Influence Primary Care and Its Impact on the Quadruple Aim

SPECIAL COMMUNICATION
How Evolving United States Payment Models
Influence Primary Care and Its Impact on the
Quadruple Aim
Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew Bazemore, MD, MPH,
and Winston Liaw, MD, MPH
Introduction: Prior research has demonstrated the associations between a strong primary care foundation with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the
United States reinforces the volume of services over value-based care, thereby devaluing primary care,
and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from
volume-based to value-based payment models, the Medicare Access and Children’s Health Insurance
Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a
taxonomy of the major health care payment models, reviewing their ability to uphold the functions of
primary care, and their impacts across the Quadruple Aim.
Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for
America’s Health payment and research tactic teams were used. Titles and abstracts were reviewed for
relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and
relevant articles.
Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a
limited evidence base. Several cross-cutting lessons from available payment models several recommendations for primary care payment models, including the following: implementing per member per
month–based models, validating risk-adjustment tools, increasing investments in integrated behavioral
health and social services, and connecting payments to patient-oriented and primary care-oriented metrics. Along with ongoing research in emerging payment models, data systems integrated across health
care and social services settings using metrics that can capture the ideal functions of primary care will
be critical to the development of future payment models that most optimally enhance the role of primary care in the United States.
Conclusions: Although the ideal payment model for primary care remains to be determined, lessons
learned from existing payment models can help guide the shift from volume-based to value-based care.
To most effectively pay for primary care, future payment models should invest in a primary care infrastructure, one that supports team-based, community-oriented care, and measures the delivery of the
functions of primary care. (J Am Board Fam Med 2018;31:588–604.)
Keywords: Delivery of Health Care, Family Medicine, Health Expenditures, Primary Health Care
Forty years ago, in the milestone “Declaration of
Alma Ata,” all member nations of the World
Health Organization declared that achieving health
for all was dependent on a foundation of primary
care.1 A quarter century later, Dr. Barbara Starfield
added to the evidence base, demonstrating that
primary care produces higher quality of care, imThis article was externally peer reviewed.
Submitted 26 September 2017; revised 11 March 2018;
accepted 13 March 2018.
From the Department of Family Medicine, Oregon
Health & Science University, Portland, OR (BP); Eugene S.
Farley, Jr. Health Policy Center, University of Colorado
School of Medicine, Denver, CO (SBG); Robert Graham
Center for Policy Studies in Family Medicine and Primary
Care, Washington, D.C. (AB, WL).
Funding: none.
Conflict of interest: none declared.
Corresponding author: Brian Park, MD MPH, Department
of Family Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Pk Rd, Mailcode FM, Portland, OR
97239 E-mail: [email protected]).
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proves health outcomes, increases access, lowers
costs, and attenuates disparities.2,3,4 She attributed
the positive impact of primary care on health systems to the “4 Cs,” which define its function: first
contact, continuity, comprehensiveness, and coordination (Figure 1).4 Subsequent research has demonstrated that supporting these 4 Cs are the elements of primary care that help health systems
achieve the Quadruple Aim of improving patients’
experience of care, population health, and physician satisfaction, while reducing costs.5,6,7,8
Starfield’s work and the healthcare system’s
longstanding inattention to primary care may explain the ongoing failure of the United States to
achieve its Quadruple Aims, given the inadequate
system level support for primary care.9,10,11,12,13,14
Its predominant fee-for-service (FFS) payment
model has long been thought to undermine or
insufficiently support the 4 Cs that explain primary
care’s positive effects.15,16,17 Under pure FFS payment models, clinicians are reimbursed retroactively for services, incentivizing higher volume,
treatment rather than prevention, and fragmentation of care without regard for quality or cost. Such
models reward greater numbers of services rendered (ie, volume) rather than the quality and cost
of care provided to patients (ie, value).18,19
Payers, public and private, are experimenting
with shifting from paying for volume to paying for
value. The Affordable Care Act included provisions
that advance primary care and value-based payment, including the creation of the Center for
Medicare and Medicaid Innovation (CMMI), which
has tested innovative payment and delivery system
models aimed at improving value.20,21,22 Five years
after the Affordable Care Act, the Medicare Access
and Children’s Health Insurance Program CHIP Reauthorization Act (MACRA) passed. Under MACRA,
providers1 will select 1 of 2 incentive tracks: the alternative payment model (APM; see Table 1) or the
Merit-Based Incentive Payment System (see Table
2).23 Both programs provide incentives for improving
quality and reducing costs.
As value-based payment spreads, better understanding of existing models can guide which approaches deserve ongoing implementation and research efforts. This narrative review of the literature
proposes a taxonomy of the major health care payment models, highlights their distinguishing characteristics (Table 3), and reviews their impacts across
the Quadruple Aim (Table 4). We also discuss the
impact of each payment model in supporting the 4
Cs of primary care; given the lack of widespread use
and standardized metrics in measuring these pri1
Eligible clinicians provide care for at least 100 Medicare
patients and bill for greater than $30,000 of Medicare Part B
services.
Table 1. Scheduled Adjustments in APM Eligibility Criteria under Medicare Access and Children’s Health
Insurance Program Reauthorization Act
Year Eligibility
2019 and 2020 25% of total Medicare revenue is from a qualified, eligible APM
2021 and 2022 50% of total Medicare revenue OR
25% of total Medicare revenue and 50% of all-payer revenue (eg, Medicaid, private insurers)
is from a qualified, eligible APM
2023 and beyond 75% of total Medicare revenue OR
25% of total Medicare revenue and 75% of all-payer revenue is from a qualified, eligible APM
APM, alternative payment model; OR, odd ratio.
Figure 1. The 4 Cs of Primary Care.
• Contact: Accessibility as the first contact with the health care system
• Comprehensiveness: Accountability for addressing a vast majority of personal health
care needs,
• Coordination: Coordination of care across settings, and integration of care for acute
and (often comorbid) chronic illnesses, mental health, and prevention, guiding access
to more narrowly focused care when needed,
• Continuity: Sustained partnership and personal relationships over time with patients
known in the context of family and community.
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mary care attributes24, when relevant, we consider
the hypothetical impacts of each model when formal metrics were not used. Based on these findings,
we provide policy and research recommendations
for payment reform to best advance primary care.
Methods
Starfield Summit I: Advancing Primary Care
Research, Policy, and Patient Care
The first iteration of this narrative review was conducted before the inaugural Starfield Summit
(http://www.starfieldsummit.com) on April 24 to
26, 2016, in Washington, D.C. It was intended to
inform and capture informant input from the Summit’s nearly 150 invited primary care leaders
(PCPs), researchers, and health care leaders to discuss and enable research and policy agenda-setting
around primary care payment, measurement, and
teams.25
Literature Review
We first conducted a literature search26 on primary
care payment, enriched through expert consultation before, during, and after the Summit. In
March 2016, an Ovid MEDLINE search was conducted using the search terms “payment” and “primary care.” The search was limited to articles published in English since 2010, yielding a total of 391
results2
, with 97 articles ultimately included in the
review. Exclusion criteria included the following:
inclusion in a subsequent systematic review, updated evidence available (ie, more recent article
from the same demonstration), not focused on payment models, not focused on Quadruple Aim
and/or the 4 Cs, and non-US evaluations that were
subnational. Additional articles and gray literature
were identified from the expert opinions of members of the Family Medicine for America’s Health
payment and research tactic teams and a “snowball”
method of reviewing the references of the search
results. The literature was summarized for each
model, and key demonstrations or projects were
selected, with agreement from at least 2 authors
from the writing group, to highlight examples.
