Pay for Performance
When compared to other industrialized countries, U.S. health care fails to deliver comprehensive primary care because of the way health care is financed. Most health care is billed and paid for as discrete “pieces” of care: a doctor’s office visit, a lab test, or a surgical procedure. Pay-for-performance initiatives are an effort to provide more comprehensive, longitudinal patient care with an eye towards improving patient outcomes. By agreeing to pay providers to meet quality standards in patient care, rather than to perform more services, health plans and employer payers seek to improve care delivery for specific chronic conditions, such as diabetes care, or for more global care transformation, such as recognition as a patient-centered medical home.
THINC works with payers in the Hudson valley to support pay-for-performance initiatives that hold the promise to both improve patient outcomes and create cost efficiencies. In 2007, THINC started its planning effort for a pay-for-performance and medical home project in conjunction with Taconic IPA. The New York State Department of Health (NYS DOH) provided nearly $150,000 of seed funding to support the development of this project. The project cleared its first major hurdle at the end of 2009 when 236 primary care providers in the Hudson Valley achieved National Committee for Quality Assurance (NCQA) Level 3 recognition for Patient-Centered Medical Home. Six commercial health plans—Aetna, CDPHP, Hudson Health Plan, MVP Healthcare, United, and WellPoint, along with local employer, IBM—partnered with THINC on this project. These plans are paying an estimated $1 million in medical home incentives this year and are populating a multi-year claims data set to enable quality and utilization outcomes research.
For 2010, THINC is garnering support from these health plans to issue incentive payments to physician participants for achievement of an enhanced set of goals surrounding care coordination. THINC is proposing that participating providers meet a set of care coordination activities to supplement what is required by NCQA. Incentive payments will also be based upon achievement of certain quality goals and a review of utilization data.