(What is global payment? Instead of providers being paid for each procedure, which is known as “fee for service,” they’re paid a “global” sum for each patient, and can earn bonus money if they stay within that budget while keeping quality high. Okay, now really stop if you’re normal.)
But if you’re a more wonkish type who’s deeply interested in the turgid ins and outs of payment reform, I’d like to offer you the following brain-dump from a Blue Cross Blue Shield of Massachusetts briefing on the global payment plan last week. I’ve tried to digest it into palatable bits, but you know how it is. For example, there’s no avoiding the jargony “AQC” for Alternative Quality Contract, the Blue Cross name for its global payment program. Warning: What follows is purely the Blue Cross point of view. See Martha Bebinger's excellent story for a more balanced report.
1. It’s spreading steadily, faster than expected.
Said Blue Cross spokesman Jay McQuaide: When we started talking about this in ’07, if you’d said we’d be sitting here in the second week of January, 2011, with a little less than half our members in the AQC, no one would have believed you.
2. Its not enough for providers to try, they have to get high-quality results.
Dana Safran, Blue Cross's quality guru (well, okay, senior vice president for performance measurement and improvement), said: The AQC’s quality requirements creates incentives not just to offer better medical care but to get better outcomes in patients. So, for example, it’s not enough just to make sure diabetics have their blood sugar, cholesterol and blood pressure tested; all three must also be under good control.
“To our knowledge, this is the first program that has created a substantial financial incentive around accomplishing certain measures,” she said. “What’s revolutionary is that it asks the provider organization to take responsibility not just for what happens within their four walls” but for what happens after the patient leaves.
But what about sicker patients whose outcomes will always be worse? And surely doctors can’t control their patients? “Our perspective,” Dana said, is that while it’s true that doctors cannot control their patients’ lives, “You can have a very important influence on it, and we believe that’s part of what it means to provide good health care.”
The impression I came away with was that the quality results for the AQC’s first year were so good that even the Blue Cross staffers were kind of pinching themselves.
This Blue Cross slide shows the dramatic improvement among the AQC groups
Those quality measures are tough bars to make, Dana Safran said, and the AQC scores are “dazzling to the rest of the country.
4. So what’s the secret? Why did it work so well?
Dana Safran: "Because the practices were provided very significant incentives based on a set of nationally accepted measures that they recognize to be important evidence-based elements of care. Because they were receiving data from us on an ongoing basis to help support their efforts to manage the best possible performance they could get. And because they had clinical leadership in place that was taking in that data and those incentives and really managing to success."
5. Concierge medicine without the concierge fees
An example of AQC style:
One practice that has many low-income patients established what to patients probably felt like concierge care without the fees. All of a sudden the practice is calling proactively to say, “Mrs. Smith, we see you’re overdue for your mammogram and while we’re at it, we’d like to get you an appointment on your diabetes. Is there anything we can do to help you make sure you can get there? Do you need a call to help you remember?"
From the patient’s perspective, it feels like, "My doctor’s office actually cares about me!”
6. Patients' assessments of their care neither improved nor eroded
The Blue Cross argument is that patient assessments are a particularly tough nut to crack. And that at least there had been no “erosion” in patients’ experience, and no alarming signs such as increased phone complaints from patients or increased turnover in primary care providers.
7. Alternative Quality What??
No one is telling patients in any systematic way that this shift to global payments is happening.
From the Blue Cross perspective, the patients have the same products with the same benefits, and their world is not changing in any way to be concerned about. And Blue Cross research suggests that patients like to hear about these kinds of changes from their own physician.
8. Bending the curve
Health costs are not rising as quickly anymore anyway because of the economy, but the AQC is on track to hit its own goal of cutting the rate at which costs are rising in half over five years.
9. So what does this mean for payment reform?
Blue Cross thinks its AQC is a good model for payment reform, potentially even for Medicare and Medicaid to think about, in terms of having financial incentives but requiring high quality. Getting the incentives right is more important than being prescriptive about the particular kind of delivery system.
10: No 'adverse events'
Blue Cross senior vice president Patrick Gilligan: One of the reasons we think the results are so good is that we haven’t had an adverse even in terms of one group having a massive deficit and feeling the deal has to come apart.
This program aired on January 21, 2011. The audio for this program is not available.