On their own, practices often lack the resources and data capabilities to fully transform the way they deliver care; ACHP members recognize the benefits practice transformation brings to patients and practices and are willing to invest staff time and resources toward the successful implementation of these initiatives. For some plans, this financial support took the form of grant funding or seed money for practice transformation, including money to hire new staff or invest in health IT capabilities.

Capital District Physicians’ Health Plan

Capital District Physicians’ Health Plan, Inc. (CDPHP) was founded in 1984 as a not-for-profit IPA model HMO in Albany, N.Y. Since then, Capital District Physicians’ Health Plan and its affiliates have grown to serve more than 400,000 people in 24 counties throughout New York state.

CDPHP’s medical home model is called Enhanced Primary Care (EPC). It aims to provide comprehensive payment for comprehensive care, align financial incentives, and create an opportunity to significantly increase primary care physician income.

The EPC payment model is a fully risk-adjusted capitation model that holds primary care physicians responsible for services they provide and includes opportunities for substantial performance-based bonuses. Providers can earn up to $5.32 per member per month (PMPM) by meeting efficiency (total cost of care), quality (HEDIS) and patient experience (CG-CAHPS) measures. These bonuses drive transformation at the practice, while ensuring high patient satisfaction.

Practices receive $20,000 grants to work on practice transformation for 12 months before they are given the opportunity to participate in the reimbursement model. Bonus payments are then given out yearly, with a lag due to collection of HEDIS data. Once providers are eligible for participation in the payment model, CDPHP recontracts with them to move them off of fee-for-service.

Bonus payments are unique to each practice; the potential bonus is determined by the number of imputed patients and their average PCAL. Patient experience scores determine the eligibility for a bonus, effectiveness scores create the available bonus, and efficiency scores determine the payout of the available bonus.

Under the EPC payment model, primary care physicians are given a 23 percent increase in reimbursement for codes covered under the capitation arrangement for their practice’s patients. Practices, however, continue to be paid under a fee-for-service (FFS) model for services that are outside the capitation code list. Combined with the 20 percent bonus payments, practices can earn up to 40 percent more under the EPC model than under the fee-for-service model.

By reimbursing primary care physicians at a higher rate, CDPHP aims to make primary care more appealing to medical school students and encourage more students to become primary care physicians.

Geisinger Health Plan

Geisinger Health Plan (GHP) is a not-for-profit health maintenance organization which serves the health care needs of more than 270,000 members in 43 counties throughout central and northeastern Pennsylvania. Geisinger Health System employs 250 primary care physicians and 450 specialty physicians who serve a predominantly poor and rural population of 2.5 million.

In 2005, Geisinger’s board of directors challenged leaders with developing approaches to improving care coordination, chronic care, patient engagement, transitions of care and acute care. As a result, GHP’s patient-centered medical home (PCMH) initiative, entitled the ProvenHealth Navigator® (PHN), was designed and implemented to deliver value by improving patient care coordination and improving the health status of each patient. The pilot originally addressed the needs of patients with chronic disease and multiple comorbidities who represent the health plan’s highest cost segment. In this pilot, GHP focused on five core components tied to PCMH transformation: 1) patient-centered primary care team practice, 2) integrated population management, 3) micro-delivery systems, 4) quality outcomes program, and 5) a value reimbursement system. The PHN model was later expanded to GHP’s entire Medicare population as well as some commercial members.

The plan supports practice transformation with monthly payments to practices of $1,800 per physician and $5 per Medicare patient. The payment model utilized was a FFS hybrid with performance and incentive bonuses capped at $3 PMPM. A shared savings model was based on savings and paid based on the percentage of quality targets achieved. Outcomes were based on a set of ten quality outcomes which were related to encounters per patient, disease-specific care scores, vaccines administered, inpatient follow-up rates, percentages of high-risk patients with a care plan or risk assessment and patient satisfaction scores.

Presbyterian Health Plan

Presbyterian Health Plan, Inc. is owned by Presbyterian Healthcare Services, a not-for-profit, integrated health care system consisting of a health plan, medical group and hospital system and New Mexico’s largest locally owned health care system. Presbyterian Health Plan serves more than 420,000 members throughout New Mexico.

PHP first rolled out its medical home pilot to the health system-affiliated Isleta Clinic in July 2009 and spread the model to three other medical groups in 2010. All practices involved in the PCMH initiative have gone through two phases. The first is a pilot phase in which PHP gives each practice a grant to support and scale primary care transformation, and during which providers and staff can build expertise. Grant money is used in a variety of ways, such as to hire staff to oversee NCQA accreditation or educate providers. Initial grants totaled approximately $2 PMPM, and often had payouts dependent on successful reduction in emergency room utilization for PHP member populations.

