RESOURCES ON PATIENT-CENTERED PAYMENT

Patient-Centered Payment for Primary Care

High-quality primary care is an essential component of a high-value healthcare system. Unfortunately, the fee-for-service payment systems currently used by Medicare and most health insurance plans do not support high-quality primary care. Moreover, none of the approaches that have been used or proposed as alternatives to standard fee-for-service payments - including pay-for-performance, medical home payments, and population-based payments - solves these problems, and some can make it even less likely that patients will receive high-quality care.

Patient-Centered Payment for Primary Care describes a better way to pay for primary care, in which:

  • The payment for each patient is based on the services that patient needs and wants to receive;
  • The payment for each patient ensures that patient receives high-quality care in the most efficient way;
  • The payment amounts are adequate to support the cost of delivering services to each patient in a high-quality manner; and
  • Services are affordable for patients with and without insurance.

The report provides a complete design for a Patient-Centered Primary Care Payment system, including all of the details needed for implementation, such as:

  • The types of payments a primary care practice would receive for each of the major categories of services it delivers;
  • How existing practice billing systems and health plan claims payment systems can be used to pay primary care practices in a better way;
  • The dollar amounts for each payment that will provide adequate revenues to support high-quality care to patients with different needs; and
  • How patients and purchasers would be assured that each patient is receiving appropriate, high-quality services.

In addition to the full report and a video, an Executive Summary, a 2-page description of the payment structure and implementation plan, and an FAQ document are available.

Patient-Centered Payment for
Care of Chronic Conditions

Although many chronic conditions can be managed effectively by a primary care practice (if the practice is paid adequately to do so), some patients with a chronic condition will need services from a specialist for diagnosis, development of a care plan, and/or treatment and care management. This is particularly true for patients who have difficult-to-diagnose symptoms and severe, complex, or uncommon conditions.

In order to ensure that all patients can receive the most effective care, specialists who diagnose and treat chronic conditions need to receive adequate and appropriate payments for their services. In a patient-centered payment system for care of chronic conditions:

  • A patient with a chronic condition should be able to receive the services that will best address their specific needs;
  • A patient with a chronic condition should be assured of receiving appropriate, evidence-based care;
  • The payment amounts should be adequate to cover the cost of delivering services in a high-quality manner to patients with chronic conditions; and
  • A patient with a chronic condition should be able to select which physician practice or provider will deliver care for the condition based on the quality and cost of the services they will receive.

Patient-Centered Payment for Care of Chronic Conditions  explains how to create a patient-centered payment system that solves the problems with both fee-for-service payments and current value-based payment systems. The report provides all of the details needed for rapid implementation, including:

  • The quality standards that a specialty physician practice would need to meet in order to receive the payments;
  • The dollar amounts the practice should be paid in each phase of care and how those amounts should differ for patients with greater needs; and
  • The process for using existing practice billing systems and health plan claims payment systems to implement the payments, without the need for the kinds of complex, problematic attribution and risk adjustment systems used in current value-based payment systems.