Results
Fee-For-Service
Under FFS, a provider is retrospectively paid a
predefined amount for each service. Consequently,
providers are incentivized to increase volume without bearing financial risk for quality or costs; insurers bear high financial risk in this arrangement.
In 1992, the Centers for Medicare and Medicaid
Services (CMS) began using the Resource-Based
Relative Value Scale to set a fee schedule for different services, which has been criticized for disproportionately weighing specialist care and procedures over primary care.27,28 Despite concerns over
the limitations of FFS, its inclusion in a payment
model may enhance the use of services that are
low-cost and underutilized29, such as vaccines in
low immunization areas, where increased volume is
desirable for population health.
Traditional (Or Full-Risk) Capitation
In response to rising costs from FFS, health maintenance organizations (HMOs)3 emerged in the
1980s to coordinate care and reduce use30 by capitating payments.26 In traditional capitation, providers are paid a prospective amount to cover all services within a specific period of time, most often as
a per member per month (PMPM) fee. Payments
vary by age-group and sex and are determined
based on prior average costs of care under FFS.31,32
A capitated fee can cover all primary care services,
all outpatient services, or all health care services,
2
In the case that a more recent report on a demonstration
project was published between the time of the initial literature search and submission of this manuscript, we replaced
the prior report with the most up-to-date evidence.
3
HMOs and other managed care models also include
other mechanisms for cost control (e.g., narrow provider
networks and pre-authorization of services). For the purposes of this paper, we have examined this model as a
surrogate for capitated payment, though we acknowledge
other mechanisms were in place to contribute to outcomes.
Table 2. Scheduled Payment Adjustments in Merit-Based Incentive Payment System
Adjustment 2019 2020 2021 2022 and beyond
Baseline payment adjustment 4% 5% 7% 9%
Maximum payment adjustment for high performers 12% 15% 21% 27%
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Table 3. Overview of Primary Care Payment Models
Description
Prospective vs
retrospective
Financially
discourages
volume of
services?
Financially
encourages
high quality of
care?
Party that primarily
bears the financial
risk?
Risk adjusts for
patient
complexity? Key Example
Fee-for-service (FFS) Paid for each individual
service rendered
Retrospective No No Insurers No Medicare
Patients (via
cost-sharing: copays, deductibles)
Traditional capitation (fullrisk capitation, global
payment)
Paid to cover all
services within a
specific period of
time
Prospective Yes No, except for
outcomes
related to
use
Primary care practices No Medicare Advantage HMOs
Pay-for-performance (P4P)
exists in addition to
underlying model
(generally FFS or
capitation)
Paid for achievement of
(or improvement in)
a quality measure
Both exist (most models
retrospectively;
however, can be paid
prospectively and
subsequently
reconciled)
Potentially
(depends on
quality metrics)
Yes, for
services
being
measured
via quality
metric
Depends on
underlying payment
model
Potentially Medicare Physician Group
Practice Demonstration
Project
Primary care
practices, if targets
not met
Bundled payment (episodeof-care) Paid for all services rendered for a given
episode of care
Mixed (generally
retrospectively
triggered and
prospectively paid)
Yes (but does not
discourage
volume of
episodes)
No, except for
outcomes
related to
utilization
Primary care
practices,
organizations
No CMMI’s Bundled Payments
for Care Improvement
Shared savings Paid based on spending
below a
predetermined
benchmark over a
period of time
(contingent on
meeting certain
quality targets)
Mixed (prospective at
level of the ACO, but
providers often still
paid via FFS)
Yes Yes ACOs Potentially Medicare Shared Savings
Program ACOs
Blended FFS and
capitation
Paid a predetermined
amount intended to
cover medical home
services for a specific
period of time in
addition to FFS
Mixed No (to the extent
that FFS is the
predominant
payment
mechanism)
No Depends on
underlying payment
model
Potentially Medicare Comprehensive
Primary Care Initiative
Comprehensive (primary)
care payment
Paid a risk-adjusted
amount to cover all
primary care services
for a specific period
of time; includes
component of P4P
Prospective Yes Yes Primary care practices Yes Iora Health
Continued
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including inpatient and outpatient. In contrast to
FFS, capitation incentivizes cost control. Capitation may also exist as part of blended models with
mixed PMPM payments and FFS, or in a further
risk-adjusted form mixed with pay-for-performance in comprehensive primary care payment;
these models are discussed in a later section. In
contrast to FFS, capitation shifts financial risk to
the provider, while the payer has lower risk.
One study examined the impact of capitation on
one of the 4 Cs and finding capitated models was
associated with decreased first contact (access).33
This may reflect the incentive for providers to
avoid sicker patients (termed adverse selection or
“cherry-picking”) to reduce costs. Another possible
negative impact on the 4 Cs is a financial incentive
to inappropriately underdeliver services, leading to
decreased comprehensiveness.34 The prospective
element of capitation could benefit primary care by
enabling upfront investments in practice components that enhance the 4 Cs (eg, care coordination)
and providing flexibility for practices to determine
how finances are spent.
Traditional capitation has demonstrated mixed
effects on cost and quality35,36,37, although most
evidence suggests a decreased use of hospitals and
other expensive resources and worse patient satisfaction, consistent with the backlash toward HMOs
in the 1990s.38
Pay-For-Performance (P4P)
P4P supplements an underlying payment model,
most often as a bonus on top of FFS. P4P refers to
payment based on the achievement of a quality
target (eg, hemoglobin A1c [HbA1c] level 8 for
diabetic patients or delivery of cancer screening) or
improvement in performance (eg, change from
baseline for HbA1c); the latter approach may attenuate variation in quality across providers, and
provide incentives for both high-performing and
low-performing practices.39
Limited evidence exists for the impact of P4P on
the 4 Cs. The United Kingdom’s Quality and Outcomes Framework (QOF) found decreased continuity rates and no differences in patient-reported
perception of coordination, when compared with
preintervention periods.40 Incentivized metrics
tended to improve, whereas nonincentivized metrics demonstrated unchanged or worsened rates of
improvement; a limited set of targeted metrics
Table 3. Continued
could thus inhibit the comprehensive function of
Description
Prospective vs
retrospective
Financially
discourages
volume of
services?
Financially
encourages
high quality of
care?
Party that primarily
bears the financial
risk?
Risk adjusts for
patient
complexity? Key Example
Direct primary care Paid outside of thirdparty insurers (often
directly from
patients) a
predetermined
amount to cover all
primary care services
for a specific period
of time
Prospective Yes No Primary care practices
for primary care
expenses
No Qliance
Patients for other
aspects of care (and
insurers if patients
have third party
insurance)
ACO, accountable care organization; HMO, health maintenance organization; CMMI, Center for Medicare and Medicaid Innovation.
