How Wellness Care Would Improve
Under Patient-Centered Payment

Mr. Jones has always considered himself to be relatively healthy. On the few occasions when he has felt the need to see a doctor for a specific problem, he has gone to an urgent care center or the hospital emergency room. However, he has been encouraged by his family and friends to get a more complete physical exam, so he makes an appointment with a local primary care practice.

Care Delivery
Under Current Payment Systems

Care Delivery
Under Patient-Centered Payment

Mr. Jones arrives at the primary care practice for his visit. Although he arrived early, he isn’t seen until 30 minutes after his scheduled appointment time. When he arrived, he noticed that another patient appeared to have an appointment scheduled with the same physician at the same time and that patient was seen first.

When Mr. Jones schedules the visit, he is asked to come to the primary care practice office a little early so the practice can perform some simple blood tests. He is also told to plan to spend as much as 90 minutes at the practice to allow the physician adequate time to perform the exam and for other staff at the practice to arrange for any follow-up care.

Mr. Jones arrives at the practice, has the tests performed, and then is seen by the physician at exactly the scheduled time.

The physician examines Mr. Jones and asks some specific questions such as whether he smokes and whether he has received a colonoscopy.

The physician examines Mr. Jones carefully and asks a number of questions about his health history, any problems he is experiencing, and whether he has any specific concerns about his health. The physician takes the time to answer all of Mr. Jones’s questions.

The physician recommends that Mr. Jones get a blood test to evaluate his blood sugar and cholesterol levels and writes a prescription ordering the test. He says that Mr. Jones can go to any hospital or laboratory to have the test performed.

The physician tells Mr. Jones that based on the blood tests performed just before the visit, his cholesterol is low enough that he doesn’t appear to need any medications for high cholesterol. (If the test had shown a high result, the physician would have asked Mr. Jones to get a repeat test after he had been fasting before deciding whether medications were warranted.)

However, the blood test shows that Mr. Jones’s blood sugar (HbA1c) level is just below the level that would indicate Mr. Jones has diabetes. The physician tells Mr. Jones that he is at risk of developing diabetes and recommends that he lose weight and change his diet in order to try and avoid developing diabetes. She asks Mr. Jones if he could stay at the practice for a little while after the visit in order to talk to one of the nurses at the practice about how to do that.

The physician tells Mr. Jones that because of his age, he should receive a colonoscopy, and recommends that he contact the local hospital to schedule the procedure.

The physician also tells Mr. Jones that because of his age, he should receive a colonoscopy to help detect colon cancer in the early stages when it most curable. She explains the risks of not having the procedure, and responds to questions Mr. Jones has about what will be involved in the procedure. Mr. Jones agrees that he will get the colonoscopy.

Mr. Jones is surprised at how little time the physician spent examining him, particularly after Mr. Jones waited so long to see the physician. He was disappointed that the physician seemed concerned only about getting responses to a list of standard questions rather than trying to get to know Mr. Jones and address his concerns.

Mr. Jones is not convinced that he gained anything meaningful from the visit, and plans to continue using the urgent care center for his acute care needs.

The physician asks Mr. Jones if he would like to enroll with the practice for ongoing wellness and preventive care. The physician says there is no obligation for him to do so, but if he does, the primary care practice will help ensure that he receives all of the preventive care services he needs. In addition, the physician says that she and the other practice staff will be able to respond to questions and provide assistance with acute problems over the phone or by email when an in-person visit is not needed. The physician tells him he can “unenroll” at any time if he is unhappy with his care.

Mr. Jones is impressed at how much time the physician spent with him, how carefully she examined him, how well his questions were answered, and how efficiently the practice delivers care. He has been frustrated that every time he goes to the urgent care center, he sees a different physician or other provider who ask him the same questions every time, so he agrees to enroll.

Mr. Jones does not get the blood test the doctor prescribed, nor does he schedule a colonoscopy. No one from the primary care practice contacts him to remind him or encourage him to do so.

Before he leaves, the staff at the primary care practice help Mr. Jones to schedule his colonoscopy at a convenient time with a high-quality gastroenterologist and ambulatory surgery center where his insurance will pay for the procedure.

The practice staff call Mr. Jones before his scheduled colonoscopy to make sure he has received instructions from the gastroenterologist on how to prepare for the colonoscopy, that Mr. Jones has obtained the necessary bowel prep materials and understands the importance of following them correctly, and that he has someone to provide transportation for him.

After the colonoscopy is performed, the primary care practice staff contact Mr. Jones to make sure everything went well and they contact the gastroenterologist to obtain the results if they have not already received them. If there is any follow-up needed (e.g., based on a biopsy result), the primary care practice staff contact Mr. Jones to help make sure the follow-up occurs and to answer any questions he has if the gastroenterologist has not already done so.

Before he leaves the practice, a nurse talks with Mr. Jones about ways he could exercise more and improve his diet. She asks a series of questions about his work and other activities and helps him develop a plan for diet and exercise that he feels would be feasible to follow.

The nurse follows up periodically with Mr. Jones by phone or email to see how well the diet and exercise plan is working, and talks with him about the kinds of adjustments that could be helpful when he says that he is now traveling more for work. The nurse also arranges for Mr. Jones to get periodic blood tests to monitor his blood sugar.

The primary care practice bills Mr. Jones’s insurance company for a new patient visit.

Mr. Jones’s failure to receive a colonoscopy reduces the practice’s score on the colonoscopy quality measure that the health plan uses to adjust the practice’s performance-based payment. Because Mr. Jones made a visit to the primary care practice and did not visit any other primary care practice during the year, the insurance company has “attributed” Mr. Jones to the primary care practice, even though he only came to the practice one time and did not intend to return.

The primary care practice is not penalized for the fact that Mr. Jones did not get a blood test because Mr. Jones was not diagnosed with diabetes or any other health problem.

The primary care practice bills Mr. Jones’s insurance company for a new patient visit as well as for the blood tests performed by the practice during the visit.

In addition, the primary care practice begins billing the insurance company for a monthly Wellness Care Payment under Patient-Centered Primary Care Payment. The practice is able to do so because Mr. Jones enrolled for wellness care services and because the practice is proactively helping Mr. Jones to receive all appropriate preventive and wellness care, including a colonoscopy and appropriate blood tests, and helping him design and implement a plan for improved exercise and nutrition.