Bill Mandell, DO, JD, Medical Director, UnitedHealthcare, Colorado
In the wake of escalating health care costs, health care reimbursement is moving away from fee-for-service and toward value-based reimbursement designs with an expectation of better care and outcomes at reduced costs.
While the scope and pace of this activity will fluctuate, movement in this direction is inevitable. The reason? Health care consumers – companies, government and individuals – are unable to afford further cost escalation and expect quality and value for their health care dollar. In this new model, physicians, hospitals, payers and consumers must work together to achieve the level of quality and value that companies, consumers and our government demand.
UnitedHealthcare is taking a disciplined approach to address this issue with incentive-based contracting models. Through the expansion of existing programs and the creation of new ones, we are able to offer financial recognition to physicians who deliver quality results based on evidence-based guidelines.
Medical home pilot
One of the first value-based programs UnitedHealthcare was involved with was the patient-centered medical home, a pilot project started nearly four years ago. UnitedHealthcare was one of seven payers involved in the project, and we paid a per-member-per-month (PMPM) management fee on top of the fee for service. The intention of the fee was to put the patient in a position of shared decision-making, provide 24/7 access, and improve communication and transitions of care for the patient. During the three-year program, we saw a cost trend reduction of 4.8 percent, a decrease in emergency room visits by 4.5 percent (15 percent for all payers), and an 18 percent decrease in hospital admissions for all payers. Due to the success of this pilot program, UnitedHealthcare is considering the continuation and expansion of this project.
We have also focused on collaborations like the Colorado Clinical Quality Improvement
Project and the Comprehensive Primary Care Initiative (CPCi). The Colorado Clinical Quality Improvement Project was a joint effort between UnitedHealthcare, the American Medical Association and the Colorado Medical Society to decrease variations in care. Working together with physicians from multiple specialties (ENT, GI and general surgeons) we developed a contract with the general surgeons to provide shared savings for changing the site of service for cholecystectomies. The contracts were effective as of Sept. 1, 2012, and will run for one year.
CPCi is a Centers for Medicare and Medicaid Services (CMS) initiative to foster collaboration between public and private health care payers. Primary care offices will receive a PMPM management fee in addition to the fee for service. The goal of this initiative is to strengthen primary care by offering bonus payments to primary care doctors who better coordinate care for their patients. There are additional payments available for achieving milestones in practice enhancement, which UnitedHealthcare will pay in the form of shared savings.
Additionally, we are pleased to have a physician organization in Colorado, New West Physicians, starting an Accountable Care Organization with UnitedHealthcare on April 1, 2013. These collaborative efforts between consumers, employers and care providers are essential to achieving the Triple Aim of improved individual experience, improved population health and decreased per-capita costs.
Our accountable care platform and outcome-based payment models reward providers for improvements in quality and cost-efficiency, while aiming to transform the delivery system to be more accountable for cost, quality and experience outcomes – making health care more affordable and helping people live healthier lives.
Ken Cohen, MD, chief medical officer of New West Physicians, says their organization is part of four ACO pilots total.
“This model has to do with balancing quality and efficiency to achieve maximal results on both of those. In the past, we have always done it because it was the right thing to do. This was the first opportunity we have had where we can actually begin to see some revenue generated out of those efforts as well as seeing some revenue flow back to the employer.”
“We are very pleased that these models have finally come to fruition. We’ve taken what we hope will be the revenue generated by these ACO projects and have funneled them back into efforts that will allow us to push the quality envelope even higher.”