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Table 4. Impact of Primary Care Payment Models on the Quadruple Aim and Tenets of Primary Care
Payment
Model
Quadruple Aim Allows Proactive
Investment in
Primary Care
The 4 Cs of Primary Care Elements Associated
with Successful
Programs
Health
Outcomes
Experience of
Care
Cost
Control
Provider
Satisfaction
Contact
(Access) Continuity Coordination Comprehensiveness
Fee-for-service
(FFS)
2 222
✕ 2 43 2 12* Billing mechanisms
available that
recognize primary
care tenets and
non-face-to-face
services
Traditional
(full-risk)
capitation
43 Mostly 2 Mostly
1
2 ✔ 2 Insuff. evidence Insuff. evidence 12 Risk limited to
primary care
services
PMPM
determination
based on
anticipated need
rather than FFS*
Pay-forperformance
(P4P)
21 21 21 2
✕ 21 2 43 2 Appropriate, aligned
measures for use
in primary care*
Bundled
payment
(episode-ofcare)
43 (weak) Insuff. evidence Insuff.
evidence
Insuff. evidence
✔/✕
(retroactively
triggered)
Insuff.
evidence
Insuff. evidence 1 (weak) Insuff. evidence N/A, may not apply
to primary care
given difficulty
defining and
assigning bundles
Shared savings 1 121 Insuff. evidence
✔/✕ (providers
often paid
FFS)
Insuff.
evidence
Insuff. evidence 1* Insuff. evidence Target high-needs
patients
Address psychosocial
needs
Appropriate riskadjustment
Non-FFS incentives
at provider level*
Physician-led or
integrated ACO
Continued
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Table 4. Continued
Payment
Model
Quadruple Aim Allows Proactive
Investment in
Primary Care
The 4 Cs of Primary Care Elements Associated
with Successful
Programs
Health
Outcomes
Experience of
Care
Cost
Control
Provider
Satisfaction
Contact
(Access) Continuity Coordination Comprehensiveness
Blended FFS
and
capitation
21 21 21 Insuff. evidence
✔/✕ 11 1 Insuff. evidence Target high-needs
patients
Appropriate riskadjustment
Multipayer
alignment
Real-time data
sharing
Optimal
FFS/capitation
blend (more
research needed)
Comprehensive primary
care
payment
1 (weak) 1 (weak) 1 (weak) 1 (weak)
✔ 1 (weak) Insuff.
Evidence
Insuff. evidence 1 (weak) Appropriate risk
adjustment
Payments based on
10% total cost of
care rather than
prior FFS
Direct primary
care
Insuff. evidence 1 (weak) 1 (weak) 1 (weak)
✔ 21* (better
indiv.
access, but
affordability
and
workforce
concerns)
Insuff. evidence Insuff. evidence Insuff. evidence Coupling with
appropriate
wraparound
insurance to avoid
high patient costs
for non-primary
care services*
1, evidence of positive outcomes.
2, evidence of negative outcomes.
21, evidence of mixed effects.
43, no significant effect or change.
✔, allows proactive investment in primary care.
✕, does not allow proactive investment in primary care.
✔/✕, some components allow proactive investment in primary care, while others do not.
Insuff. evidence, no available evidence; (weak), limited or poor quality evidence (ie,
1 study examined and/or not a comparison study).
*No or limited evidence, but a strong theoretical likelihood of effect.
Proactive investment in primary care can support all of the 4 Cs.
ACO, accountable care organization; PMPM, per member per month.
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primary care.41,42 P4P targeted to the 4 Cs could
hypothetically support primary care; however, current metrics focus predominantly on disease-focused and process-oriented outcomes (eg, HbA1c)
outcomes, rather than patient-centered outcomes
(eg, quality of life) or primary care attributes (eg,
continuity).41,43 Metrics for the latter remain underdeveloped and under used,42 despite growing
recognition of the importance of measuring the 4
Cs.45 As P4P is a bonus payment, the shortcomings
of the underlying payment model often prevail.
Overall, the evidence supporting P4P has been
mixed, with inconsistent impacts across the Quadruple Aim.41,45,46,47,48,49,50 In 2 large systematic
reviews, 1 from QOF and 1 from the United States,
some modest yet positive impacts on rate of improvement for targeted quality and patient outcomes were observed initially, but these benefits
stagnated over time, if not regressed to preintervention rates.41,51 Providers reported decreased patient-centered care and continuity41, which are important predictors of provider satisfaction.52 The
return on investment of P4P may be low, given
significant time and financial costs of implementation.53
Bundled Payment/Episode-of-Care Payment
Under bundled payment, providers receive a predetermined payment for all services rendered for an
episode-of-care; this payment may be provided
prospectively or retrospectively. This model has
been used in hospitals (ie, Diagnosis Related
Groups), which receive a set fee for services (ie,
labor and delivery). As with capitation, providers
are at financial risk if their costs exceed the fee but
profit from cost savings. Bundled payments may be
optimal for high-cost, low-frequency conditions or
episodes (eg, hip fractures), as there is incentive to
limit the costs for the given episode, but not to
limit future episodes.30
Limited evidence exists of the impact of bundled
payment on the 4 Cs. As reimbursements for an
episode of care are bundled for multiple providers,
coordination across specialties is encouraged54,
with improvements demonstrated in a Netherlands
bundled-payment initiative.55 Like capitation,
global payment could support the 4 Cs by enabling
investment in a strong primary care infrastructure.
Unfortunately, bundled payments can be difficult
to implement in primary care due to issues around
defining episodes of care. Although acute conditions like fractures and pregnancy have clearer beginning and end points, defining what constitutes a
chronic condition episode is more challenging, a
problem amplified in patients with multiple chronic
conditions. Furthermore, as a retrospectively triggered but prospectively defined fee, bundled payment shares some of the disadvantages of both FFS
and capitation. Though costs may be saved within
episodes, there is a financial incentive to increase
episodes, similar to FFS. Because financial incentives are predicated on savings, there may be a
disincentive to care for sicker patients.
Although Diagnosis Related Groups decrease
overall health care expenditures56, evidence for the
use of bundled payments in primary care is limited.
This was evaluated in a 2006 pilot, where none of
the primary care sites were able to implement the
model over 3 years due to challenges in defining an
episode and identifying and tracking included services based on FFS claims.57 Data from the Netherlands suggest no significant impact on quality58
;
otherwise there is a paucity of evidence for bundled
payment outside of an acute care setting.59 In summary, there is a lack of evidence on the impact of
bundled payments in primary care on the Quadruple Aim, possibly because the model may not be
applicable to that setting.
Shared Savings
Under shared savings, providers or an accountable
care organization (ACO) are responsible for the
costs and quality of care for a defined population
through the provision of a global budget.60 Most
often, the global budgets are calculated based on
expenditures from prior years and supplied by insurers as a risk-adjusted PMPM.61 Expenditures at
the end of 1 year are compared against a benchmark, which are also often calculated from expenditures from prior years. Risk arrangements can be
1-sided, where the ACO or equivalent group is
eligible for shared savings if their costs are below
the benchmark and they meet predetermined quality targets; or they can be 2-sided, where they are
also at risk of penalty if they exceed the benchmark.62 As with other global budget arrangements
(eg, capitation, bundled payment), the 2-sided arrangement shifts some financial risk from payers to
the ACO.
