Massachusetts BCBS proposes to stop per-visit payments

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Blue Cross Blue Shield of Massachusetts (BCBSM) has proposed to overhaul the way it pays doctors and hospitals, in an attempt to slow runaway healthcare costs and improve the quality of care. BCBSM wants to stop paying doctors and hospitals for each patient visit or treatment, a common arrangement that most experts agree has led to unnecessary, inefficient, and fragmented care that is sometimes harmful to patients, reported The Boston Globe.

Instead, the insurer wants to pay doctors and hospitals a flat sum per patient each year, adjusted for age and sickness, plus a significant bonus if the providers improve care, BCBSM officials said. In most cases, officials said the payment would cover all services from primary care doctors, specialists, counselors, and hospitals–forcing them to work together closely.

"We're not looking to spend less than we do today, but we want spending to grow at a rate that's affordable," Andrew Dreyfus, executive vice president for healthcare services at BCBSM, reported to The Globe. "And we want to empower physicians and hospitals to provide the right care."

As national and state pressure intensifies to control healthcare spending, BCBSM hopes to halve the growth in medical costs in two to four years among providers who accept the new payment system. The insurer also expects the move to attract more business, increasing its market share, which already includes about half of Massachusetts residents.

The Globe reported that BCBSM expects patients could see dramatic changes, such as quicker access to the doctor by phone or email or same-day appointments, home visits by nurses to the chronically ill, and smoother transitions between hospital, rehabilitation center and home.

"If we don't try something like this, the alternative is a continual free-for-all of spending or some sort of regulation," said Stuart Altman, dean of the Heller School for Social Policy and Management at Brandeis University in Waltham, Mass., to The Globe. Altman believes the new payment plan should be mandatory for providers instead of optional, as BCBSM proposes.

Under the BCBSM contract, the hospital or doctor might instead send a nurse to visit the patient on the first day home from the hospital, since those healthcare providers could get a bonus for providing continuity of care and ensuring patients understand how to care for themselves. The nurse could make sure the patient took needed medication and help the patient stock cabinets with healthy food. For the first few weeks, the nurse might call the patient daily to check on weight and give advice.

If any problems cropped up, the patient could get in to see the doctor quickly and would be likely to avoid another hospital stay with a simple medication change. The savings from fewer hospitalizations would go to the doctors and hospitals, to pay for home visits or for bonuses, but eventually could lead to slower growth in healthcare costs, Blue Cross said.

While many insurers' contracts already include performance measures, the Blue Cross plan goes further, by offering up to a 10 percent bonus, based on progress toward dozens of quality standards, such as keeping blood pressure and diabetes under control, and providing immediate access to the doctor around the clock.

According to The Globe, BCBSM must get widespread participation from doctors and hospitals before the effort could slow the rise in insurance premiums. Officials at Partners HealthCare and at Beth Israel Deaconess Medical Center said they support the principles driving BCBSM’s initiative but are not quite ready to sign on. They are worried about the impact on their bottom lines and about being held responsible for care and costs over which they have little control, such as patient stays in nursing homes.

BCBSM said it is still figuring out how the plan could work for doctors in small practices and for patients not in HMOs.