Medical practices wary of insurer efforts on new payment programs

Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82. Coventry Health Care, which Aetna is acquiring, was last at 1.66. Other health plans in the survey included Aetna, Anthem, Cigna and Humana.

When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68. United Healthcare again was the highest-rated private plan, at 1.62, and Coventry again brought up the rear, at 1.48.

The survey found practices gave much higher grades to insurers on other questions. For example, on promptness of payments, scores ranged from 3.99 for Medicare Part B to 3.12 for Coventry. In overall payer satisfaction, Medicare Part B was rated highest at 3.53, and United Healthcare was lowest at 2.77. For that question, a score of 3 was considered neutral.

Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms. Overall, the survey rated insurers only in the mid-2s for conducting good-faith contract negotiations.

Medical practices also were frustrated with the technological and business investments they are required to make for ACO and medical-home programs, and they aren’t sure they will get much of a return. Sometimes the issue is that the practice is ready to handle an ACO or patient-centered medical home, but its main insurer hasn’t finalized a program.

“[We] understand that the industry is still developing these options,” said Susan Turney, MD, MGMA-ACMPE’s president and CEO. “It’s important for our members not to rush into new models if they aren’t beneficial for their patients and practices.”

Practices sometimes feel they’re not getting what they need from insurers to make an innovative payment model work. WESTMED Medical Group, a multispeciality group with 240 physicians based in Purchase, N.Y., started establishing accountable care organizations with insurers three years ago. In July, it received ACO designation from the Centers for Medicare & Medicaid Services. But the group said insurers have hesitated to negotiate on some programs that they don’t believe match their own. In addition, WESTMED said getting the information it needs from insurers to make an ACO work can be challenging. In an ACO, physicians often track a specific population, including their visits and treatments at other practices, to ensure quality of care.

“Being capable of successfully performing within a value-based contract is not easy to do,” said Barney Newman, MD, the practice’s medical officer. “Not many practices have a lot of experience in this. You have to really build the infrastructure and the culture of an organization. And most insurers don’t have much experience with this either.”

Several insurers responding to the MGMA-ACMPE data said that, although the programs on offer may not be a good fit for all practices, they will continue to expand so that they are. ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.

Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. The insurer is aiming for 100 practices by the end of 2014, with 20,000 physicians providing care for 1 million members. Cigna said it also is looking for ways to allow smaller practices to take part. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs. The insurer covers 12.6 million people.

“We’re finding a lot of traction, and a lot of interest from physicians,” said Dick Salmon, MD, PhD, Cigna’s national medical director. “And there are improvements we want to make.”

Meanwhile, patient-centered medical home programs backed by commercial insurers now operate in nearly ever state, according to the Patient-Centered Primary Care Collaborative.