Our review of shared savings models found few
evaluations offering insights into their impact on
the 4 Cs. Like other models using global payments,
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shared savings theoretically allows ACOs to invest
upfront in a primary care infrastructure. Like bundled payment, because cost savings are shared
across provider groups, shared savings could improve coordination.63 Shared savings, as it has been
operationalized thus far, may present limitations
for primary care. First, because benchmarks are
often calculated from expenditures from previous
time periods, inefficient, high-spending providers
could be rewarded, while high-functioning, coordinated practices delivering comprehensive care
could receive comparably lower payments. Second,
due to the payment lag from distributing cost savings retrospectively at the end of the year, practices
may not be able to invest this money upfront in
services that deliver on primary care functions. Finally, despite being paid by a global budget, many
ACOs continue to reimburse their providers based
on FFS64,65, limiting both the effectiveness of the
model and the benefits reaped at the provider level.
The most significant data examining shared savings are the preliminary results of 2 CMMI initiatives: the Medicare Shared Savings Program
(MSSP; with results currently available for its third
performance year) and the Pioneer ACO (with results currently available for its fourth performance
year).
In 2015, 392 organizations participated in
MSSP; there were 12 participating organizations in
the Pioneer ACO program. Although 31% of
MSSP and Pioneer ACO practices earned shared
savings, the programs operated at a net loss of $216
million to CMS after accounting for bonus payments.66 The majority of quality measures improved in 2015.67 There was no significant correlation between quality performance and cost
savings in the MSSP.68 Cost savings were more
likely in ACOs that were smaller and physician-led
or integrated (physician-hospital partnership), had
been participating in the program longer, and had
higher benchmarks. As with many other programs,
although the ACO is paid through a global budget,
many providers continue to be paid via FFS.69,65
Hennepin Health, a safety-net ACO serving
Medicaid enrollees in Minnesota, is a partnership
between federally-qualified health centers, the
county hospital, the county health department, and
a nonprofit HMO.63 The ACO’s model centers
around interdisciplinary primary care teams, and
the flexibility of PMPM funds under the global
budget has been used to address a broader set of
patients’ needs, including behavioral health care
and social services. Early results demonstrate decreased emergency department (ED) visits improved quality of chronic disease care and high
patient satisfaction.63 Approximately $3 million in
savings over 3 years has been reinvested in interventions to meet social needs.63
Across the Quadruple Aim, shared savings seems
to have positive impacts on quality of care and
mixed results on costs; cost savings have been observed in particular when there is physician leadership in the ACO, the ACO has been in existence for
a longer period of time, and care coordination and
inclusion of nonmedical services are emphasized.
Continued FFS payments at the provider level may
limit benefits.
Blended FFS and Capitation
Capitated PMPM payments are given in addition
to FFS in the form of care management fees, care
coordination fees, or patient-centered medical
home (PCMH) payments in blended payment
models. These fees are intended to finance PCMH
infrastructure, staffing, and services not covered by
reimbursement for traditional office visits, particularly activities that coordinate care across the health
care system. These fees may be adjusted to diminish the risk of cherry-picking. By adjusting payment
systems that are already in place, blended FFS and
capitation may present fewer barriers to widespread
implementation than models that require systemic
overhaul.
The largest source of emerging evidence regarding impact of blended FFS and capitation in the
primary care setting comes from 2 large Medicare
demonstration projects: the Comprehensive Primary Care Initiative (CPCI) and the Multi-Payer
Advanced Primary Care Practice (MAPCP). In the
third year of CPCI, improvements in care access
and continuity were observed.70 The capitated
PMPM payments could allow practices to proactively invest in an infrastructure that supports primary care, and practices implementing risk-adjustment could guard against cherry-picking. As
capitation and FFS often have opposite effects,
blending the 2 models could mitigate the shortcomings of each; however, as the PMPMs supporting PCMH services are often disproportionately
smaller than FFS payments71, the incentive for
higher volumes of services may predominate.
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Results from the first 3 years of CPCI, encompassing 445 primary care practices, over 2100 providers, and nearly 2.9 million patients in 7 regions,
show practices have not yet achieved cost savings.72
Statistically significant reductions were noted in
expenditures for skilled nursing facilities (5%), primary care services (2%), and outpatient services
(2%). ED visits were significantly reduced in the
CPCI group, but decreases in hospitalization did
not reach statistical significance. However, after
including care management fees, Medicare expenditures increased by $7 PMPM more for CPCI
than comparison practices. Most quality of care
measures did not change, with the exception of
small improvements in some measures of diabetes
care quality and likelihood of ED revisit.
The MAPCP demonstration project started in
2011, involving 8 states, approximately 850 primary
care practices, over 6300 providers, and about
712,000 Medicare beneficiaries.70 In all 8 states,
Medicare, Medicaid, and private health plans are
participating. Preliminary results from the second
(with cost saving estimates) and third year are available for MAPCP. Only Michigan demonstrated
significant net savings after accounting for demonstration fees paid out to each state for MAPCP
participation. Significant heterogeneity in PMPM
payments exists among the MAPCP group, ranging
from $1.20 to $60.81.70
Quality outcomes and utilization for MAPCP
have been mixed. In the second year evaluation, 5
out of 8 states had some improvement in guidelinerecommended services for diabetes, while in 2
states these measures declined.70 Similarly, in 6 out
of 8 states, there were no significant differences
found in preventable hospitalizations; in 2 states,
there were increases observed.70 In the third year,
some commercial payers and Medicaid in New
York and Vermont reported reductions in hospitalizations and ED visits, with some payers finding
a decrease in total PMPM costs.
Other studies in our review found similarly
mixed Quadruple Aim outcomes for blended FFS
and capitation models.73,74,75,76 Commonalities
across more effective programs include being in
place for a longer period of time, multipayer alignment77, focusing on high-cost patients78,79,80,81,
and investing in population health data systems that
provide real-time information on health care
use.80,81,82 Some experts have suggested blended
FFS and capitation as a transition to fully global
budgets.83,84
Comprehensive Primary Care Payment
Like traditional capitation, under comprehensive
primary care payment, insurers provide a prospective payment to cover all primary care services
within a specific period of time (eg, PMPM).
Rather than basing capitated payments on historic
FFS reimbursements, these payments are calculated to account for the delivery of primary care
services and costs necessary to support medical
homes. To address cherry-picking, comprehensive primary care payments are risk-adjusted
based on patient complexity and include a component of P4P to address concerns about potential inappropriate under use of services. Furthermore, PCPs are financially responsible for primary
care expenditures rather than total costs, relieving
some of the financial risk seen in traditional capitation and transferring part of the risk to payers30
;
however, providers continue to maintain some financial accountability.
Relatively little evidence exists for the impact of
comprehensive primary care payment on the Quadruple Aim or the 4 Cs. Like other prospective
models, the model allows for flexible, proactive
investments in a primary care infrastructure that
could support the 4 Cs. Unlike traditional capitation, however, the risk-adjustment of comprehensive primary care payment may guard against
cherry-picking and continue to facilitate access
for high-complexity patients. Although the capitated model could hinder comprehensive care by
incentivizing underdelivery of services, linkages to
quality of care in this model through P4P, if appropriate measures for primary care are employed,
could hypothetically guard against inappropriate
underdelivery of care.
