By Tina Morey
Recently, America’s Health Insurance Plans (AHIP) gathered some of the nation’s most innovative plans and providers together to discuss their accountable care models with the expectation to share outcomes, successes and failures. The hope was to spur on creativity for possible duplication in other markets.
Among the models, several common themes emerged, including collaboration between the plans and providers, focus on the triple aim and creating long-term relationships. Many of the groups discussed the change from a combative payer/provider relationship to one of a partnership in an effort to optimize each organizations bottom line. In fact, there were several groups represented whose pilot was multi-stakeholder — multiple plans, providers, employer groups, etc. Competition was put aside for the best interest of the community.
Critical to the models’ success was the ability to share data between the plan and provider. For example, one plan discovered that their model had neglected to place incentives on downstream referrals. Without cost information, practitioners had no idea if the MRI machine across the street was cost effective. The plan armed the practitioners with cost data, added incentives to use lower cost providers and, in turn, created significant savings. Does it really make sense that a hip replacement should vary in price by $20,000 in the same community? Information is power and timely data will be instrumental to the success of Accountable Care Organizations (ACO’s). An interesting comment made by one of the national plans was that he saw the insurance industry moving from a financing organization to one of data information.
The models varied on reimbursement from the current Relative Value Unit (RVU) system, Per Member Per Month (PMPM) based on attribution, full global payment to a combination of all. Most of the models were built placing quality as the key component to achieving any shared savings. The number of quality metrics in any one model varied dramatically, as did the payout. One plan required the meeting of all quality metrics in order to receive a gainshare on savings. While another model offered a higher percent of return to the provider, depending on a quality index score. This model was also unique in the fact that it reimbursed using a global payment, calculated year-end surplus and deficit. Those with a high quality index were able to keep 80 percent of the surplus or not pay back 80 percent of the deficit.
In all of the models it became apparent, very quickly, that clinics would need an infusion of capital in order to make the necessary infrastructure changes. The funding varied from upfront cash, increased PMPM, paying for certification to supplying care coordinators.
As with all new products and designs, there are a few flaws for investigation and change. It is difficult to accurately attribute a patient to a clinic or primary care physician when plan designs allow open access. Who is really responsible for the care of the patients? Administrative Services Only (ASO) self-insured group contracts can be restrictive in a plan’s ability to share data and fund projects. One of the models presented had 100,000 members attributed to the pilot, but was only able to fund 20,000 through PMPM due to ASO contract restrictions. The clinics treated everybody the same, but only received payment for 20 percent of the population.
These accountable care models were not just about cost and quality — they were about partnerships, care delivery transformation and putting the patient at the center of the care. They were a series of experiments, trials and errors, redesign and retry; a series of events that is defined as innovation. This innovation came from leaders willing to be bold, working with purpose and the desire to create change.
Tina Morey has been working in the health care industry for over 20 years and currently works as the director of provider contracting at PreferredOne. Her interests include payment reform and physician compensation models. She is a student in the Health Care UST MBA program.