Transcript Document

The Emerging Challenge of
Chronic Care
Robert A. Berenson, M.D.
Senior Fellow, The Urban Institute
27 September, 2007
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Chronic Condition
• An illness, functional limitation or cognitive
impairment that lasts (or is expected to last)
at least one year
• Limits what a person can do
• Requires ongoing care
Source: National Academy of Social Insurance, “Medicare in the 21 st Century: Building a Better Chronic Care System,” January 2003.
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Projected Total Number of People
With Chronic Conditions
(in millions)
180
171
164
157
160
149
141
140
133
125
120
118
100
1995
2000
2005
2010
2015
Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment”; RAND Corporation, 2000.
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2020
2025
2030
Chronic Conditions by Age Group
100%
Percent of Population
84%
80%
62%
62%
60%
38%
40%
Two or More
Chronic
Conditions
35%
24%
20%
13%
5%
0%
0-19
20-44
Ages
45-64
65+
Source: Partnership for Solutions. “Disease Management and Multiple Chronic Conditions”; Agency for Healthcare Research and Quality, MEPS, 1998.
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One or More
Chronic
Conditions
Chronic Condition Prevalence
By Race (Total Population)
80%
0 Conditions
1 Condition
2 Conditions
3+ Conditions
70.6%
65.7%
70%
60%
57.8%
50%
40%
30%
20%
24.2%
21.4%
10.2%
7.8%
10%
7.1% 5.9%
20.6%
5.3% 3.6%
0%
Caucasian
African-American
Source: Hwang, W., et al., “Out-of-Pocket Medical Spending for Care of Chronic Conditions,” Health Affairs, December 2001.
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Hispanic
Proportion of Adults 50+ with
Chronic Conditions, by Race
Africa-American
77
Latino
68
White
64
Asian American
42
0
10
20
30
40
50
60
70
80
90
Source: “Cultural Competence in Health Care,” Center on an Aging Society, Georgetown University. No. 5, February 2004.; K. Collins, et al., “Diverse Communities, Common Concerns; Assessing Health
Care Quality for Minority Americans,” New York: The Commonwealth Fund, 2002.
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Chronic Conditions for Children
Upper Respiratory Disease
64
Asthma
31
60
Preadult Disorders
34
65
Eye Disorders
26
70
Disorders of Teeth and Jaw
19
65
0%
Single Condition
20%
31
40%
Condition +1
60%
Condition +2
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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80%
5
5
7
8
4
100%
Chronic Conditions for Adults
Chronic Respiratory
Infection
42
Upper Respiratory
Disease
28
46
26
14
8
7
14
7
8
Mental Conditions
30
30
16
11
13
Hypertension
30
29
18
11
13
Arthritis
26
0%
Single Condition
25
20%
Condition +1
40%
Condition +2
20
60%
Condition +3
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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13
16
80%
100%
Condition +4+
Chronic Conditions in Seniors
Diabetes
8
Eye Disorders
9
23
Heart Disease
10
21
Hypertension
Arthritis
22
17
11
0%
Single Condition
25
25
25
24
22
20%
Condition +1
22
19
22
19
24
19
23
20
23
40%
Condition +2
16
22
60%
21
80%
Condition +3
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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100%
Condition +4+
Percent of Services Used by People
with Multiple Chronic Conditions
Multiple Chronic Conditions and
Medical Service Usage
100%
82%
80%
69%
55%
60%
50%
40%
20%
0%
Home Health
Visits
Prescription
Drugs
Inpatient
Stays
Physician
Visits
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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Percent of People with Inpatient
Hospital Stays
Hospitalizations by Number of
Chronic Conditions
50%
40%
32%
30%
22%
17%
20%
12%
10%
8%
4%
0%
0
1
2
3
4
Number of Chronic Conditions
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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5+
Hospitalizations for Ambulatory
Care Sensitive Conditions
Hospitalizations per 1000
Medicare Beneficiaries
300
261
236
250
219
200
169
131
150
95
100
50
62
0
7
18
0
1
2
36
0
3
4
5
6
7
8
Number of Chronic Conditions
Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; Medicare Standard Analytic File, 1999.
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9
10+
Percent with Activity Limitations
Activity Limitations by Number of
Chronic Conditions
80%
67%
52%
60%
43%
40%
20%
28%
15%
4%
0%
0
1
2
3
4
Chronic Conditions
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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5+
Annual Prescriptions by Number
of Chronic Conditions
49.2
Average Annual
Prescriptions*
50
33.3
40
24.1
30
17.9
20
10
10.4
3.7
0
0
1
2
3
4
Number of Chronic Conditions
*Includes Refills
Sources: Partnership for Solutions, “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; MEPS, 1996.
