Health

HEALTH • Spring 2015 21 management" under a global payment system is starkly different than the dominant "fee for service" system health care providers are accustomed to. Under fee for service, the more services a doctor renders, the more he or she gets paid, while global payments require providers to care for a group of patients within a budget contracted by the insurer and the provider "In the fee-for-service world, you're paid for more tests, more procedures," Muldoon said. "In popula- tion health (management), you think completely differently." The Blue Cross model The number of these arrange- ments is expected to grow; in January, U.S. Secretary of Health and Human Services Sylvia Mathews Burwell announced that Medicare would shift 50 percent of its provider payments into accountable care organiza- tions and other alternative pay- ment methods by 2018. But it's not just the ACO model that's leading more doctors to adopt this type of approach to managing their patients' care. The commercial insurance industry is also moving in this direction by inking risk-based contracts with providers. Risk-based contracts precede the govern- ment's Medicare ACO program, and were actually pioneered here in Massachusetts by the state's largest commercial insurance company, Blue Cross Blue Shield of Massachusetts. In 2009, Blue Cross launched its Alternative Quality Contract program for doctors, which oper- ates in a manner similar to an ACO. In fact, it served as a model for the federal program and for other commercial insurers who have since adopted risk- based contracting, according to Chantal Buchanan, ACO operations director at the New England Quality Care Alliance (NEQCA). NEQCA, the doctors group affiliated with Tufts Medical Center in Boston, launched its own ACO in January. Buchanan said what Blue Cross and other insur- ance payers (including the government) are realiz- ing in offering risk-based contracts is, "if you don't pay somebody to do something, they're not going to do it." "The whole theory is: If you do well (with manag- ing costs),you save money," Buchanan said. To Buchanan, risk-based contracts mean better care, because of the quality standards that are attached. Doctors that are operating under risk- based contracts have incentive to be more proactive with patients, Buchanan explained. For example, patients who are discharged from the hospital might be tracked by their doctors' offices more closely to ensure they're recovering. "(Risk-based contracting) is really about ways for physicians to basically take more care of the patient after they leave the office," Buchanan said. Is this capitation again? But how do patients feel, now that doctors are view- ing them in these terms? Buchanan said there isn't much skepticism among consumers because they're not that aware of the rise in risk-based contracts. In fact, they would have to do some digging to find out if they are indeed being managed under one. Of course, this isn't the first time the health care industry has tested the waters in managing health care on a budget. In the 1990s, the capitation model was tested and failed, in part because policy makers struggled to describe it to consumers effectively, according to Barbra Rabson, executive director of Massachusetts Healthcare Quality Partners, an industry coalition that provides quality information on the state's health care industry. Rabson said capitation left a bad taste in people's mouths. "I think a lot of the failure from the nineties had a lot to do with language," Rabson said. For example, Rabson said case managers who were responsible for coordinating patient care were called "gatekeepers," which, Rabson said, gave the impression that providers were trying to prevent a patient from receiving services in order to keep costs down. And she said, sometimes, that was the case. But today, quality metrics tied to risk-based con- tracting used by both commercial and government payers are much more advanced and screen for inad- equate treatment as well as overuse, such as unnec- essary or duplicate screenings, according to Rabson. The metrics used by Massachusetts insurers and providers are particularly strong, she added. "There are parts of the country that I would worry about global payments … but not so much here in Massachusetts," Rabson said. Navigating the system One local company that's ramping up population health management on the insurance side is Worcester-based insurer Fallon Health. The compa- ny employs a couple hundred "navigators," who perform case management services for patients who subscribe to Fallon insurance plans. There is one Navigator assigned to every physician office that sees Fallon patients, and they coordinate care for patients with complex needs, said Dr. Sarika Aggarwal, chief medical officer at Fallon. The idea, she said, is to reduce the fragmentation among providers so health care is more efficient and effective. "This is the person who follows them wherever they are," Aggarwal said. Patients like it because they have a point person who can guide them through a complex health care system that can be very confusing, Aggarwal said. And she said the health benefits are striking. For instance, using the navigators, Fallon launched a campaign to boost flu vaccination rates this year after reviewing last year's low vaccination rate among the elderly population it insures. The outreach they performed over eight weeks doubled the vaccination rate over the prior year. "It's just so exciting what we can use this work for," Aggarwal said. Barbra Rabson, executive director of Massachusetts Healthcare Quality Partners Source: Center for Health Information and Analysis Alternative payments Fee-for-service Commercial MassHealth MCO Commonwealth Care 34% 32.1% 30.8% 65.7% 67.9% 69.2% 1.6% 7.4% 15.5% Alternative payments percent change, 2012-2013 Fee-for-service contracts still dominated in 2013, but alternative payments were on the rise PAYMENTS BREAKDOWN

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