By MATT COLLINS The primary care structure in the U.S. is in the midst of an important overhaul. For too long, primary care practices have been paid based on a fee-for-service model, which rewards volume of visits and doesn't allow primary care to
The primary care structure in the U.S. is in the midst of an important overhaul. For too long, primary care practices have been paid based on a fee-for-service model, which rewards volume of visits and doesn’t allow primary care to deliver all of the value it can. Fortunately, around the country we’re starting to see a shift to a performance-based model, which rewards quality of care and positive health outcomes for patients.
For these reasons, Blue Cross & Blue Shield of Rhode Island (BCBSRI) has made the transformation of the care delivery system a top priority. We believe it’s imperative to accelerate the development and growth of value-based accountable care in Rhode Island, to make the shift from sick care to well care. Our partnership with Oak Street Health during the last few years has demonstrated the positive impact accountable, value-based care and alternative payment models can have.
Oak Street Health currently has four state-of-the-art primary care centers in Rhode Island for the Medicare-age population. Through our arrangement with Oak Street, our Medicare Advantage members experience a high-touch, member-centric type of care that focuses on their unique healthcare and social needs. This is a perfect example of an alternate care model that has the potential to enhance our members’ experience, improve their health outcomes and stabilize medical costs.
The Oak Street Health model also features an alternative provider payment structure, one in which the practice is accountable for the total cost, quality and experience of care of patients. This payment model represents the epitome of accountable care, but there are others that make primary care providers accountable for the cost of primary care alone. In 2019, the Rhode Island Office of the Health Insurance Commissioner (OHIC) issued guidance calling for more alternative payment partnerships. These sorts of payment arrangements, also called a “PCP cap” or “comprehensive primary care payment,” are currently in place with two local provider groups. One of those groups is WellOne, a primary medical and dental care practice, which began an alternative payment model on a pilot basis with BCBSRI in early 2020.
The model features a flat amount of payment per member per month, or PMPM, to provide primary care services to commercial (as well as Medicare Advantage) patients at the group’s four Rhode Island locations, and to coordinate their care in a patient-centered medical home environment. The model also builds in incentives for hitting certain quality benchmarks. WellOne President and CEO Peter Bancroft, CPA, explained why this model was the right move for his practice. “This type of model has allowed our providers to practice and care for our patients the way that they should, allowing for increased and enhanced ways to communicate with them, as well as to get out of the cycle of trying to see as many patients as possible per day for financial reasons,” he said.
“While our 2020 results will need to be reviewed under the unique lens of the pandemic, we’re confident this arrangement will also show positive results in terms of closing gaps in care, encouraging care management activities, and lowering emergency room and inpatient utilization, and hospital readmissions,” Bancroft added.
COVID-19 has clearly changed things in the healthcare industry, pronouncing the need for telehealth and other innovative ways to deliver the right care at the right time in the right setting. But either way, it’s clear that the future delivery model of primary care must change. The type of care we provide to patients must be more coordinated. The needs of the patient have to come first. And coordinating the best care for each individual, whether that means telehealth, or involving pharmacists, nutritionists, care managers or a range of other practitioners is essential. The model should also feature patient panel sizes that allow open access, minimal wait times and a personalized experience, as well as increased access to primary care through virtual and digital means that promote more convenient and cost-effective care.
This is the model of care that we at BCBSRI are committed to building as we transform healthcare delivery from sick care to well care. We look forward to continuing to work and learn with the provider community and our members so that together, we can achieve the vision of comprehensive health and well-being across Rhode Island. Matt Collins, M.D., MBA, is executive vice president and chief medical officer for Blue Cross & Blue Shield of Rhode Island.