Primary Care Docs Weigh Advantages of PCMH

WellPoint Inc.'s plan to increase reimbursements for primary care physicians who transition to patient-centered medical homes could signal a tipping point in the move toward the new care management model.

That's according to Glen R. Stream, MD, a family physician from Spokane, WA, and the president of the 100,300-member American Academy of Family Physicians.

"It is a significant step in the right direction," Stream told HealthLeaders Media. "WellPoint is a large insurer and their program has some features that are very much in line with what the academy has been promoting for some time: to align the payment model to support the medical home model of delivering primary care."

Indianapolis-based WellPoint, with 34 million members in affiliated plans, announced last week that it would "increase revenue opportunities" for some primary care practices that participate in patient-centered primary care medical home model.

The plan calls for care management fees for primary care physicians, who could see fee increases of about 10% with incentives that could improve payments by as much as 50%. The Wall Street Journal reported that WellPoint now spends between 6% and 8% of its $100 billion in annual claims on primary care, but that the payout could increase by an additional two percentage points under the new model.

"Primary care physicians who are committed to expanding access, to coordinating care for their patients and being accountable for the quality of care and the health outcomes of those patients, will get paid more than they do today, and we're committed to helping them achieve these quality and cost goals," Harlan Levine, MD, WellPoint executive vice president, Comprehensive Health Solutions, said in a media release.

"Primary care is the foundation of medicine, and it can and should be the foundation of our members' health."

Levine said that WellPoint's medical home models have seen an 18% decrease in acute inpatient admissions and a 15% decrease in total ER visits, while also improving compliance with evidence-based treatment and preventative care guidelines.

The AAFP's Stream says WellPoint's announcement that it will pay for care management "sends a message to primary care physicians that there is an advantage for them to transform practices because payments will align with that," he says.

"We have had a bit of a chicken-and-egg problem with patient-centered medical homes," he says. "Physicians say 'pay us more we will transform the practice.' The plans say 'transform practice and we'll pay you more.' Our responsibility in the academy is to see that there are enough of these plans moving to this payment model in an assured way so we can communicate and assist our members in transforming."

Any move to pay for care management would also make primary care a more attractive field for medical students, Stream says. "It sends an important message to medical students that we are trying to get people to choose primary care specialties," he says. "We don't want them to have that financial barrier of their educational debt and the serious discrepancy between subspecialty and primary care pay to be a disincentive to choose primary care."

Stream says a number of initiatives announced over the last several months by the federal government and private payers indicate that the patient-centered medical home model may soon expands beyond pilot project status.

He notes that at the end of September the Center for Medicare & Medicaid Innovation announced a primary care initiative that includes a similar care management fee for Medicare and Medicaid patients in a half-dozen test markets. 

"The idea in those five to seven pilot markets to get to at least 60% of their patients in the practice covered under that payment model, including the care management fee that supports the services that are part of the patient-centered medical home," he says. "I'm not sure how they came up with that 60% number but it seems like a reasonable tipping point to get the practice and enough of its payers aligned with that to make it meaningful."

But until more private payers across the nation are willing to embrace the patient-centered medical home concept within their networks, Stream says many primary care doctors will keep their distance.

"You have an issue if you are in a market where only 20% of your business is WellPoint," he says. "This is a great initiative but is 20% enough if 80% of your patients are still covered by more traditional fee-for-service payment that is not paying adequately in primary care? Is that going to be enough to make the transition?"

"This is all a step in the right direction, but it is not the be all and end all," he says. "The real issue how many other payers are going to be willing to do this? Can we get to that critical mass that gets us over the hump for individual practices having enough patients under this payment model that allows them to transform and maintain their practices?"