National Commercial Payer Trends

Linda Davis

Consultant

Background

Why this project? – Critical mass problem– Purchasers can drive the market– Employers have been left out of the conversation

Many names: PCMH, HCH, Advanced Primary Care, Intensive Outpatient Program (IOP)

Primary care shortage and need for transformation is NOT a new problem

– Defined in 1978 by WHO– Studied by researchers in the 90s– Attempts to delivery some services through retail clinics,

onsite clinics, urgent care chains

National Commercial Payer Landscape

It’s a BIG DEAL for providers and health plans– Early support from multiple physician organizations and State Medicaid – Conferences, consultants, publications, articles, organizations, studies

Evolving– Various approaches to targeted populations

Intensive care for complex patients only Tiered/segmented populations

– Multiple payment models: enhanced FFS, grants, pmpm, shared savings Moving from pilot stage to scaling, nationally

– Standards for credentialing established by NCQA and JCAHCO– Recent agreement, by researchers, on evaluation criteria, methods for

cost, utilization and quality– Announcements by national payers

2012 National Payer Announcements

January 27 - WellPoint Launches Innovative Reimbursement Initiative …

January 30 - Aetna Launches National Patient Centered Medical Home Program…

February 2 - United HealthCare – New Way to Pay Doctors, WSJ

April 10 - CIGNA Works with Physicians to Bring Accountable Care to 65,000 more individuals from Maine to Texas

National Payer Activities

Single payer pilots 27 multi-payer pilots (as of 12/11) since 2005 Military involvement; VA, DOD, TRICARE Employer efforts

– Boeing – Seattle and St. Louis– Nevada casino workers– Freelancers Union, New York– Dartmouth College– Atlantic City casino workers union*

*Described in New Yorker Hot Spotters article by Atul Gawande, mentions Rushika Fernandopulle MD

Self Reported Pilots - Patient Centered Primary Care Collaborative

So….

Ask your health plans what they are doing related to payment and care reform

Review benefit plan design for barriers to care

Consider implications for disease management, other vendors

Leading indicators show positive results