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ABSTRACT
In 2011 CareFirst BlueCross BlueShield, a large mid-Atlantic health insurance plan, implemented a payment and delivery system reform program. The model, called the Total Care and Cost Improvement Program, includes enhanced payments for primary care, significant financial incentives for primary care physicians to control spending, and care coordination tools to support progress toward the goal of higherquality and lower-cost patient care. We conducted a mixed-methods evaluation of the initiative's first three years. Our quantitative analyses used spending and utilization data for 2010-13 to compare enrollees who received care from participating physician groups to similar enrollees cared for by nonparticipating groups. Savings were small and fully shared with providers, which suggests no significant effect on total spending (including bonuses). Our qualitative analysis suggested that early in the program, many physicians were not fully engaged with the initiative and did not make full use of its tools. These findings imply that this and similar payment reforms may require greater time to realize significant savings than many stakeholders had expected. Patience may be necessary if payer-led reform is going to lead to system transformation.
Efforts by insurers to transform the health care system have often focused on changing provider incentives. The broadest of these, population-based payment models, typically focus on primary care: Patients choose from a list of designated primary care providers or are assigned to a provider group based on their use of primary care services. Evaluations of population-based payment models are ongoing, but they generally have found positive, though often small, savings.1-6
While alternative payment models create incentives for savings, realization of their potential requires transforming how care is delivered. It is not clear that delivery systems, particularly small primary care groups, are well suited to meet that challenge. Moreover, populationbased payment models with downside risk (that is, financial penalties for failing to meet performance goals) might not be suitable for small practices (which tend to be more actuarially unstable than large practices). As a result, insurers have been experimenting with new models and making sizable investments to support delivery system reforms.
One such approach is the patient-centered medical home. This approach supports the delivery of whole-person, first-contact, coordinated care that emphasizes quality, safety, and enhanced access. As of 2013, more than 115 payer-sponsored...