Most of the evidence on comprehensive primary
care payment comes from Iora Health4
, a national
network of primary care practices, which receives a
fixed, risk-adjusted PMPM from large self-insured
employers, unions, or insurers, and incorporates
additional payments for meeting quality or use targets.85,86 Ten percent of the total cost of care is
invested in primary care services, roughly doubling
4
Iora Health has also opened one DPC practice; a second
DPC practice, Turntable Health, closed in January 2017.
doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 597
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the percentage the US health care system spends
on primary care.87 These primary care investments
enable Iora to redesign care delivery, such as increasing access (eg, same-day appointments, e-mail
contacts) and comprehensiveness (eg, personal
health coaches).90 Furthermore, the group developed its own electronic health record to enhance
quality monitoring and performance feedback.
There have not been independent evaluations of
outcomes, but Iora reports increased patient and
provider satisfaction, improvements in blood pressure and HbA1c, a 12.3% decrease in health care
expenditures, a 48% reduction in ER visits, and a
41% reduction in inpatient admissions.85,88
Direct Primary Care (DPC)
DPC has emerged as a model outside of the insurance system attempting to reorganize both the delivery and payment of health care to enable the
primary care function.4 In DPC, patients pay the
provider directly, without third-party billing; definitions vary on whether or not employers paying
providers directly also fall under this model. Patients are charged a fixed, age-adjusted monthly fee
for all their primary care, independent of preexisting medical conditions.89 Common ancillary services are generally provided as part of the monthly
fee, including on-site lab tests, x-rays, and electrocardiograms.
There is limited evidence on the potential impact of DPC on specific primary care functions.
DPC providers have increased visit lengths (typically 30 minutes to 60 minutes per visit), which
could support coordination of care and allow for
greater comprehensiveness.90 Decreased volume of
face-to-face visits has increased time for access via
e-mail and telephone communications.91 As with
other prospective payment models not linked to
volume, DPC grants practices the flexibility to invest revenue in nonvisit-based services that support
primary care.
Some concerns have emerged about the ways
DPC could inhibit the 4 Cs. First, there is the
potential for high cost-sharing90, as the DPC fee
covers only outpatient primary care services. Second, DPC may limit access for individuals of lower
socioeconomic status, although DPC groups have
explored arrangements with Medicaid to cover
these patients (by definition, however, this would
no longer constitute a DPC payment arrangement).89 Because DPC panels are one-fifth the size
of non-DPC providers, there are concerns that
expanding the model would decrease access by
compounding the PCP shortage.90
Like comprehensive primary care, few studies
exist that examine the impact of DPC on the
Quadruple Aim. Most of the available evidence
comes from Qliance, a Seattle-based DPC network. Qliance reported 35% fewer hospitalizations, 65% fewer ED visits, and 66% fewer specialist visits.92 In addition, they estimated cost
savings of 19.6% per patient per year and scored at
the 95th percentile for patient experience.93
Qliance recently closed its doors due to financial
difficulties, raising concerns about the financial sustainability of DPC, although this may be related to
efforts to rapidly scale the model.
Discussion
Our review identified 8 distinct payment models
which differentially shape primary care delivery in
the United States: FFS, traditional capitation, P4P,
bundled payment, shared savings, blended FFS and
capitation, comprehensive primary care payment,
and DPC; many payers use combinations of these
models. Each model is currently in various stages of
implementation, with significantly less evidence
available for newer models.
Few studies examined the impact of payment
models on the 4 Cs of primary care. Nonetheless,
several key characteristics were consistently noted.
First, payment models can be viewed along a spectrum from FFS (retrospective) to capitated (prospective) payment. Whereas retrospective payment
may incentivize the delivery of services, prospective
payments offer flexibility for primary care practices
to invest in services and infrastructure that can
enhance the 4 Cs, such as nursing follow-up calls to
enhance coordination, same-day appointments to
improve access, and integrated behavioral health
for more comprehensive care. Second, because
capitated models may encourage adverse selection
and underdelivery of appropriate services, risk-adjustment may be used to preserve the primary care
attributes of access and comprehensive care, respectively. Third, P4P has been used as a bonus to
5
DPC differs from concierge medicine in that concierge
practices continue to bill insurance for services, but also
charge a retainer (usually annually, and significantly higher
than DPC payments) to patients.
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incentivize quality; however, measures are largely
disease-oriented and generally do not assess the
tenets of primary care or patient-centered outcomes. Finally, newer payment models have prioritized sufficient funds to support primary care services that uphold the 4 Cs, but inpatient and
specialty services are paid for separately. Although
in a prospective payment model this may reduce
the financial risk to providers, ongoing research
will be needed to assess whether doing so limits
coordination (eg, incentives not aligned across primary care and specialty care, or inpatient and outpatient settings). Studies that examine the role of
and optimal payment for PCMHs within ACOs
may be particularly useful.94
These principles, and the evidence available for
payment models, provide cross-cutting lessons that
guide the following recommendations for the future of primary care payment.
Implement and Research Payment Models Based in
PMPMs for Primary Care
Despite the shift from volume to value, FFS remains the dominant model95 As the United States
transitions away from FFS, more primary care payment models based in prospective payment should
be implemented. The most promising evidence
across the Quadruple Aim came from comprehensive primary care payment and DPC. Both models
use prospective fees that allow practices to tailor
services to the needs of their communities and
proactively implement a primary care infrastructure supporting the 4 Cs. However, evidence for
both models is generally lacking, so ongoing research is critical. Recently, the Physician-Focused
Payment Model Technical Advisory Committee
recommended testing the American Academy of
Family Physicians’ proposed Advanced Primary
Care APM. This primary care payment model includes a risk-adjusted PMPM along with P4P (essentially, comprehensive primary care payment)
that could impact 30 million Medicare patients.96
Risk-Adjusted Payments to Ensure Access for All
Populations to Primary Care
Risk-adjusted payments can protect against cherrypicking healthier patients that negatively impacts
access and also decreases financial risk to providers,
which could improve satisfaction. It is difficult to
assess the impact of risk-adjustment alone however,
as it is a single component of a more complex
model, and significant heterogeneity exists in how
payments are risk-adjusted. Nonetheless, several
risk-adjusted payment models in our review
found decreased health care costs/use for highneeds, high-using populations.97,98,99,80,100 More
research is needed to validate risk-adjustment
tools.101
Broaden Investments in Primary Care to Include
Behavioral Health and Social Services
One safety-net ACO in our review supporting
comprehensive care inclusive of social and behavioral needs demonstrated significant promise.
CMS’s Accountable Health Communities demonstration project provides another opportunity to
research the effect of varying levels of medicalsocial services partnerships on costs and use.102
This initiative aims to connect medical and social
services by creating a community-based system that
identifies social barriers to health in the clinical
setting and enables referrals to appropriate community services.103 More research of similar models is needed to understand how data, costs, and
risks can be shared across a truly integrated medical-social neighborhood.