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5
Utilization of Physician Services
by Number of Chronic Conditions
37.1
Unique Physicians
Physician Visits
19.5
14.9
13.8
11.3
7.8
2.0
1.3
0
4.0
5.2
1
8.1
6.5
2
3
4
5+
Number of Chronic Conditions
Sources: R. Berenson and J. Horvath, “The Clinical Characteristics of Medicare Beneficiaries and Implications for Medicare Reform,” prepared for the Partnership for Solutions, March, 2002; Medicare SAF
1999.
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Breakdown of Total
Health Care Spending
78%
Health Care Spending for
People with Chronic
Conditions
22%
Health Care Spending for
People without Chronic
Conditions
Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.
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Number of Chronic Conditions
Health Care Spending by Number
of Chronic Conditions
0
$800
1
$1,900
2
$3,400
3
$5,600
4
$8,900
5+
$11,500
$0
$2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000
Average Per Capita Health Care Spending
Sources: Partnership For Solutions. “Disease Management and Multiple Chronic Conditions”; Agency for Healthcare Research and Quality, MEPS 1998.
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Medicare Spending Related to
Chronic Conditions
20.3%
65.8%
11.3%
14.8%
16.3%
15.1%
22.1%
Percent of Medicare
Population
12.7%
10.3%
6.8%
3.5%
0.9%
Percent of Medicare Spending
Source: Partnership for Solutions, “Medicare: Cost and Prevalence of Chronic Conditions,” July 2002; Medicare Standard Analytic File, 1999.
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5+ Conditions
4 Conditions
3 Conditions
2 Conditions
1 Condition
0 Conditions
Medicare Spending on Beneficiaries
with Chronic Conditions
4 Chronic
Conditions
12%
3 Chronic
Conditions
10%
5+ Chronic
Conditions
68%
2 Chronic
Conditions
6%
0 Chronic
Conditions
1%
1 Chronic
Condition
3%
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Growth of Medicaid Spending
Disabled Beneficiaries
All Beneficiaries
$200
$168
In Billions
$150
$142
$120
$100
$124
$91
$50
$73
$49
$54
$60
$34
$0
1992
1995
1997
1998
2000
Sources: J. Crowley and R. Elias. “Medicaid’s Role for People with Disabilities,” The Kaiser Commission on Medicaid and the Uninsured, August 2003; Urban Institute estimated based on HCFA-2082 and
HCFA-64 Reports.
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Projected Total Medicaid
Spending Per Enrollee
$16,300
FY 2001
FY 2006
$11,200
$1,400
$2,000
$2,300
Children
$17,200
$12,300
$3,200
Adults
Disabled
Elderly
Note: Includes federal and state spending on benefits.
Sources: J. Crowley and R. Elias. “Medicaid’s Role for People with Disabilities,” The Kaiser Commission on Medicaid and the Uninsured, August 2003; KCMU analysis based on CBO baseline for Jan. 02.
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Private Health Insurance Spending on
Individuals with Chronic Conditions
4 Chronic
Conditions
13%
5+ Chronic
Conditions
31%
0 Chronic
Conditions
13%
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American
Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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3 Chronic
Conditions
14%
2 Chronic
Conditions
15%
1 Chronic
Condition
14%
Incidents in the Past 12 Months
Among persons with serious chronic conditions, how often
has the following happened in the past 12 months?
Sometimes or often
1. Been told about a possibly
harmful drug interaction
54%
2. Sent for duplicate tests or
procedures
54%
3. Received different
diagnoses from different
clinicians
52%
4. Received contradictory
medical information
45%
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Barriers to Improvement
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Barriers to Implementing Change
in Most of Medicare
• The nature of medical education and the
resultant professional culture and
orientation of clinical practices
• Traditional Medicare is based in traditional
indemnity insurance
• Major benefit limitations and restrictions in
the Medicare statute
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Professional Issues
• Hard to influence by public policy
• Based on an orientation to identifying and caring
for acute illnesses and injuries, not chronic
conditions
–
–
–
–
“find it and fix it”
solve, rather than manage problems
“the tyranny of the urgent”
Failure to find the unusual and the life-threatening is
worse than overlooking the common and considering
quality of life
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Professional Issues (cont.)
• Oriented to those who present for care, rather than to
populations who inhabit their chronic conditions
• Little division of labor – M.D. as captain of the ship
• Underuse of information management and decision
support tools
• Resistance to change, even in the face of
demonstrable failures
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Specific Structural and
Organizational Deficiencies
• Residency training takes place in hospitals
• Shortage of geriatricians
• Guidelines (even when followed) usually ignore
co-morbidities – may conflict or produce
overwhelming compliance burden
• Disease management and primary/principal care
are not well coordinated
• Lack of integrated care orientation (also fostered
by siloed payment systems)
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Medicare Statute Based on
Indemnity Insurance of the ’60s
• Kenneth Arrow in 1963: for people with
chronic illness, “insurance in the strict sense
is probably pointless.”
