Regardless of the type of reimbursement arrangement providers and insurers set up, the ultimate goal is to provide value to the patient. For all of the chatter about risk-based models, there are still pockets where fee-for-service reimbursement is proving that providers can deliver high-quality care and reduce costs.
CareFirst BlueCross BlueShield in Baltimore released new results from a fee-for-service, patient-centered medical home it runs in Maryland, Washington, D.C., and northern Virginia. In 2014 alone, the experiment showed significant improvements:
- 5 percent fewer hospital admissions
- 11 percent fewer days in the hospital
- 8 percent fewer readmissions for all causes
- 12 percent fewer outpatient health facility visits
Results have been equally impressive for the program's four-year run (2011–2015):
- 19 percent fewer hospital admissions
- 15 percent fewer days in the hospital
- 20 percent fewer readmissions for all causes
- 5 percent fewer outpatient health facility visits
At the same time, the average reward for a participating provider grew to between $41,000 and $49,000 in 2014 from $25,000 to $30,000 the previous year.
The total cost of care in 2014 through the program was $345 million less than what would have otherwise been expected. And it was achieved without some of the typical attributes of a PCMH.
"We do call it a patient-centered medical home, and that's what it's focused on, but it is different from what other [organizations] are doing in this space," said CareFirst spokesman Michael Sullivan. "It's not based, for instance, around [National Committee for Quality Assurance] certification as a medical home. It doesn't pay per member, per month fees."
But the plan does offer robust support to those who participate, starting with a 12 percent increase just for joining and maintaining membership.
The number of participating physicians and advanced practice nurses grew to 4,052 as of this year, up from 2,152 the first year of operation in 2011, according to a performance report. Attributed membership grew to 1.1 million in 2015 from 490,000 in 2011. An important part of gaining the broad 80 percent participation rate is the fact that the program is fee for service, which is more practical and familiar to providers, Sullivan said.
Incentives are paid through CareFirst's established rate schedule, taking into account quality and financial metrics.
"Because there are incentives for both quality and cost, there's no incentive to withhold care," Sullivan said. If a physician provides value-added care, he or she will be paid for it, but it also gives [physicians] a direct incentive to consider the cost of care for their patients who are CareFirst members, he said.
And this is for all of the costs, not just those that are primary care, he added.