Julia Adler-Milstein, Dori A. Cross, Genna R. Cohen, Christy Harris Lemak
D. A. Cross, G. R. Cohen, C. Harris Lemak, and J. Adler-Milstein, “Sustained Participation in a Pay-for-Value Program: Impact on High-Need Patients,” American Journal of Managed Care, Feb. 2017 23(2):e33–e40.
High-need patients with multiple chronic conditions account for a disproportionate share of health spending. Researchers explored whether these patients would use fewer health services and receive higher-quality care if their primary care providers (PCPs) participated in a pay-for-performance program that uses financial incentives to encourage the delivery of effective, value-based care.
Commonwealth Fund–supported researchers identified 17,443 Blue Cross Blue Shield of Michigan members with two or more chronic diseases, including mental health problems. They compared outcomes for members assigned to a PCP that participated in the insurer’s pay-for-performance program for at least four years to outcomes for members assigned to PCPs not in the program.
Results were inconsistent. High-need patients with physicians who participated in the program had almost 20 percent fewer 30-day hospital readmissions and 27.5 percent fewer 90-day readmissions. This was a reduction of 25 readmissions per 1,000 patients. In addition, quality scores improved modestly compared to the control group. However, total spending did not decline. Noting higher drug costs among the incentive group practices, the researchers theorize that increased medication management may have driven higher drug utilization, which partially defrayed savings from reduced readmissions.
Sustained involvement by PCPs in pay-for-value programs may be important to improving specific quality and cost outcomes for high-need patients. But PCPs do not have control over overall spending and broader approaches may be needed to improve costs for complex patients.