• Why? Moral hazard
• Yet, 80% of beneficiaries have one or more
chronic condition and 20% have 5 or more
and account for two-thirds of program
spending
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Example of the Problem: Should
Medicare Pay for E-mails?
• Why not phone calls, while you’re asking?
• In a fee-for-service payment system, there
are a number of concerns:
– Relatively high transaction costs relative to the
value of the underlying service
– Substantial program integrity concerns
– “Nuclear force” moral hazard
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Problems in How Traditional
Medicare Pays for MD Services
• Many Medicare payment systems have evolved
from FFS to prepayment for episodes of care –
physician payments is the main exception
• Physician payment is for discrete, narrowly
defined services or transactions
• Partly fails to account for complexity
• Pays based on resources expended, whether serve
a useful purpose or not
• And doesn’t pay differently for quality
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Medicare Benefits Need to Be
Improved and Upgraded
• Now, reasonable coverage for prescription drugs
(although still 4 million not in)
• Sensory loss support devices not covered
(eyeglasses, hearing aids)
• DME and home health limitations, e.g., the
“homebound” definition
• Program interpretation that rehabilitation services
require prognosis of improvement, and not
maintenance or slowed deterioration
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Various Models of Enhanced
Chronic Care Management
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Disease Management
• I use the term to refer to third parties attempt to
influence patients directly, bypassing physicians
• Relies on predictive modeling, decision-support
software, and remote monitoring devises to
complement core nurse-patient communication,
which focuses on patient self-management
(diabetes) and early detection of clinical
deterioration (CHF)
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Case Management
• Targeted to a subset of patients who are
typically the most complex – with a
combination of health, functional, and
social problems
• Approach is more customized to needs of
particular patients
• Relies mostly on telephonic interventions
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The Wagner Chronic Care Model
• Pioneered by Wagner and associates at Group
Health Cooperative of Puget Sound and The
MacColl Institute
• Offers a multidimensional approach to a complex
problem
• Identifies 6 essential elements: community
resources, health care organization, selfmanagement support, delivery system redesign,
decision support, clinical information systems
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Delivery System Redesign
• Specialized assessment tools to identify
patients at risk
• Multi-professional team responsibility and
delineation of roles
• Active promotion of patient selfmanagement
• Proactive follow-up/communication,
outside of the anachronistic office visit
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Chronic Care Strategies That
Bypass Physicians Make No Sense
• From 30 years of Medicare demos -- approaches
that are supplemental to the patient/physician
relationship have had little impact – the MMA
disease management demo seems to be failing; in
commercial and Medicaid settings D.M. may have
some, but limited, usefulness.
• In contrast, CMS just announced modest positive
results from the Medicare physician group practice
demo, which incentivizes, rather than bypasses,
practices – mostly, but not only, large groups
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Challenging the Status Quo in
Chronic Disease Care: Seven Case
Studies
Robert A. Berenson, M.D.
September, 2006
Available on California Health Care Foundation
website
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Seven Case Studies
• Sutter Health Sacramento Sierra Region
• Park Nicollet Health Services
• Integrated Resources for Middlesex Area (Ct.)
• Billings Clinic
• Care Level Management
• Washington Hospital Center Medical House Call
• MDxL
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Case Study Finding 1
• Physicians and hospitals can do much more
to manage patients with chronic conditions
• Physicians and hospitals do not think thirdparty disease and case management has
worked because of the absence of physician
engagement
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Finding 2
• Viable models of chronic care management
fall between the Chronic Care Model and
third-party approaches
• Case study sites do not attempt to redesign
traditional practice of frontline primary care
physicians
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Finding 3
• Although third-part D.M. remains the
dominant framework for chonic care
improvement, some health plans also
support innovative approaches that more
closely relate to patients’ regular sources of
care
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Finding 4
• Provider-based programs carefully
distinguish among patients based on their
specific clinical conditions and other
assessments
• Differentiators include: whether patient
home-bound, have limitations in activities
of daily living, and specific conditions, e.g.
CHF vs. diabetes vs others
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Finding 5
• Approaches to case management for
medically complex patients vary more than
do disease management programs for
patients with one or more specific chronic
conditions
• For the former, programs rely more on point
of care decision-making by clinicians
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Finding 6
• Capitation is more compatible with chronic care
programs and their populations than fee-forservice reimbursement
• Capitation provides greater flexibility and
organizations can benefit from reduced
expenditures
• The Medicare “shared savings” approach used in
the PGP demo also may be a practical approach
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Finding 7
• Current Medicare payment rules greatly
influence the configuration of chronic care
programs, e.g., how to get reimbursed for
diabetes education or the “incident to” rules.
