Anthem Blue Cross and Blue Shield’s announcement Monday that it is expanding its “accountable care organization” network to Bangor is the latest example of insurance companies enacting payment reforms that will change the way family doctors are reimbursed and how they care for patients, health experts say.
The changes will eventually improve efficiency in the primary care system by reducing duplication of medical services, overuse of medical devices and unnecessary trips to the emergency room, said Mitchell Stein, a Cumberland-based health policy analyst.
Stein said that should result in lower costs for everyone – patients, doctors and insurance companies.
“Pretty much everyone across the country is trying to do similar things, although there’s all these different iterations on how it’s going to change,” Stein said.
In a nutshell, insurance companies are moving away from reimbursing doctors for specific services – such as paying a fee every time a piece of medical equipment is used – and toward creating financial incentives for doctors to improve the overall wellness of their patients.
“Fee-for-service tends to be inefficient and puts the focus on volume, which doesn’t work well for patients and preventive care,” said Kevin Lewis, CEO of Maine Community Health Options, a Lewiston-based insurance co-op that implemented similar payment reforms when it began doing business in 2013.
Instead of reimbursing based on volume of patient visits and procedures, insurance companies are reimbursing more for patient outcomes, such as avoiding unnecessary emergency room trips.
“From Day One, this has made sense to us,” said Dan Corcoran, president of Anthem Blue Cross and Blue Shield in Maine. Anthem’s expansion Monday to its patients enrolled in Eastern Maine Health System’s Beacon Health in Bangor adds 40,000 Mainers to the company’s “accountable care organization” payment reform system. Anthem’s new reimbursement model is now available to 75 percent of primary care doctors in Maine.
Corcoran and Stein said they expect similar payment reforms will sweep the country within the next few years.
In Colorado, where Anthem’s system, called “enhanced personal care,” has been fully implemented for more than a year, avoidable emergency room admissions have declined 15 percent, and hospital readmissions have been reduced 18 percent for Anthem customers, insurance officials said.
“It cuts down on the number of people going to the emergency room at 3 p.m. with an earache,” said Dr. Jeffrey Holmstrom, Anthem’s medical director in Maine.
Under the system, patients with chronic diseases – such as asthma, common heart conditions or diabetes – are assigned “care teams” that include doctors, physician assistants, nurse practitioners, nurses and other medical professionals.
Dr. Phyllidia Ku-Ruth, a family physician at InterMed in Portland, said the Anthem changes align with what InterMed’s network of primary care doctors has been working on for the past decade.
“Sometimes when the patient is not in front of you, they need something. Now, we’re delivering that to them,” Ku-Ruth said. “That’s the essence of what preventive, accountable care is.”
Ku-Ruth said the problem has been that 10 years ago, insurance companies were not reimbursing for those services, which are often phone consultations with patients. InterMed built a database of patients with chronic conditions, and the “care team” can check up on them to monitor their conditions and make sure they’re taking medications and practicing preventive care.
“We can look at the database registry and see, ‘Oh, Mrs. Smith is a diabetic and she needs her eye exam, or Mr. Jones needs to have his feet checked,” Ku-Ruth said. She said the registry is also helpful when patients are transitioning to home after a trip to the hospital, because many are confused about what to do and what medications to take. Making the transition to home easier helps reduce hospital readmissions, she said.
Holmstrom said the system more efficiently uses the doctor’s time by assigning physician assistants, nurses and others to preventive care while saving the more difficult cases for the doctor.
“It allows the doctor to see sick people when they need to be seen,” Holmstrom said. “It expands the capabilities of the doctor.”
By reimbursing for outcomes instead of volume, the doctor’s office can see patients for longer and not have to be concerned about meeting patient quotas to maintain the financial viability of the practice, Holmstrom said.
“It gets us off the hamster-wheel system of care,” he said.
Corcoran said Anthem’s payment reform was already in the works before the Affordable Care Act became law in 2010, although the ACA encourages such reforms.
Stein said that although the ACA did not instigate many of the payment reforms, the law encourages such changes by prohibiting insurance companies from denying coverage to patients with pre-existing conditions and charging sick people higher premiums.
Instead of companies having a financial incentive to have only healthy people in their insurance pools – as was the case before passage of the ACA – they now have incentives to keep the patient population as healthy as possible, he said.
“It changes the motives of the insurance companies. They have different goals,” Stein said. “The ACA has accelerated payment reform and shined a spotlight on the problem.”
This story was updated at 5:15 p.m., Nov. 11. to correct the state were the “enhanced personal care,” system has been fully implemented.