Here's a look at five of the major takeaways WellPoint has developed over the course of the PCMH pilot:
1. Money matters
There is no delivery system reform without payment system reform. Hummel cautions that payment reform is not just about aligning incentives for clinical interventions, it's also about providing physicians and other providers with the funds to invest in resources such as electronic medical records (EMR) or a disease registry.
Hummel notes that the fee-for-service system provides no compensation for physicians to conduct the clinical interventions that take place outside of a traditional patient encounter, such as helping a patient get an appointment with a specialist and then following up with that specialist.
WellPoint has designed a program that includes clinical coordination fees as well as shared savings. The fees are paid on a per-member-per-month basis and are not tied to patient visits or services. Payments for shared savings are based on projected medical expenses for a defined population supported by historical experience and trends. If physicians have performance that's less than the projected expenses and they meet quality projections then they participate in a portion of the savings.
Hummel explains that physicians compensated with clinical coordination fees are incentivized to dig deeper to optimize the health of their patients. "It's not just about the disease. It's also about socioeconomics, patient preferences, and the cultural issues that a patient brings to the table that can impact compliance."