Collins Sarah, Piper Kevin B Kip, Owens Gary
President, America's Health, Oak Hill, VA.
President, Health Results Group, Washington, DC.
Am Health Drug Benefits. 2013 Jan;6(1):30-8.
The large and growing costs of healthcare will continue to burden all payers in the nation's healthcare system-not only the states that are struggling to meet Medicaid costs and the federal government, but also the private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries. Cost will increasingly become a concern as millions more people become newly insured as a result of the Patient Protection and Affordable Care Act (ACA). Primary care delivery through patient-centered medical homes (PCMHs) and other coordinated-care models have improved care and reduced costs. Health plans have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Health plans can play an important role in transforming the US healthcare system, as well as better position themselves for long-term corporate success.
To discuss several examples of organizations that serve a variety of beneficiaries and have been successful in promoting medical homes and coordinated primary care, and to suggest steps that health plans can take to improve the quality of care and reduce costs.
The models discussed in this article take a number of different approaches to create incentives for high-quality, cost-effective, coordinated primary care. Several health plans and groups use enhanced fee-for-service or per-member per-month payment models for primary care physician (PCP) practices that reach a specified level of medical home or electronic health record certification. Most of the examples addressed in this article also include an additional payment to encourage care management and coordination. The results showed a significant decline in costs and in the use of expensive medical services. One Medicaid coordinated-care program we reviewed saved almost $1 billion in reduced spending over 4 years, and achieves savings of approximately 15% within 6 months of the beneficiaries' enrollment into their program. Another PCMH payer program led to an approximate 28% reduction in acute care hospital admissions among Medicare beneficiaries and an approximate 38% reduction in admissions among commercial beneficiaries.
Based on the review of real-world examples, we recommend 6 steps that health plans can use to take advantage of the opportunity to embrace medical homes as a means to improve healthcare quality and to reduce costs. These recommendations include getting feedback from PCPs to improve plan provider networks, creating value-based primary care reimbursement systems, encouraging biannual visits with high-risk patients, funding case managers for high-risk patients, considering Medicaid coordinated-care models, and promoting ACA policies that support primary care.
医疗保健费用庞大且持续增长，这将继续给美国医疗体系中的所有支付方带来负担，不仅是那些努力应对医疗补助成本的州和联邦政府，还有为商业保险、联邦医疗保险优势计划及医疗补助受益人提供服务的私人健康保险计划。随着《患者保护与平价医疗法案》（ACA）使数百万更多人首次获得保险，成本问题将日益受到关注。通过以患者为中心的医疗之家（PCMH）及其他协调式护理模式提供初级保健，已改善了医疗服务并降低了成本。健康保险计划有一个战略机遇，即通过接纳医疗之家并鼓励其发展，以更低成本促进更好的医疗服务。健康保险计划在美国医疗体系转型中可发挥重要作用，同时也能为自身的长期企业成功创造更有利的条件。
讨论几个为各类受益人提供服务且在推广医疗之家及协调式初级保健方面取得成功的组织实例，并提出健康保险计划可采取的提高医疗质量和降低成本的措施。
本文所讨论的模式采取了多种不同方法，以激励提供高质量、具成本效益的协调式初级保健。一些健康保险计划和团体针对达到特定医疗之家或电子健康记录认证水平的初级保健医生（PCP）执业机构，采用强化的按服务收费或每月每位会员付费模式。本文所提及的大多数实例还包括额外付款，以鼓励护理管理与协调。结果显示成本及昂贵医疗服务的使用显著下降。我们审查的一个医疗补助协调式护理计划在4年内通过减少支出节省了近10亿美元，并在受益人加入该计划的6个月内实现了约15%的节省。另一个PCMH支付方计划使联邦医疗保险受益人中的急性护理医院住院率降低了约28%，商业保险受益人中的住院率降低了约38%。
基于对实际案例的审查，我们建议健康保险计划可采取6个步骤，利用接纳医疗之家这一机遇来提高医疗质量并降低成本。这些建议包括从初级保健医生处获取反馈以改善计划的提供者网络、创建基于价值的初级保健报销系统、鼓励对高危患者进行半年一次的就诊、为高危患者资助个案管理员、考虑医疗补助协调式护理模式以及推广支持初级保健的ACA政策。
