CareFirst's promising idea for primary care

It's a triumph of hope over experience, perhaps, but as much as Maryland physicians complain about insurance company cost-cutting, there seems to be genuine optimism among doctors over CareFirst BlueCross BlueShield's latest effort to reduce the cost of health care in this state. That alone bodes well for what amounts to a voluntary program that will rely on support from primary care doctors for it to have any chance to work.

Approved this week by the Maryland Health Care Commission, CareFirst's Primary Care Medical Home or PCMH is designed to move away from the nearly universal fee-for-service model that offers financial incentives to the medical community for treatment of illnesses but not for any improvement in the health of patients. Now, a primary care doctor who successfully prevents patients from incurring greater costs — hospitalization or surgery, for instance — may finally receive some financial reward.

Here's how the nonprofit's program works: Doctors who sign up are given higher reimbursements (12 percent higher than what they receive now) for seeing patients. In return, they agree to write care plans for patients with multiple chronic conditions or at risk of conditions like diabetes, heart disease, asthma and the like.

The doctor takes more time and arranges more follow-up monitoring. In return, CareFirst compensates the doctors for these additional services and, if these high-risk patients under their care get better (that is, they incur less in overall medical care costs than CareFirst had expected based on their claim histories), the providers share in that savings — up to 80 percent more than what they've already been paid.

This is not an entirely new idea. Other insurance plans, notably the capitation model (where networks of doctors are compensated by patient load, not by services provided to them) have attempted to go after these kinds of savings in the past but ended up mostly rationing health care. Maryland launched a pilot program based on the same concept this summer, and similar programs are being tried elsewhere. But CareFirst's will be the largest effort yet in Maryland (and among the largest in the country) involving the patient-centered medical home model that places a welcome emphasis on primary care and patient support.

For CareFirst, the program has little risk and much potential reward. What Maryland's largest health insurer pays to primary care doctors today is relative chump change (about 5 percent of $6 billion spent annually on medical care), so any increase in reimbursements to them is unlikely to increase rates or otherwise affect their bottom line. Hospitals and drug companies would likely be the net losers (if their billings decrease or at least level off, as CareFirst hopes), and patients the biggest winners if the quality of their lives improves.

The project raises any number of uncertainties. Will CareFirst be able to recognize good outcomes based mostly on claims history? Will the incentive payments be adequate to encourage participation? Will enough patients follow their doctors' orders and actually get better? It's already restricted to doctors in group practices because, at least in theory, individual doctors wouldn't see enough patients in the aggregate to draw conclusions about claims histories and extrapolate cost savings.

Some physicians are bound to complain that if insurers like CareFirst simply offered adequate reimbursements for medical care today, doctors would be able to give their patients the time and attention needed. But the medical home model really goes one step better by allowing doctors to put greater emphasis on the sickest — or at least the ones most at risk of being sick.

One unintended consequence is that the program may serve as a report card on Maryland's primary care doctors. Those who keep their patients healthy get paid more; those who do not earn less. At the very least, you can bet a lot more doctors will start taking late-night phone calls from patients rather than referring them to emergency rooms.

Thursday, as some aspects of federal health care reform take effect (including requirements that insurers not cap lifetime benefits, provide coverage to sick children and allow offspring to stay on parents' policies until age 26), it's important to remember that the U.S. still faces difficult questions in health care, both in raising quality and meeting demand. One year from now, Maryland and CareFirst will have a clearer idea whether the medical home concept, with its ability to reduce costs and improve patient care, is a critical part of the answer.

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