Some Goals For Costs , Utilization , And Quality

Primary care must be reengineered to improve outcomes and affordability. To achieve those goals, WellPoint invested in ten patientcentered medical home pilots that encourage care coordination, preventive care, and shared decision making. Two of the three pilots described in this article—in Colorado and New Hampshire—layer incentive payments for care coordination and quality improvement on top of a traditional fee-for-service payment. The third—in New York—pays doctors an enhanced fee that is tied to achievement of quality levels. Preliminary evaluations show encouraging signs that the Colorado and New Hampshire pilots are meeting some cost, utilization, and quality objectives. A full evaluation in all three states is ongoing. To help enable systemwide transformation, WellPoint is now applying similar payment strategies to primary care practices that may not have the resources to become full-fledged medical homes. P rimary care essentially is designed to encourage health and wellness, provide an initial level of medical care to the individual patient and his or her family, and ensure that appropriate specialist care is delivered. All of these elements are central components of high-quality, cost-effectivehealth care. But today most primary care physicians are not compensated for important elements of care, such as coordinating care among specialists and other providers and providing access outside of normal business hours. The patient-centered medical home redesigns primary care reimbursements to reward physicians for aspects of care that are most important to good patient outcomes. In patient-centered medical homes, for instance, additional payments are given to physicians to support care coordination and preventive activities that improve the health of patients. To demonstrate the benefits of this model, WellPoint engaged in ten patient-centeredmedical home pilots. The three described in this article provide enhanced payments to primary care physicians through a blended payment model. In Colorado and New Hampshire, WellPoint’s affiliated health plans paid physicians fees based on services provided, then distributed monthly care management payments to support comprehensive services to meet patient needs. In addition, physicians who met certain utilization and quality targets were eligible for a pay-forperformance bonus. In New York,WellPoint’s affiliated health plan implemented an enhanced fee-for-service initiative that provides physicians with reimbursement in addition to standard fee-for-service payments to encourage quality-improvement measures such as care coordination and preventive care. Each pilot program shares the goal of transdoi: 10.1377/hlthaff.2012.0364