Connect Payments to Performance on PatientCentered and Primary Care-Centered Metrics
P4P studies in our review demonstrated inconsistent and mixed results on the Quadruple Aim and
the 4 Cs. The overwhelming majority of quality
metrics are disease-oriented measures, and the
remaining measures largely focused on process
measures and adherence to evidence-based
guidelines104, rather than health outcomes.105
We recommend, as Dr. Starfield did in response
to the QOF, connecting payments to metrics that
capture how well a practice delivers the 4 Cs and
improve patient-centered outcomes, to better account for multimorbidity and the contexts of patients’ lives.106
Both the complexity of primary care and the
administrative burden of measurement stand as
barriers to adequately evaluating the 4 Cs.107 Already, the health care system pays $15.4 billion
annually to measure quality metrics.108 Early
brightspots exist in evaluating some of the attributes of primary care, such as continuity109, comprehensiveness110, and contact111, as well as patient-centered outcomes19, but much more work
remains in developing those measures and confirmdoi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 599
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ing their validity across various populations.112 We
support the recommendations of others for more
research to create metrics that effectively measure
primary care113, health information technology to
capture those metrics114, and a national organization that validates, disseminates, and implements
these measures.115
Rapid Dissemination and Research is Necessary in
Emerging Primary Care Payment Models
Our review revealed several remaining areas for
research in primary care payment. Evidence is particularly limited regarding provider satisfaction and
comprehensiveness, and the emerging primary care
payment models (eg, comprehensive primary care,
DPC) lack independent evaluation of their impact
on the Quadruple Aim. Furthermore, the majority
of models in our review demonstrated mixed results, pointing to the need for ongoing research in
variation of Quadruple Aim outcomes within each
model that could elucidate which factors (eg, clinical characteristics/settings, payer characteristics,
variations in payment amounts) most impact outcomes, and accounting for how payment impacts
delivery of care.
Limitations
As a narrative review, our search may not have
captured all the relevant evidence. Similarly, a quality assessment was not conducted, although articles
with higher levels of evidence (eg, systematic reviews) were prioritized. Furthermore, our recommendations were guided by seminal examples of
these models of the main payment models represented in US health care, rather than strictly
through randomized control trials, which do not
exist for the majority of the models reviewed.
Given this, as well as significant heterogeneity in
study design, populations, delivery settings, and
metrics evaluated, standard quantitative summary
methods were not possible. Finally, although our
review focused on payment models, significant heterogeneity in the delivery and services stemming
from the payment structure is a possible confounder to interpreting our results; however,
changes in payment enable changes in delivery, and
in many instances, it may be difficult to separate
their effects.
Conclusion
Evidence from Starfield and others2–15 supports the
central role of primary care in high-performing
health systems and the achievement of population
health goals. Effective payment for primary care
delivery, supportive of the 4 Cs, can lead to achieving the Quadruple Aim. Findings from this review
can help guide future implementation and research
efforts to successfully shift away from a FFS model
that has inhibited primary care. MACRA, through
its support of APMs, as well as a host of multipayer
initiatives such as the CMMI’s Comprehensive Primary Care Plus demonstration project and the
American Academy of Family Physicians’s Advanced Primary Care APM, signal an opportunity
for the US health care system to continue the
transition from volume-based to value-based
care. Increasing investments into primary care is
necessary but not sufficient for improving health
care; how we invest in a comprehensive primary
care infrastructure—spanning health care delivery, research, practice transformation support,
and HIT—to evolve how care is both delivered
and measured will be critical.
The authors gratefully acknowledge the support of Family Medicine for America’s Health, along with the additional sponsors of
the Starfield Summit, the Pisacano Leadership Foundation, and
the American Board of Family Medicine.
To see this article online, please go to: http://jabfm.org/content/
31/4/588.full.
References
1. World Health Organization. Declaration of Alma-Ata. International Conference on Primary
Health Care, Alma-Ata, USSR, 6 –12. September
1978. Available from: URL: http://www.who.int/
publications/almaata_declaration_en.pdf.
2. Starfield B, Shi L. Policy relevant determinants of
health: an international perspective. Health Policy
2002;60:202–21.
3. Shi L, Macinko J, Starfield B, Politzer R, Xu J.
Primary care, race, and mortality in U.S. states.
Social science & medicine 2005;61:65–75.
4. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q
2005;83:457–502.
5. Kringos DS, Boerma WG, Hutchinson A, van der
Zee J, Groenewegen PP. The breadth of primary
care: a systematic literature review of its core dimensions. BMC Health Serv Res 2010;10:65.
6. Friedberg MW, Hussey PS, Schneider EC. Primary care: a critical review of the evidence on qual600 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org
on 24 February 2022 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Med: first published as 10.3122/jabfm.2018.04.170388 on 9 July 2018. Downloaded from
ity and costs of health care. Health Aff 2010;29:
766 –72.
7. Shi L. The impact of primary care: a focused review. Scientifica 2012.
8. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family physicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med 2015;13:206 –13.
9. Organization for Economic Co-operation and Development (2014). OECD health data 2014: how
does the United States compare? The Organization
for Economic Co-operation and Development.
Paris, France. Available from: http://www.oecd.
org/unitedstates/BriefingNoteUSA2014.pdf. Published
2014. Accessed March 4, 2016. Available from: http://
www.oecd.org/unitedstates/Briefing-Note-UNITEDSTATES-2014.pdf.
10. Berwick DM, Hackbarth AD. Eliminating waste in
U.S. health care. JAMA 2012;307:1513– 6.
11. Mossialos E, Wenzl M, Osborn R, Anderson C.
International profiles of health care systems, 2014.
New York (NY): The Commonwealth Fund; 2015.
12. National Research Council, Institute of Medicine.
US Health in international perspective: shorter
lives, poorer health. Washington, DC: National
Academies Press; 2013.
13. The Institute of Medicine. U.S. health in international perspective: shorter lives, poorer health. Washington, DC: The National Academies Press; 2013.
14. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the
provider. Ann Fam Med 2014;12:573– 6.
15. Woolf SH, Aron LY. The US health disadvantage
relative to other high-income countries: findings
from a National Research Council/Institute of
Medicine report. JAMA 2013;309:771–2.
16. Phillips RL Jr., Bazemore AW. Primary care and
why it matters for US health system reform. Health
Aff (Millwood) 2010;29:806 –10.
17. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult
primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007;22:410 –5.
18. World Health Organization (WHO). Health system financing. Geneva: WHO; 2010. P. 72–5.
19. Rollow W, Cucchiara P. Achieving value in primary
care: the primary care value model. Ann Fam Med
2016;14:159 – 65.
20. Patient Protection and Affordable Care Act, 42
U.S.C. § 18001; 2010.
21. Davis K, Abrams M, Stremikis K. How the Affordable Care Act will strengthen the nation’s primary
care foundation. J Gen Intern Med 2011;26:1201.
22. Center for Medicare & Medicaid Services. About
the CMS Innovation Center. Available from: https://
innovation.cms.gov/About/index.html. Published
2015. Accessed March 30, 2016.
23. Centers for Medicare & Medicaid Services (CMS).
Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment
Model (APM) incentive under the physician fee
schedule, and criteria for physician-focused payment models. Final rule with comment period. Federal register 81.214 (2016): 77008. Available from:
https://www.federalregister.gov/documents/2016/11/
04/2016 –25240/medicare-program-merit-basedincentive-payment-system-mips-and-alternativepayment-model-apm. Accessed January 06, 2018.
24. Stange KC, Nutting PA, Miller WL, et al. Defining
and measuring the patient-centered medical home.
J Gen Intern Med 2010;25:601–12.
