, MD, PhD Harvard Medical School; Massachusetts General Hospital, Department of Medicine

    25

  • Avoidable or Triage-able Visits Principal diagnosis ICD-9 Code Proportion of all

    visits (%) Avoidable visits1, among visits for the principal diagnosis (%)

    Triage-able visits2, among visits for the principal diagnosis (%)

    Hypertension 401.9 8.4 23.7 53.0

    Diabetes 250 6.3 19.5 54.3

    Routine exam V700 4.2 17.0 36.0

    Hyperlipidemia 272.4 1.9 14.1 42.7

    URI 465.9 1.6 7.6 61.8

    Avoidable visits: visits for a routine chronic problem for which the treating physician did not order any laboratory studies, imaging studies, medications, or provide any health education/counseling.

    Triage-able visits: visits for which no new diagnostic codes were assigned to a patient, and no laboratory studies, imaging studies, or medications were ordered by the physician.

    26

  • Potential Impact on Panel Size

    27

    Alternatives to Fee-for-Service in Primary Care: Insights from Multi-Payer Efforts and ResearchWelcome Today's PanelPayment for Primary Care: Implications from a Microsimulation Model BackgroundSlide Number 6Key AssumptionChanges in Care Delivery Strategies Under PCC ResultsCapitation Threshold Take Home Points Thank [email protected] Main Goals Underlie CPC+ CPC+ Program OverviewCPC+ Two Tracks CPC+ Payment Innovations LAN Action CollaborativesThe Role Of The PACTrack 2 Alternative to FFS Payment:PAC Work FlowLAN ResourcesExit Survey Contact UsThank You!Back Up SlidesTeam MembersAvoidable or Triage-able VisitsPotential Impact on Panel Size


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