Changing The Way Doctors Are Paid Made Patients Healthier And Saved Money, Study Finds

[Greenbeard]

A decade ago, Blue Cross Blue Shield of Massachusetts started an experiment to change the financial incentives health care providers face. That approach has since gone national, as it was built into the reforms passed in the Affordable Care Act the following year. The latest results from the experiment in Massachusetts show impressive results in the first eight years:

During the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses.

A little more context from recent media coverage:

Changing The Way Doctors Are Paid Made Patients Healthier And Saved Money, Study Finds

The program, called the Alternative Quality Contract, works in two key ways. First, health care providers like Atrius Health, which joined in 2009, received bonuses to pay for upgrades at their medical practices like additional staff and improved electronic medical records.

“That allows us to invest in infrastructure and connect better with our patients and do a better job,” Strongwater says. “The goal [of that] is to keep patients healthier through prevention and early intervention.”

The idea, he says, is that healthier patients cost the system less overall.

The second part of the program changed how doctors, hospitals and other providers are paid. In a typical health payment system, providers receive payments for each service they perform, but Blue Cross Blue Shield’s new program uses a different system, known as a global payment model.

In this system, primary care providers receive a spending target from Blue Cross Blue Shield for their members’ care. If they spend less than the target amount by the end of the year, the providers and the health insurance company split the cash. If the doctors overspend, they and insurer split the extra cost.

The theory is that this will encourage physicians to take extra steps to avoid expensive care like emergency room visits and hospital stays.

BCBSMA's Andy Dreyfus takes a victory lap: ‘Meticulous’ study shows that value-based care works

The researchers saw smaller growth in average annual medical spending on claims for the Blue Cross Blue Shield members than for those in other states, with savings deepening over time, up to 12%. At the same time, patients cared for under the AQC model received better preventive care compared to the control group and achieved better management of chronic illnesses such as diabetes and high blood pressure. . . Unnecessary emergency room visits dropped, as did unneeded imaging.

A decade ago, Blue Cross Blue Shield of Massachusetts started talking with local physicians about alternatives to traditional fee-for-service payment. Many told us they would welcome financial incentives to do what was best for their patients, not what was most costly. Under the AQC model that we developed with their insights, physicians receive a global budget for each member’s care, with incentives tied to quality improvement and savings.

Health care delivery is far too complex for incentives alone to bring about systemic improvements in quality, efficiency, and effectiveness. Physicians also need information they can act on. We provide AQC physicians with weekly, monthly, and yearly data reports and analytics, including how they’re doing on quality measures, how satisfied their patients are with their care, and where their greatest opportunities for improvement may be in areas ranging from prescriptions to cost trends to emergency department use. We also arrange forums for groups of physicians to share their best practices.

 

[jaeger19]

A decade ago, Blue Cross Blue Shield of Massachusetts started an experiment to change the financial incentives health care providers face. That approach has since gone national, as it was built into the reforms passed in the Affordable Care Act the following year. The latest results from the experiment in Massachusetts show impressive results in the first eight years:



A little more context from recent media coverage:

Changing The Way Doctors Are Paid Made Patients Healthier And Saved Money, Study Finds


BCBSMA's Andy Dreyfus takes a victory lap: ‘Meticulous’ study shows that value-based care works

Pooh... the problem with such studies is that the metrics used.. like hospital stays and emergency room visits are not measures of quality of care.

Things like physical functioning, Independence in activities of daily living. Need for medications, prevention of comorbidities and complications.

Those are actual valid metrics that should be used.. but they are not.

Things like hospital stays and aftercare and emergency room visits are easily manipulated by the hospital systems.

Two patients after a CVA.

One patient stays in the hospital for three days, qualifies for rehab.. goes to rehab for 40 days and then is discharged to home and is walking independently,, is driving, and is returned to full activity.

The other patient is on a bundled payment system. He stays two days in the hospital. They send him to an assistive living instead of rehab because the hospital gets paid better for a lower level of care.
the hospital tells that assisted living and the home health that go out there that if he ends back up in the hospital in the ER.. that they will get a 1 star rating and will not get anymore referrals.
At the end of 40 days. the patient is still in the assistive living, unable to drive, unable to walk, and has about 1/2 to 1/3 of the function that the first patient has.

BUT.. he is cheaper and has not gone back to the hospital nor back to the ER.

Which person do you want to be?

This is actually happening and continues to happen in healthcare all around the country. Its the unintended consequences of some of the efforts to "pay for quality".

 

[Greenbeard]

Pooh... the problem with such studies is that the metrics used.. like hospital stays and emergency room visits are not measures of quality of care.

Nor are they presented as measures of quality. That's how money was saved, not how quality was demonstrated.

BCBSMA's Alternative Quality Contract arrangements contain dozens of quality metrics, generally drawn from the HEDIS measure set or other NQF-validated metrics. The measures considered in the NEJM piece are process measures for chronic disease management (6 measures), process measures for adult preventive care (5 measures), process measures for pediatric care( (6 measures), and outcome measures for glycated hemogloblin and blood-pressure control.

 

[jaeger19]

Nor are they presented as measures of quality. That's how money was saved, not how quality was demonstrated.

BCBSMA's Alternative Quality Contract arrangements contain dozens of quality metrics, generally drawn from the HEDIS measure set or other NQF-validated metrics. The measures considered in the NEJM piece are process measures for chronic disease management (6 measures), process measures for adult preventive care (5 measures), process measures for pediatric care( (6 measures), and outcome measures for glycated hemogloblin and blood-pressure control.

Bingo. So there is no real measure of quality here.


So a patient that goes in with a fractured hip.. there is an incentive.. to not provide much therapy in the hospital.. in order to get more out of the DRG.. and then a disincentive to send the patient to a SNF or rehabilitation hospital.. even when they qualify for it.. and they functionally would benefit from it. The same for a physicians office when there is a demonstrated need for more functional care. There is an incentive to send them to a lower level of care and then pressure that level of care to NOT send them back to the ER or they hospital or physicians office will punish them by refusing to make further referrals...


Just look at your quality measurements that are given. Are any of those actual measures of how the patient is really doing? Medication management? Walking ability? ADLS? Memory? Cognitive functioning? Skin integrity? Weight and nutrition?


NOPE.