25. Doohan N, Coutinho AJ, Lochner J, Wohler D,
DeVoe J. “A Paradox Persists When the Paradigm
Is Wrong”: Pisacano scholars’ reflections from the
inaugural Starfield Summit. J Am Board Fam Med
2016;29:793– 804.
26. Grant MJ, Booth A. A typology of reviews: an
analysis of 14 review types and associated methodologies. Health Info Libr J 2009;26:91–108.
27. Goodson JD. Unintended consequences of resource-based relative value scale reimbursement.
JAMA 2007;298:2308 –10.
28. Sinksy CA, Dugdale DC. Medicare payment for
cognitive vs procedural care: minding the gap.
JAMA Intern Med 2013;173:1733–7.
29. Miller HD. From volume to value: better ways to
pay for health care. Health Aff 2009;28:1418 –28.
30. Draper DA, Hurley RE, Lesser CS, Strunk BC.
The changing face of managed care. Health Aff
2002;21:11–23.
31. Rice N, Smith PC. Capitation and risk adjustment
in health care financing: an international progress
report. Milbank Q 2001;79:81–113.
32. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment
of Medicare capitation payments using the CMSHCC model. Health Care Financ Rev 2004;25:119.
33. Miller RH, Luft HS. HMO plan performance update: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.
34. Llanos K, Rothstein J. Physician pay-for-performance in Medicaid: a guide for states. Center for
Health Care Strategies, Incorporated; 2007.
35. Miller RH, Luft H S. HMO plan performance
update: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.
36. Miller RH, Luft HS. Does managed care lead to better
or worse quality of care? Health Aff 1997;16:7–25.
37. Berwick DM. Payment by capitation and the quality of care. N Engl J Med 1996;335:1227–31.
38. Miller RH, Luft HS. HMO plan performance update: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.
39. Llanos K, Rothstein J. Physician pay-for-performance in Medicaid: a guide for states. Center for
Health Care Strategies, Incorporated 2007.
doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 601
on 24 February 2022 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Med: first published as 10.3122/jabfm.2018.04.170388 on 9 July 2018. Downloaded from
40. Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the
quality and outcomes framework—a systematic review. Ann Fam Med 2012;10:461– 8.
41. Roland M, Campbell S. Successes and failures of
pay for performance in the United Kingdom.
N Engl J Med 2014;370:1944 –9.
42. Doran T, Kontopantelis E, Valderas JM, et al.
Effect of financial incentives on incentivized and
non-incentivised clinical activities: longitudinal
analysis of data from the UK Quality and Outcomes
Framework. BMJ 2011;342:d3590.
43. Starfield B, Mangin D. An international perspective
on the basis of pay-for-performance. The Quality
and Outcomes Framework: QOF-Transforming
General Practice 2016;147.
44. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family physicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med, 2015;13:206 –13.
45. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early
experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788 –93.
46. Lemak CH, Nahra TA, Cohen GR, et al. Michigan’s fee-for-value physician incentive program reduces spending and improves quality in primary
care. Health Aff 2015;34:645–52.
47. Scott A, Sivey P, Ait Ouakrim D, et al. (2011). The
effect of financial incentives on the quality of health
care provided by primary care physicians. Cochrane
Database Syst Rev 2011:9.
48. Eccles MP, Shepperd S, Scott A, Flodgren G, Parmelli E, Beyer FR. An overview of reviews evaluating the effects of financial incentives in changing
healthcare professional behaviours and patient outcomes. The Cochrane Library; 2010.
49. Nelson, L. Lessons from Medicare’s demonstration
projects on value-based payment. Congressional
Budget Office, Working Paper, 2012;2.
50. Marshall L, Charlesworth A, & Hurst J. The NHS
payment system: evolving policy and emerging evidence. London: The Nuffield Trust; 2014.
51. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of
financial incentives on the quality of health care
provided by primary care physicians. Cochrane Database Syst Rev 2011;9(9).
52. Mittelstaedt TS, Mori M, Lambert WE, Saultz JW.
Provider practice characteristics that promote interpersonal continuity. J Am Board Fam Med 2013;
26:356 – 65.
53. Roland M, & Guthrie B. Quality and outcomes framework: what have we learnt? BMJ 2016;354:i4060.
54. de Bakker DH, Struijs JN, Baan CA, et al. Early
results from adoption of bundled payment for diabetes care in the Netherlands show improvement in
care coordination. Health Aff 2012;31:426 –33.
55. de Bakker DH, Struijs JN, Baan CB, et al. Early
results from adoption of bundled payment for diabetes care in the Netherlands show improvement in
care coordination. Health Aff (Millwood) 2012;31:
426 –33.
56. Bertko, J, Effros, R. Analysis of Bundled Payment.
RAND Health COMPARE. Available from: http://
www.rand.org/pubs/technical_reports/TR562z20/
analysis-of-bundled-payment.html. Published 2010.
Accessed March 9, 2016.
57. Hussey PS, Ridgely MS, Rosenthal MB. The PROMETHEUS bundled payment experiment: slow
start shows problems in implementing new payment models. Health Aff 2011;30:2116 –24.
58. Wesselink SFO, Lingsma HF, Ketelaars CAJ,
Mackenbach JP, Robben PBM. Effects of government supervision on quality of integrated diabetes
care: a cluster randomized controlled trial. Med
Care 2015;53:784 –91.
59. Wojtak A, Purbhoo D. Perspectives on advancing
bundled payment in Ontario’s home care system
and beyond. Healthcare Q 2015;18:18 –25.
60. Hayen AP, van den Berg MJ, Meijboom BR, Struijs
JN, Westert GP. Incorporating shared savings programs into primary care: from theory to practice.
BMC Health Serv Res 2015;15:580.
61. Hayen AP, van den Berg MJ, Meijboom BR, Struijs
JN, Westert GP. Incorporating shared savings programs into primary care: from theory to practice.
BMC Health Serv Res 2015;15:580.
61. Barnes AJ, Unruh L, Chukmaitov A, van Ginneken
E. Accountable care organizations in the USA:
types, developments and challenges. Health Policy
2014;118:1–7.
63. Sandberg SF, Erikson C, Owen R, et al. Hennepin
Health: a safety-net accountable care organization
for the expanded Medicaid population. Health Aff
2014;33:1975– 84.
64. Goroll AH, Schoenbaum SC (2012). Payment reform for primary care within the accountable care
organization: a critical issue for health system reform. JAMA 2012;308:577– 8.
65. Muhlestein DB, Croshaw AA, Merrill T P (2013).
Risk bearing and use of fee-for-service billing
among accountable care organizations. Am J Manag
Care 2013;19:589 –92.
66. Jha, A. ACO winners and losers: a quick take. The
Health Care Blog. Available from: http://thehealth
careblog.com/blog/2016/08/30/aco-winners-andlosers-a-quick-take/. Published August 30, 2016.
Accessed December 3, 2016.
67. Medicare ACOs: incremental progress, but performance varies. Available from: http://healthaffairs.
org/blog/2016/09/21/medicare-acos-incrementalprogress-but-performance-varies/. Published September 21, 2016. Accessed December 03, 2016.
68. Medicare ACOs: incremental progress, but performance varies. Available from: http://healthaffairs.
org/blog/2016/09/21/medicare-acos-incremental602 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org
on 24 February 2022 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Med: first published as 10.3122/jabfm.2018.04.170388 on 9 July 2018. Downloaded from
progress-but-performance-varies/. Published September 21, 2016. Accessed December 03, 2016.
