”From 2002 to 2010, about 75% of [the province of Ontario’s] 13 million residents and 10,000 primary care physicians joined medical home models…. The single most notable change … was to switch from predominantly fee-for-service to predominantly capitation practices…. Parties involved in the negotiations could not agree on case-mix or socioeconomic adjustments (… capitation payments were adjusted for age and sex alone).” [P 2186] ”From 2002 to 2010, about 75% of [the province of Ontario’s] 13 million residents and 10,000 primary care physicians joined medical home models…. The single most notable change … was to switch from predominantly fee-for-service to predominantly capitation practices…. Parties involved in the negotiations could not agree on case-mix or socioeconomic adjustments (… capitation payments were adjusted for age and sex alone).” [P 2186]
” Without finer case-mix adjustment, practices in the healthier and wealthier areas obtained attractive revenue projections with capitation, and the majority chose this model…. Conversely, physicians treating sicker patients had no incentive to join a capitation model…. Such adverse risk selection and ‘cherry picking’ was accentuated because capitated medical homes were allowed to de-roster patients who sought outside primary care. This provided a strong incentive for some medical homes to drop precisely those patients with higher health needs and complex care [P 2186)…. Major cities with urban poor and recent immigrants were much less likely to be served by primary care physicians working in a capitated medical home.” [P 2187] ” Without finer case-mix adjustment, practices in the healthier and wealthier areas obtained attractive revenue projections with capitation, and the majority chose this model…. Conversely, physicians treating sicker patients had no incentive to join a capitation model…. Such adverse risk selection and ‘cherry picking’ was accentuated because capitated medical homes were allowed to de-roster patients who sought outside primary care. This provided a strong incentive for some medical homes to drop precisely those patients with higher health needs and complex care [P 2186)…. Major cities with urban poor and recent immigrants were much less likely to be served by primary care physicians working in a capitated medical home.” [P 2187] Richard H. Glazier and Ronald Redelmeier, “Building the patient-centered medical home in Ontario,” Journal of the American Medical Association 2010;303”21862187
“We simulated performance-based payments to Massachusetts practices serving higher and lower shares of patients from these vulnerable communities in Massachusetts.” [P 925] “We did not adjust for most potential confounders….” [P 926] “Typical practices serving higher shares of vulnerable populations would receive less per practice compared to others, by estimated amounts of more than $7,000.” [P 925] “We simulated performance-based payments to Massachusetts practices serving higher and lower shares of patients from these vulnerable communities in Massachusetts.” [P 925] “We did not adjust for most potential confounders….” [P 926] “Typical practices serving higher shares of vulnerable populations would receive less per practice compared to others, by estimated amounts of more than $7,000.” [P 925] Mark Freidberg et al., “Paying for performance in primary care: Potential impact on practices and disparities,” Health Affairs 2010;29:925-932, 926.
Size (ACOs could be much smaller); Size (ACOs could be much smaller);insurance risk (will be shifted to ACO doctors and hospitals in increments); andlimitation on patient choice of provider (ACO membership will be “attributed,” “enrollees” will not be notified of their “attribution” to an ACO, and they will not have to stay within the ACO network).
“Under this option [37], groups of providers meeting certain qualifications would have the opportunity to participate … in Medicare as bonus-eligible organizations (BEOs). The concept of BEOs is similar to the accountable care organization models proposed by some researchers.” “Under this option [37], groups of providers meeting certain qualifications would have the opportunity to participate … in Medicare as bonus-eligible organizations (BEOs). The concept of BEOs is similar to the accountable care organization models proposed by some researchers.” Congressional Budget Office, Budget Options: Volume 1, Health Care, December 2008, http://www.cbo.gov/doc.cfm?index=9925. The CBO estimated this option would cut Medicare spending by $5.3 billion over the 2010-2019 period. According to the National Health Expenditure Accounts, Medicare will spend $6.8 trillion over this period (National Health Expenditure Projections 2009-2019, CMS, Table 2 http://www.cms.gov/NationalHealthExpendData/downloads/NHEProjections2009to2019.pdf). Under the CBO’s Option 38, primary care doctors would be paid by partial capitation. But CBO’s savings estimate for this option is virtually identical to its estimate for Option 37 -- $5.2 billion over the 2010-2019 period.
Examine research on HMOs;Examine results of 2005-2010 Physician Group Practice demonstration;- prevention and disease management
- “coordination”
- report cards and P4P schemes
- electronic medical records
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