Accelerating and Aligning
Primary Care Payment Models White Paper

Report: Released: March 1, 2017

Description

Primary care is a critical link in health care delivery. Often patients’ first point of contact with the health care system, primary care practitioners make decisions that broadly impact both patient health and total health care spending. This Primary Care Payment Model (PCPM) White Paper views primary care teams as uniquely positioned to serve as catalysts for innovative care as well as effective stewards of health care resources. The paper offers principles and recommendations for implementing PCPMs that can help overcome the barriers to effective primary care tied to traditional fee-for-service payments based on the volume of services provided rather than the quality and value of care.

Related Papers

Authors

Primary Care Payment Models (PCPM) Work Group of the Health Care Payment Learning & Action Network

Publication Info

Publication date: March 1, 2017
43 pages

Suggested Citation: Health Care Payment Learning & Action Network. Accelerating and Aligning Primary Care Payment Models White Paper.
March 1, 2017.

Alternative Payment Models (APMs)

Alternative payment models deviate from traditional fee-for-service (FFS) payment, insofar as they adjust FFS payments to account for performance on cost and quality metrics, or insofar as they use population-based payments that are linked to quality performance.

Behavioral Health

The full range of mental health and substance abuse disorder conditions, services, clinicians.

Data Sharing

Data sharing lies at the heart of two important and ambitious goals of PBP models and APMs: 1) It promotes the availability and use of real-time comprehensive, patient-level data and information to inform clinical care and decision making, enable true integration of care, and improve care delivery and outcomes; and 2) It improves the health care market, such that care is purchased on the basis of transparent and reliable assessments of cost and quality performance for populations.

Fee for Service (FFS)

The existing FFS system creates incentives for additional volume of services, while also undervaluing certain services. The current FFS system is not conducive to the delivery of person-centered care because it does not systematically reward high-quality, cost-effective care.

Full Continuum of Care

All aspects of care delivery, spanning preventive to end-of-life services in all settings.

Mental Health

Conditions, services, clinicians specifically related to the substance use disorder field (e.g., anxiety, depression, and schizophrenia).

Patient-Level Data

The entire range of diagnostic, clinical, utilization, experience of care, and patient-reported data that is attributed to a particular individual, irrespective of where the data were collected. Such data are stored in a cyber-secure, HIPAA-compliant environment to address security and privacy concerns and can be reported in both patient-identified and de-identified views.

Population-Based Payment (PBP)

Population-based payment models offer providers the incentives and flexibility to strategically invest delivery system resources, treat patients holistically, and coordinate care.

Population-Based Payment Model

A payment model in which a provider organization is given a population-based global budget or payment and accepts accountability for managing the total cost of care, quality, and outcomes for a defined patient population across the full continuum of care. PBP models discussed in this paper correspond to payment models in Categories 3 and 4 of the LAN’s APM Framework.

Population-Level Data

An aggregation of patient-level data, which is attributed to higher-level entities for reporting, such as plans, provider organizations, and patient populations in different geographic regions.

Primary Care

Integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Substance Use Disorders

Conditions, services, clinicians specifically related to the substance use disorder field (e.g., substance dependence and abuse).

Total Cost of Care (TCOC)

A broad indicator of spending for a given population (i.e., payments from payer to provider organizations). In the context of PBP models, in which provider accountability spans the full continuum of care, TCOC includes all spending associated with caring for a defined population, including provider and facility fees, inpatient and ambulatory care, pharmacy, behavioral health, laboratory, imaging, and other ancillary services.

The LAN has written a suite of papers to help align payment reform efforts.
The papers include recommendations on the design of two payment reforms—population-based payments and clinical episode payments—from the two most comprehensive categories defined in that framework. These recommendations are the result of input from a wide variety of persons and organizations with either direct experience with implementing one or the other payment reform or deep experience in the health care field.

Data sharing cover sheet

Briefing Deck – Primary Care Payment Model

Figure 1: Payment Flow in PCPMs

figure-1-thumbnail

Figure 3: Structural Components of PCPMs in Relation to the APM Framework

Figure 4: Types and Degrees of Accountability and Risk in APMs

figure 4 thumbnail

No, it is not the sole consideration, because practices will always need to consider their ability to operationalize delivery systems that are conducive to financial risk arrangements. Nevertheless, assuming those basic capacities exist, panel size will be the dominant criterion for determining how much financial risk a practice is able to assume.