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Finding 8
• The negative business case for hospitals to
support chronic care management does limit
the robustness of programs
• However, in some circumstances, there are
offsets to the negative ROI
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Finding 9
• Communications, monitoring, and datasharing technologies enhance chronic care
programs but, state-of-the-art, “high tech”
technologies are not essentail.
• EMRs, disease registries, PDAs, yes
• Sophisticated telemonitoring devices, not
really
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Some Final Thoughts on Physician
Payments to Support All of This
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We Should Not Expect Pay-forPerformance to Solve the Problem
• It focuses on marginal dollars and ignores the
incentives in the basic payment system -- which
drive behavior
• A lot of what we want physicians to do is not
easily measurable. Are we looking under the light
for the keys lost in the bushes?
• P4P can’t easily address “overuse” and “misuse”
quality dimensions, much less cost.
• We are still learning about P4P. Don’t overload it.
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The Bottom Line
• A one-size fits all, RBRVS fee schedule no longer makes
sense as physicians increasingly do very different things
– Perhaps, PCPs need mixed FFS and prospective
monthly payments (with a dash of P4P)
– Surgeons could be paid for episodes (but addressing the
bias to inappropriate surgical episodes)
– Other specialists who perform one-time, discrete
services might still be paid FFS for their services
• The payment system should promote integrated care,
including multi-specialty groups, but not single specialty
consolidation
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Continuum of Approaches for Paying
for “Medical Home” Services
• Aggressive, politically difficult RBRVS/fee schedule
revaluations
• New CPT codes for targeted medical home activities
• A new payment, i.e. pmpm or pppm, for chronic care
management activities to the practice on top of FFS
payments
• Bundled payment for medical services and medical home
activities – either a more improved pmpm or a hybrid
FFS/bundled payment approach
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FFS Revaluations
• Hope that better payment for E&M services crosssubsidizes medical home activities (as some are already
included in pre and post service work, according to the
RBRVS methodology
• Avoid difficult design issues of a formal medical home -• Who qualifies for payment, e.g. primary care or
principal care?
• The physician or the practice?
• Is there a formal patient lock-in – hard or soft?
• No obligation to hold any one accountable and all that
that entails
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FFS Revaluations -- Cons
• No obligation to hold any one accountable and
all that that entails – in a FFS system, it might
be putting good money after bad
• Politically difficult to redistribute within a fee
schedule context
• A CPT code based payment system that pays
for specific services cannot really accommodate
the set of “soft” activities we want to promote
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New CPT Codes for Particular
Medical Home Activities
• Or particular services in the Chronic Care Model
• As examples, palliative care family conferences,
“email consultations,” geriatric health assessment
• These should be included in CPT and paid for, but
can’t really include most medical home or care
coordination activities on a FFS payment basis, as
discussed before
• Even here, face political obstacles to adoption
from vested interests who are involved in CPT
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PPPM Payment for Medical Home
and/or Chronic Care Management
• Assumes there is a definable and designated
subpopulation that “qualifies” for additional
activities supported with additional payment
• Would small practices reengineer their
processes for a small subset of patients which
may make up a highly disproportionate share of
health spending but not a relatively small share
of their time and attention?
• Compounded if not an all-payer approach
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An Add-on PPPM Payment (cont.)
• Which raises the fundamental question, do all
patients benefit from a medical home or should the
approach be targeted to only some, for efficiency?
• How would eligible patients be selected –
physician referral (then self-referral issues),
history of high costs, data mining re conditions
and co-morbidities – the issues that are relevant to
eligibility for case management?
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Bundled (“Capitated”) Payments for All
Services and All Patients or a FFS Hybrid
• The advantage is that all patients are included, so no
practice dissonance for different patients and risk
adjustment handles the fact that different patients have
different needs for chronic care management
• But should medical home services be provided to
everyone? Do they all want a home? Is this efficient? (But
some of us think FFS sends wrong signals for all patients)
• Can we correct the execution errors of 1990s capitation
approaches related to: insurance risk, absence of risk
adjustment, mechanical actuarial conversion of pmpms
under FFS to a situation when more is expected of the
practice?
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A FFS/Bundled Payment Hybrid
• Some very smart people, e.g., Joe Newhouse, have
recommended a mixed approach to soften the
effects of capitation and FFS payment incentives
• Some European primary care payment models,
e.g. Denmark, is a hybrid
• But surely more complex operationally for the
payer and maybe the practice and may negate
some of the appeal of bundled/“capitated”
payments
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