Case 13.2 The Total Care and Cost Improvement Program In 2011 CareFirst BlueCross BlueShield, a plan


Case 13.2

The Total Caution and Absorb Increase Program

In 2011 CareFirst BlueCross BlueShield, a plan assistance coverage in Maryland, the District of Columbia, and northern Virginia, implemented a enduring-centered medical abode (PCMH) program that included enhanced payments for primitive caution practices, financial incentives for primitive caution physicians to diminish spending, and caution coordination tools to support reformd caution. The mould, determined the Total Caution and Absorb Improvement Program, modifiable payments to primitive caution physicians, increasing fees by 12 percent to remunerate for extra caution coordination and population management activities. The program to-boot regularityatic a one-sided regularity of shared savings, increasing fees for the subjoined year if spending was under the target. For example, savings realized in 2012 would acception fees in 2013. The acceptions depended on the savings achieved by the panel, a kind score, panel largeness, and savings congruity balance term. The acceptions were corporeal, an middle of 45 percent by 2013 (Afendulis et al. 2017).

How polite did the program execution? That is not clear. Afendulis and colleagues (2017) close that savings were trivial and that abundant physicians were not easily chosen after a while the program. Cuellar and colleagues (2016) fame savings of almost 3 percent in 2013, amply driven by reductions in conjunction office and hospital use. They close that “a PCMH mould that does not demand practices to find infrastructure investments and that rewards absorb savings can diminish spending and utilization” (Cuellar et al. 2016, 1382). The contendences show to be driven by analytic decisions about whether to irritate use of services by endurings who switched to PCMH practices during the primeval three years (Afendulis et al. 2017).

The contending interpretations may not matter. In September 2017 CareFirst issued a lean free hailing “an historic slowing of balanceall medical absorb growth” (CareFirst BlueCross BlueShield 2017). In 2016 CareFirst members inspection PCMH providers had hospital admittance rates that were 10.4 percent inferior and readmittance rates that were 34.7 percent inferior than those of endurings receiving caution from other providers. What modifiable? First, PCMHs had behove a greatly over contemptible advent to primitive caution by 2016. Second, in 2014 CareFirst got a give from Medicaution to prolong the program to cover Medicaution beneficiaries. This vary acceptiond its clinical and financial effects.

The give to-boot undisputed CareFirst to train staff in the PCMH practices and to commission caution coordinators, protect subject managers, consultants, pharmacy managers, clinical track specialists, and analysts. Third, organizational vary takes term, and three over years had spent. Bleser and colleagues (2014) contend that decorous an serviceable PCMH demands three things:

1. zealous yearn for vary and a assurance in the demand for vary,

2. accommodation to propel out execution improvements, and

3. inferential discernment of popular and best-practice clinical protocols.

It is not bright that these elements were present during the existing years of the Total Caution and Absorb Increase Program. Afendulis and colleagues (2017) fame that physicians in the program were receptive to making kind reformments but were short spirited in absorb reductions. In observation, most were not everyday after a while or spirited in the shared savings incentives.

Discussion Questions

• Why would physicians not be spirited in absorb reductions?

• How should the program accept been framed to align the goals of CareFirst and physicians?

• How did including Medicaution beneficiaries vary incentives?

• The Medicaution give adventitious infrastructure to the program. Was that significant?

• Accept other PCMH programs behove over serviceable as they consummate?

• What should accept been done to reform physicians’ information of popular clinical protocols?

• How could one reform physicians’ information of best-practice clinical protocols?

• Why were most physicians averse to vary their practices to arrogation incentives?

• Most PCMH programs pay caution coordination fees per enduring per month for endurings after a while constant illnesses. How do the incentives contend from those of the CareFirst program?

• Would caution coordination fees accept been a better management than excellent investigate fees?

• Abundant of the practices were trivial. Do you expect that they could propel out execution reformment projects?