Health insurer could boost PCP pay by half

National insurer WellPoint announced a medical home program that could raise your compensation by 50%. Eligibility won’t be easy and could affect your whole practice.

WellPoint, one of the nation’s largest health insurers, announced a Patient-Centered Medical Home (PCMH) program that could boost by half the insurer’s compensation to primary care physicians (PCPs) who meet the requirements.

The company is an independent licensee of the Blue Cross and Blue Shield Association. Under its Anthem, UniCare, and other subsidiaries, the company has more than 34 million members,in 14 states.

WellPoint said the national PCMH program, announced January 27, will incorporate the most effective aspects from the company’s multiple regional pilots.

A WellPoint representative told eConsult that the most effective aspects of their pilot programs were, “paying participating physicians a traditional fee-for-service model, but also a per-member, per-month care management fee and enhanced quality-based payments. Other pilots saw success using additional support from social workers, nurses and other care coordinators.”

Some of the pilots achieved an 18% decrease in acute inpatient admissions and a 15% decrease in total emergency department visits while improving adherence to evidence-based treatment and preventive care guidelines, said Harlan Levine, MD, WellPoint executive vice president of comprehensive health solutions, in a statement.

According to the company’s announcement, physicians will be able to earn additional revenue in several ways:

a general increase in the regular fees paid to practices for specific services;

payment for “non-visit” services currently not reimbursed, with an initial focus on compensation for preparing care plans for patients with multiple and complex conditions; and

shared saving payments for quality outcomes and reduced medical costs.

To participate in the shared savings, practices must meet plan quality requirements, which include standards established by organizations such as the National Committee on Quality Assurance, the American Diabetes Association, and the American Academy of Pediatrics, according to WellPoint.

PCPs who maintain or improve quality in the shared savings program may earn 30% to 50% more than they earn today. Over time, WellPoint estimates that the program will substantially improve quality and member health, potentially reducing overall medical costs by as much as 20% by 2015.

“This is a huge step in the right direction,” Glen Stream, MD, MBI, FAAFP, president of the American Academy of Family Physicians, tells eConsult. “Hopefully, this is the tipping point for other health plans.”

Stream said that although the company’s program is encouraging, doctors can’t implement PCMH principles at their practices to serve only certain health plan members.

“Even if WellPoint is 20% of your practice, you can’t treat those patients differently,” he says.

WellPoint plans to begin implementing the patient-centered primary care program during the third quarter in markets that show the greatest need based on health quality data, member outcomes, and healthcare costs. The company’s goal is to implement the program across its primary care network by the end of 2014.

“PCPs 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,” Harland says. “Primary care is the foundation of medicine, and it can and should be the foundation of our members’ health.”

Go back to current issue of eConsult