Looking Forward: 4 Boons Coming Your Way in 2014

Leigh Page


January 02, 2014

In This Article

Insurance Goals Are More Aligned

4. Pilot Program Unites Medicare With Commercial Insurers

Although several new Medicare payment initiatives reward practices for reaching out to patients beyond the usual office visit, they do not include commercial payers. This means that practices are forced to treat non-Medicare patients differently from Medicare patients or absorb the losses if they treat all patients the same. But now, a new CMS pilot program addresses this problem.

The Comprehensive Primary Care Initiative[6] includes commercial payers and state Medicaid programs, as well as Medicare in certain parts of the country. The 4-year pilot, which began in fall 2012, could be "a vision of the future" for primary care practices, said Bruce Bagley, MD, President and CEO of TransforMED, a subsidiary of the AAFP. TransforMED, which helps practices transform into patient-centered medical homes, has been a strong supporter of the new pilot.

Dr. Bagley said the CMS pilot is pushing practices to take on new capabilities, such as electronic health records, the medical home, and 24-hour coverage. He added that participating physicians are able to spend more time with patients, better coordinate care for the chronically ill, and provide additional wellness services. They are expected to create a plan of care that addresses each patient's health risks and to use evidence-based pathways for care.

Using a competitive process, CMS chose almost 500 primary care practices to participate in the pilot in 4 states (Arkansas, Colorado, New Jersey, and Oregon) and 3 regions (the Capital District-Hudson Valley region of New York; Southwest Ohio-Northern Kentucky region; and greater Tulsa, Oklahoma). At least 60% of the payer market in each area is involved. A total of 45 commercial health plans are participating in the pilot, including UnitedHealthcare, Humana, and several Blues plans.

The initiative uses a blended payment model, involving fee-for-service reimbursement as well as a patient management fee that is risk-adjusted, depending on the severity of the patient's conditions. In the first 2 years, the management fee averages $20 per member per month, but it ranges from $8 to $40 owing to the risk adjustment. In years 3 and 4, the fee drops to an average of $15, but practices are able to receive shared savings for improving care, such as keeping patients out of the hospital.

Although the pilot of the Comprehensive Primary Care Initiative is not open to any more practices, it is still interesting to watch. This initiative could provide a glimpse into how physicians will be paid in the future.


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