Afendulis CC, Hatfield LA, Landon BE, Gruber J, Landrum MB, Mechanic RE, Zinner DE, Chernew ME
Abstract
In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higher-quality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative’s first three years. Our quantitative analyses used spending and utilization data for 2010–13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses). Our qualitative analysis suggested that early in the program, many physicians were not fully engaged with the initiative and did not make full use of its tools. These findings imply that this and similar payment reforms may require greater time to realize significant savings than many stakeholders had expected. Patience may be necessary if payer-led reform is going to lead to system transformation.
Insights Results
Overview of article/program
This work explored how providers viewed the Total Care and Cost Improvement Program and how it affected their behavior
The Total Care and Cost Improvement Program, by CareFirst, is an ongoing project that combines aspects of population-based payment and patient-centered medical home initiatives. Program attributes include enhanced payments for primary care (e.g., one sided shared-savings system), significant financial incentives for primary care physicians to control spending, and care coordination tools (e.g., hiring care coordinators to work with physicians to develop care plans, provision of physician panels with regular web-based reports of patient demographic characteristics, clinical patterns, spending and risk profiles to identify candidates for care management)
By the end of 2013, the program consisted of 3,774 primary care physicians in 1,143 practices, organized into 282 panels that collectively served 1,181,548 enrollees
Methods
The study used a mixed-methods approach to evaluate 5 outcome variables: 1) Total spending; 2) Inpatient spending; 3) Outpatient spending; 4) Evaluation; and 5) Management visits
Quantitative analyses used spending and utilization data for 2010–13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups
Qualitative analyses included conducting 39 semi-structured interviews across 20 primary care panels. They interviewed 30 primary care physicians, 4 individual practice administrators and 5 executives from larger panels. 8 were in panels that were part of larger medical groups
Results
The study found no significant differences in overall spending between those in the program and those not in it. There was also a positive, but not significant change in inpatient spending, and a negative, but small change in outpatient spending
Qualitative findings were generally consistent with the quantitative findings. In general, physicians supported the goals of the program, but there was little evidence of substantial cost-reducing behavior change. Many physicians reported they did not change their practices due to the program and many of those that did change said they did it with a focus on quality rather than cost savings. Many factors suggest why cost saving behavior was difficult including most physicians were overwhelmingly focused on clinical activities and had limited exposure to administrative or financial matters, and many physicians did not understand (or didn’t care) about the program’s shared-savings incentive
Effects on evaluation and management were small and generally not significant
Key takeaways/implications
Overall, results suggest that the CareFirst Total Care and Cost Improvement Program was largely budget-neutral during its first 3 years, when fees and bonuses are included
Challenges faced in the program include physician education about the program and recruitment and retention of nurse care coordinators
Limitations to the study include the intent-to-treat strategy included only primary care physicians and their patients in the program at its onset, concern about nonrandom physician participation, accumulation of average effect results only, limited generalizability by geographic concentration of the patient population, and few subjects involved in the qualitative analysis
