The Collaborative Payer Provider Model Enhances Primary Care, Producing Triple Aim Plus One Outcomes: A Cohort Study
Abstract
:1. Introduction
2. Study Methods Part One: The Collaborative Payer Model
2.1. Radical Alignment of Incentives between Payer, PCPs and Patients
2.2. Transparency
2.3. Reciprocal Responsibilities and Accountability
3. Study Methods Part Two: Data
4. Results
5. Discussion
6. Conclusions
Author Contributions
Conflicts of Interest
References
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CPPM Element | Critical Success Factor |
---|---|
I | Radical alignment of incentives between payer, physicians, and patients |
| |
II | Complete clinical, financial, and comparative performance transparency |
| |
III | Reciprocal responsibilities and accountability |
|
Item | Traditional Payer | Collaborative Payer |
---|---|---|
(1) Alignment of Incentives | ||
Risk sharing | In the late 1990s, the payers typically gave all the risk to the doctors and had little interest in their success. The payers cared about the payers’ outcomes, such as membership and revenue growth. | Radical alignment of incentives. Providers get up to 80% of the share back, and payers 20% of the share back. The payer is only financially successful if the provider is successful. The collaborative payer cares about PCP outcomes because their economic fates are linked together. |
Incentives | Providers are rewarded for increasing volume of care. | Providers (and the payer) are rewarded for increasing the value of care. Up to 25% of share back may be based on quality and patient satisfaction metrics. |
Quality Incentives | Typically too many metrics with inadequate funding. For example, a 2% bonus for 50 measures. | 10 to 15 achievable metrics. Up to 20% of the share back for improvement and for absolute performance. |
Contracting | Adversarial contracting and unit cost management. Zero sum negotiations. | Collaborative contracting. Win-win negotiations, as the 30% of health care spending that is waste is decreased. |
(2) Transparency | ||
Clinical and financial data sharing | Minimal information sharing. When shared, typically too late for interventions. Information asymmetry is exploited for the payer’s advantage. | Complete clinical, financial, and comparative performance data transparency as soon as available. |
(3) Responsibilities and Accountability | ||
Customer | Members and employers | CMS/employers, members, physicians |
Provider network strategy Provider network strategy (con’t) | Large networks to increase sales and revenue, contract with everybody, hammer down unit costs. Pass cost increases onto employers. | Narrow or preferred networks, PCPs recommend particular specialists for inclusion in the networks. Limit the number of PCPs to increase their engagement with the payer. |
Cost management | Traditional burdensome utilization management. Cost increases are passed onto the employers. | Referrals usually only for notification and communication. Utilization management is focused and coordinated. Wasteful care is reduced, creating profitability. |
Payer relationship with physicians and members | Payers go around the doctors to care for their members. | Mutual dependence; collaborative payer supports the doctor–patient relationship. All three work to reduce waste and increase quality. |
Payer contracts with vendors who provide care for patients | Has many vendor contracts to meet their members’ needs. They go around the PCPs and directly provide care to members. | Minimizes these. Collaborates with PCPs to mutually approve a few vendors. Honors the PCP–patient (member) relationship. |
Year | # CPPM Members | CPPM Costs † | CPPM MCR * | CPPM BD/K | CPPM RAF | #FFS Patients | FFS Costs † | FFS RAF | CPPM/FFS Costs † | p Value |
---|---|---|---|---|---|---|---|---|---|---|
2010 | 24,054 | $485 | 73.4% | 1188 | 1.09 | 8827 | $672 | 1.18 | 72.2% | <0.001 |
2011 | 27,898 | $482 | 72.2% | 1181 | 1.11 | 8878 | $675 | 1.16 | 71.4% | <0.001 |
2012 | 31,143 | $476 | 72.5% | 1138 | 1.14 | 8804 | $682 | 1.17 | 69.8% | <0.001 |
2013 | 33,195 | $498 | 77.9% | 1113 | 1.13 | 8815 | $671 | 1.12 | 74.2% | <0.001 |
2014 | 36,516 | $540 ‡ | 79.4% | 1151 | 1.05 | 8350 | $672 | 1.12 | 80.4% | <0.001 |
Average | 30,561 | $496 | 75.1% | 1154 | 1.10 | 8375 | $674 | 1.15 | 73.6% |
Year | CPPM Cohort † | FFS Cohort † | CPPM/FFS Cohort † |
---|---|---|---|
2010 | $370 | $561 | 66.0% |
2011 | $360 | $559 | 64.4% |
2012 | $351 | $562 | 62.5% |
2013 | $373 | $576 | 64.8% |
2014 | $442 | $620 | 71.3% |
Average | $379 | $576 | 65.8% |
© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Doerr, T.; Olsen, L.; Zimmerman, D. The Collaborative Payer Provider Model Enhances Primary Care, Producing Triple Aim Plus One Outcomes: A Cohort Study. Healthcare 2017, 5, 48. https://doi.org/10.3390/healthcare5030048
Doerr T, Olsen L, Zimmerman D. The Collaborative Payer Provider Model Enhances Primary Care, Producing Triple Aim Plus One Outcomes: A Cohort Study. Healthcare. 2017; 5(3):48. https://doi.org/10.3390/healthcare5030048
Chicago/Turabian StyleDoerr, Thomas, Lisa Olsen, and Deborah Zimmerman. 2017. "The Collaborative Payer Provider Model Enhances Primary Care, Producing Triple Aim Plus One Outcomes: A Cohort Study" Healthcare 5, no. 3: 48. https://doi.org/10.3390/healthcare5030048