Estimates of how many patients are required for a primary care practice to assume accountability for capitated primary care payments (i.e., Category 4A in the LAN APM Framework) are associated with a significant amount of uncertainty, and are largely dependent on the patient population in question. Nevertheless, a threshold of 5,000 patients is required to be accountable for total cost of care but insufficient to be at full financial risk, which requires much larger panel sizes typically seen in larger health systems and accountable care organizations (ACOs).

As discussed in the context of Recommendation 3, certain types of Category 3 PCPM arrangements are appropriate for small practices, and would represent an important step away from traditional fee-for-service. Please consult Table 1 for comparative characteristics of payment methods in PCPMs.

No. Some type of claims-based record-keeping will always be required, so that practices can implement quality improvement initiatives and be evaluated on utilization measures. However, the types of records and reporting for these purposes should be considerably less onerous than evaluation and management (E&M) codes.

The Work Group believes so, and the White Paper reflects this in the discussion of Recommendation 17: PCPMs should foster data sharing and analysis to facilitate care coordination, patient engagement, population health management, and performance assessment.

Yes, these types of data will be important for the long-term success of PCPMs. For additional information and recommendations on data sharing in population-based payment models, please see the LAN White Paper on Accelerating and Aligning Population-Based Payment Models: Data Sharing.

Yes, these types of data will be important for the long-term success of PCPMs. For additional information and recommendations on data sharing in population-based payment models, please see the LAN White Paper on Accelerating and Aligning Population-Based Payment Models: Data Sharing.

Yes, the White Paper’s Recommendation 18 now explicitly notes that practices will need external coaching support and technical assistance on these topics to help them transition to new payment and delivery models.

As discussed in the context of Recommendations 8 and 12, PCPMs may help alleviate issues associated with geography and provider shortages by giving practices the flexibility needed to establish non-traditional linkages to specialists, particularly behavioral therapists. E-consultations, similar to the model established by Project Echo, may be a useful approach that PCPMs would encourage. If these types of arrangements are still insufficient, then it is acceptable to carve behavioral health out of PCPMs, while still holding practices accountable for behavioral health management. These more limited arrangements would reduce the imperative to coordinate with behavioral health specialists, but would not eliminate it entirely.

As discussed in the context of Recommendation 13, PCPMs may help alleviate issues associated with high levels of social and medical complexity by giving practices the flexibility needed to establish linkages to social and community service providers. This is because population-based payments and care management fees can promote investments in infrastructure support for referrals to services that address social determinants of health.

No, practices will not be required to do so. However, PCPMs will give practices additional flexibility to establish linkages to social services, and establishing these linkages may result in improved health outcomes and better performance in the PCPM.

No, co-location may not be feasible in all cases and locations. However, close coordination between behavioral health and primary care, and integration of behavioral and physical health, are critical for success in PCPMs.

The White Paper identifies several implementation issues that will need to be addressed in order to operationalize successful PCPMs. However, questions of implementation are beyond the scope of the White Paper. The LAN’s Primary Care Payer Action Collaborative is a good source for additional guidance and information about implementing PCPMs.

Webinars

November 02, 2016 Webinar: LAN Listening Session for Providers (archive)

November 04, 2016 Webinar: LAN Listening Session for Payers (archive)

Blogs

Paying Providers For Value: The Path Forward (Update)
by Sam Nussbaum, MD; Patrick Courneya, MD, MSc; Mark McClellan, MD, PhD; and Mark Smith, MD, MBA

Ensuring the Debate Has the Patient in Mind and in the Room
by Patrick Courneya, MD

Why Regional Data and Local Relationship Will Reform Health Care Payment Nationally
by Elizabeth Mitchell

Population-Based Payment Models: Overcoming Barriers, Accelerating Adoption
by Dana Gelb Safran, ScD; Glenn Steele, Jr, MD, PhD; and Elizabeth Mitchell

Archival Materials

LAN Summit Session: Listening Session: Primary Care Payment Model (PCPM) Recommendations (archive)

Copyright © 1997-2018, The MITRE Corporation. All rights reserved. MITRE is a registered trademark of The MITRE Corporation. Material on this site may be copied and distributed with permission only.

Log in with your credentials

or    

Forgot your details?

Create Account