Document Detail

Risk-adjusted payment and performance assessment for primary care.
MedLine Citation:
PMID:  22525609     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped.
RESEARCH DESIGN: Using MarketScan's claims-based data on 17.4 million commercially insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multipayer medical home implementation with commercially insured, Medicare, and Medicaid patients.
METHODS: Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R(2)'s at patient and practice levels, and within policy-relevant subgroups.
RESULTS: The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types, and provider specialties; it explains 72% of practice-level variation. In 9 performance measures, the outcome-specific models explain 17%-86% of variation at the practice level, often substantially outperforming a generic score like the one used for full capitation payments in Medicare: for example, with grouped R(2)'s of 47% versus 5% for predicting "prescriptions for antibiotics of concern."
CONCLUSIONS: Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.
Arlene S Ash; Randall P Ellis
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Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Medical care     Volume:  50     ISSN:  1537-1948     ISO Abbreviation:  Med Care     Publication Date:  2012 Aug 
Date Detail:
Created Date:  2012-07-11     Completed Date:  2012-09-26     Revised Date:  2014-04-08    
Medline Journal Info:
Nlm Unique ID:  0230027     Medline TA:  Med Care     Country:  United States    
Other Details:
Languages:  eng     Pagination:  643-53     Citation Subset:  IM    
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MeSH Terms
Age Distribution
Benchmarking / economics,  methods
Comprehensive Health Care / economics,  organization & administration*
Insurance Claim Review / statistics & numerical data
Outcome and Process Assessment (Health Care) / organization & administration
Patient-Centered Care / organization & administration
Primary Health Care / economics,  organization & administration*
Quality Indicators, Health Care / economics
Reimbursement, Incentive
Risk Adjustment / methods*
Sex Distribution
Grant Support
Comment In:
Med Care. 2012 Aug;50(8):640-2   [PMID:  22683593 ]
Med Care. 2012 Aug;50(8):637-9   [PMID:  22683594 ]
Med Care. 2012 Aug;50(8):635-6   [PMID:  22683592 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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