Hope for Primary Care … from a Payer? A White Paper on the Collaborative Payer Model

by Tom Doerr, MD and Randy Bak, MD, JD

What if the health care payer were re-imagined as a service to the primary care doctor – supplying the tools, information and funding primary care physicians needed to meet the call to reform health delivery?

The structure of physician payment is considered one of the most problematic aspects of our health care system.  Driven by volume instead of coordinated, proactive care and favoring procedures over cognitive work, the payment system has driven primary care into decline and stifled improvements in quality and efficiency.  Indeed, primary care physicians are overstressed and demoralized by demands, coming from every direction, that drive them only to see more patients, as quickly as possible.   In this state, primary care cannot attract new physicians at a time when an expansion of the primary care workforce is desperately needed.  Without new primary care doctors, how will medicine meet the future volume demands of the aging “baby boomers”, much less deliver the kind of comprehensive approach to patient health needed to correct the defects in today’s care?  Despite these growing concerns, little in the way of innovation is arising from payers.

So, what if the payer model was re-imagined?  What would such a payer look like?  At ESSENCE Healthcare, we have developed the Collaborative Payer Model (CPM), which takes the first steps at answering these questions. 

The CPM brings a new approach to address what is missing in much of health care reform, including:

• Use of funding and information to preserve capitation’s benefits while mitigating its risks and concerns.
• Giving the Centers for Medicare & Medicaid Services (CMS) and Congress a repaired use of risk-adjustment in Medicare Advantage, collaboration by payer and physicians, promotion of primary care and better management of supply sensitive-care.
• Offering patients better access and more time with PCPs, earlier attention to health problems, and affordability.
• Providing medical leadership transparency of premiums flow, access to rich administrative information, flexible and rational innovation planning and support for organizational development.
• Equipping primary care providers (PCP) with the information, tools, support and compensation needed to deliver coordinated, comprehensive and effective care.
• Providing other health service providers the opportunity to focus on value creation by collaborating with PCPs within their own community, instead of at a remote corporate or agency headquarters.

We have put the CPM into practice in all five of our service area states.  Thus far, it has performed well in patient benefits, shown best by maximum-out-of-pocket expenses (MOOP); in patient satisfaction as demonstrated by the CAHPS survey; and in HEDIS measures of performance. 

We believe the CPM is an innovative, dynamic partnership between a payer and a medical organization, built on aligned incentives, shared control, transparency and heightened reciprocal accountability.  The re-aligned funding serves to reinvigorate primary care, allowing time and resources to provide for coordinated, comprehensive and proactive care.  We hope by promoting the CPM model, CMS and Congress can advance the promise of risk-adjusted global payment lost in the initial implementation of Medicare Advantage.  For a detailed description of the CPM, please click here.

Tom Doerr is an internist in St. Louis, and a founder of ESSENCE Healthcare, a merger of a physician-founded Medicare Advantage health plan with a health information technology company.  He is currently chairman of the executive committee of the board, and an active evangelist for the Collaborative Payer Model.

Randy Bak is a pediatrician, attorney and former CIO of a 70 doctor primary care practice.  He is Director, Medical Affairs, for Essence Healthcare and is responsible for strategic policy development and bringing practice administration perspective to the health plan leadership. 

Contact the authors through CollaborativePayer@gmail.com.