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National Commercial Payer Trends

National Commercial Payer Trends. Linda Davis Consultant. Background. Why this project? Critical mass problem Purchasers can drive the market Employers have been left out of the conversation Many names: PCMH, HCH, Advanced Primary Care, Intensive Outpatient Program (IOP)

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National Commercial Payer Trends

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  1. National Commercial Payer Trends Linda Davis Consultant

  2. Background • Why this project? • Critical mass problem • Purchasers can drive the market • Employers have been left out of the conversation • Many names: PCMH, HCH, Advanced Primary Care, Intensive Outpatient Program (IOP) • Primary care shortage and need for transformation is NOT a new problem • Defined in 1978 by WHO • Studied by researchers in the 90s • Attempts to delivery some services through retail clinics, onsite clinics, urgent care chains

  3. National Commercial Payer Landscape • It’s a BIG DEAL for providers and health plans • Early support from multiple physician organizations and State Medicaid • Conferences, consultants, publications, articles, organizations, studies • Evolving • Various approaches to targeted populations • Intensive care for complex patients only • Tiered/segmented populations • Multiple payment models: enhanced FFS, grants, pmpm, shared savings • Moving from pilot stage to scaling, nationally • Standards for credentialing established by NCQA and JCAHCO • Recent agreement, by researchers, on evaluation criteria, methods for cost, utilization and quality • Announcements by national payers

  4. 2012 National Payer Announcements • January 27 - WellPoint Launches Innovative Reimbursement Initiative … • January 30 - Aetna Launches National Patient Centered Medical Home Program… • February 2 - United HealthCare – New Way to Pay Doctors, WSJ • April 10 - CIGNA Works with Physicians to Bring Accountable Care to 65,000 more individuals from Maine to Texas

  5. National Payer Activities • Single payer pilots • 27 multi-payer pilots (as of 12/11) since 2005 • Military involvement; VA, DOD, TRICARE • Employer efforts • Boeing – Seattle and St. Louis • Nevada casino workers • Freelancers Union, New York • Dartmouth College • Atlantic City casino workers union* *Described in New Yorker Hot Spotters article by Atul Gawande, mentions Rushika Fernandopulle MD

  6. Self Reported Pilots - Patient Centered Primary Care Collaborative

  7. So…. • Ask your health plans what they are doing related to payment and care reform • Review benefit plan design for barriers to care • Consider implications for disease management, other vendors • Leading indicators show positive results

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