The second is a care management fee phase; it includes higher expectations for outcomes to be achieved, shared savings, expanded measures and meaningful targets that drive financial incentives. Based on practices’ commitment and outcomes during the pilot phase, they move to the care management phase. The phase is modeled after similar shared savings arrangements PHP has with employer groups, whereby they can get a reduction in premiums based on their employees’ participation in wellness programs. PCMH practices receive tiered incentives based on the level of NCQA accreditation they achieve as well as quality and utilization measures.

PMG-affiliated primary care physicians have, in the past, had salaries based almost entirely on relative value unit (RVU) production and FFS with annual quality performance bonuses capped at approximately $15,000. For practices in the care management phase, PHP reduces RVU/FFS compensation to around 60 percent of total payment. The other 40 percent of physicians’ salaries is dependent on quality outcome performance, panel/population management and the frequency with which patients engage in alternative venues of care. Pharmacy and behavioral health services are reimbursable, as are eVisits; PHP also provides diabetes incentive payments.

Priority Health

Priority Health is a not-for-profit health plan serving about 550,000 members in 65 counties in lower Michigan. More than 12,000 employers offer Priority Health coverage to their employees, and more than 14,000 health care providers participate in its network. Priority Health offers products for employer groups, individuals and Medicare and Medicaid patients.

Priority Health views the health plan as an essential partner to practices in enabling population level management necessary for success under defined budgets. The health plan brings several resources to the table, including comprehensive population-level data, care management expertise, payment methods that align financial incentives, and financial reserves to share in accountability for a population.

Patient-Centered Medical Home

For its PCMH pilot, Priority Health allowed practices to hire and train care coordinators and direct their change management processes independently by providing up-front funding to its PCMH sites.

Payment incentives came in two phases; grant money, then both grant money and PMPM payments. Grants to PH pilot practices totaled $2 million dollars and were allocated based on the merit of practices’ individual PCMH proposals. Beginning in 2009, depending on the level of NCQA recognition achieved, practices received PMPM reimbursement ranging from one to three dollars ($1 for each level of NCQA recognition). In 2009, the health plan began reimbursing providers using standard contracts to pay network providers for after-hours visits, group visits, e-visits and patient-initiated telephone visits

Thirteen of the 15 sites chose to use grant funding to hire health educators who were tasked with making patient visits more comprehensive. As needed, health coaches could spend extra time with patients and were available to offer educational support aimed at increasing their medical literacy and empowering them to more effectively manage chronic conditions. The health coaches also provided patients with information about community resources available to them locally. Practices used the health coach/care coordinator role to implement group visits, create more intensive diabetes education processes, perform population management and registry analysis, redesign office workflows and help implement open access scheduling (reserving time for same-day appointments).

In 2010, recognizing that there were a number of PCMH designations in Michigan and to decrease the burden on providers, Priority Health began recognizing any PCMH designation, including NCQA, the Utillization Review Accreditation Commission (URAC), and others; this gave practices the opportunity to earn 20 to 50 percent more for quality outcomes, such as preventive health and chronic disease management, without requiring them to pass through multiple certification processes. Finally, based on the learnings from the PCMH pilot, in 2011 PH began paying a care coordination PMPM for practices demonstrating care coordination competencies. In addition to a care management PMPM, Priority Health currently has an additional Medical Home Uplift incentive program focused on clinical outcomes and HEDIS measures, and allows providers to bill for FFS codes that support access and patient engagement.

While base pay has continued to increase for primary care, an average of 18 percent of money paid to providers is tied to infrastructure and performance. Some high-performing practices are earning up to 30 percent incremental revenue. However, maximizing revenue at the provider and practice level continues to be a challenge for some practices, particularly for integrated systems where incentive money is distributed among multiple providers. In response, starting in 2013, Priority Health will begin including system-level incentives as part of its primary care incentives, with a recognition that the plan must work with delivery systems as well as primary care providers.

Prometheus Bundled Payments

Priority Health was also involved in the PROMETHEUS (Provider Payment Reform for Outcomes, Margins, Evidence, Transparency Hassle-reduction,Excellence, Understandability and Sustainability) payment model, which was an episodes of bundled care payment pilot. Savings achieved were to be allocated based on quality performance and share among treating providers based on a percentage of E&M codes.

PROMETHEUS faced challenges in defining bundles, defining the payment model, implementing quality measurement, determining accountability, engaging providers, and redesigning care delivery. However, all three pilot sites had found value in using PROMETHEUS as a measurement tool and have increased care coordination and improvement activities.