69. Goroll AH, Schoenbaum SC. Payment reform for
primary care within the accountable care organization: a critical issue for health system reform. JAMA
2012; 308:577– 8.
70. RTI International. Evaluation of the multi-payer
advanced primary care practice (MAPCP) demonstration, third annual report. Available from:
https://downloads.cms.gov/files/cmmi/mapcpthirdevalrpt.pdf. Published 2016. Accessed January
30, 2017.
71. Merrell K, Berenson RA. Structuring payment for
medical homes. Health Aff 2010;29:852– 8.
72. Peikes D, Swankoski K, Mutti A,et al. Evaluation of
the Comprehensive Primary Care initiative: third
annual report. Available from: https://innovation.
cms.gov/Files/reports/cpci-evalrpt3.pdf. Published
2016. Accessed January 30, 2017.
73. Werner RM, Duggan M, Duey K, Zhu J, Stuart
EA. The patient-centered medical home: an evaluation of a single private payer demonstration in
New Jersey. Med Care 2013;51:487–93.
74. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medicare coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.
75. Lemak CH, Nahra TA, Cohen GR, et al. Michigan’s fee-for-value physician incentive program reduces spending and improves quality in primary
care. Health Aff 2015;34:645–52.
76. Jabbarpour Y, DeMarchis E, Bazemore A, Grundy
P. The impact of primary care practice transformation on cost, quality, and utilization: a systemic
review of research published in 2016. Patient-Centered Primary Care Collaborative July, Washington, DC; 2017.
77. Nielsen M, Buelt L, Patel K, Nichols LM. The
Patient-Centered Medical Home’s impact on cost
and quality: annual review of the evidence 2014 –
2015. Patient-Centered Primary Care Collaborative, Washington DC; 2016.
78. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medicare coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.
79. Fillmore H, DuBard CA, Ritter GA, Jackson CT.
Health care savings with the patient-centered medical home: community care of North Carolina’s
experience. Popul Health Manag 2014;17:141– 8.
80. Koshy RA, Conrad DA, Grembowski D. Lessons
from Washington state’s medical home payment
pilot: what it will take to change American health
care. Popul Health Manag 2015;18:237– 45.
81. Phillips RL, Han M, Petterson SM, Makaroff LA,
Liaw WR. Cost, utilization, and quality of care: an
evaluation of Illinois’ Medicaid primary care case management program. Ann Fam Med, 2014;12:408–17.
82. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medicare coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.
83. Goroll A, Bagley B, Harbrecht M, Kirschner N,
Kenkeremath N. Payment reform to support highperforming practice. Report of the Payment Reform Task Force of the Patient-Centered Primary
Care Collaborative. Washington, DC: PatientCentered Primary Care Collaborative; 2010.
84. Goroll AH. Payment reform to support lasting
practice reform in primary care. J Ambul Care
Manage 2011;34:33–7.
85. Fernandopulle R. Learning to fly: building de novo
medical home practices to improve experience, outcomes, and affordability. J Ambul Care Manage
2013;36:121–5.
86. Fernandopulle, R. Breaking the fee-for-service addiction: let’s move to a comprehensive primary care
payment model. Health Affairs Blog. Available
from: http://healthaffairs.org/blog/2015/08/17/
breaking-the-fee-for-service-addiction-lets-moveto-a-comprehensive-primary-care-payment-model/.
Published August 17, 2015. Accessed March 10, 2016.
87. Phillips RL, Bazemore AW. Primary care and why
it matters for US health system reform. Health Aff
2010;29:806 –10.
88. Fernandopulle, R. To cure physician burnout, unburden doctors. AthenaInsight. Available from:
https://www.athenahealth.com/insight/to-curephysician-burnout-unburden-doctors/. Published 2016.
Accessed February 13, 2018.
89. Wu WN, Bliss G, Bliss EB, Green LA. A direct
primary care medical home: the Qliance experience. Health Aff 2010;29:959 – 62.
90. McCorry D. Direct primary care: an innovative
alternative to conventional health insurance. Backgrounder 2014;2939:1–13.
91. Wu WN, Bliss G, Bliss EB, Green L. A. A direct
primary care medical home: the Qliance experience. Health Aff 2010;29:959 – 62.
92. Page L. The rise and further rise of concierge
medicine. BMJ 2013;347:f6465.
93. Qliance. Direct primary care model delivers 20
percent lower overall healthcare costs, increases patient satisfaction and delivers better care. PRNewswire. Available from: http://www.prnewswire.com/
news-releases/new-primary-care-model-delivers20-percent-lower-overall-healthcare-costs-increasespatient-satisfaction-and-delivers-better-care300021116.html. Published January 15, 2015. Accessed March 11, 2015.
94. Edwards ST, Abrams MK, Baron RJ, et al. Structuring payment to medical homes after the Affordable Care Act. J Gen Intern Med 2014;29:1410 –3.
95. Zuvekas SH, Cohen J. W. Fee-for-service, while much
maligned, remains the dominant payment method for
physician visits. Health Aff 2016;35:411–4.
doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 603
on 24 February 2022 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Med: first published as 10.3122/jabfm.2018.04.170388 on 9 July 2018. Downloaded from
96. The American Academy of Family Physicians.
Advanced primary care: a foundational alternative payment model (APC-APM) for delivering
patient-centered, longitudinal, and coordinated
care. Available from: https://www.aafp.org/dam/
AAFP/documents/advocacy/payment/apms/PRPTAC-APC-APM-41417.pdf. Published April 14,
2017. Accessed January 22, 2018.
97. Sandberg SF, Erikson C, Owen R, et al. Hennepin
Health: a safety-net accountable care organization
for the expanded Medicaid population. Health Aff
2014;33:1975– 84.
98. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medicare coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.
99. Fillmore H, DuBard CA, Ritter GA, Jackson CT.
Health care savings with the patient-centered medical home: community care of North Carolina’s
experience. Popul Health Manage 2014;17:141– 8.
100. Phillips RL, Han M, Petterson SM, et al. Cost,
utilization, and quality of care: an evaluation of
Illinois’ Medicaid primary care case management
program. Ann Fam Med 2014;12:408 –17.
101. Thomas JW, Grazier KL, Ward K. (2004). Economic Profiling of Primary Care Physicians: Consistency among Risk-Adjusted Measures. Health
Serv Res 2004;39:985–1004.
102. Center for Medicare & Medicaid Services. Accountable health communities model. Available
from: https://innovation.cms.gov/initiatives/ahcm/.
Published February 17, 2017.
103. Alley DE, Asomugha CN, Conway PH, Sanghavi
DM. Accountable health communities—addressing
social needs through Medicare and Medicaid.
N Engl J Med, 2016;374:8 –11.
104. Porter ME, Larsson S, Lee TH. Standardizing patient outcomes measurement. N Engl J Med 2016;
374:504 – 6.
105. Casalino LP, Gans D, Weber R, et al. US physician
practices spend more than $15.4 billion annually to
report quality measures. Health Aff 2016;35:401– 6.
106. Starfield B, Mangin D. An international perspective
on the basis of pay-for-performance. The Quality
and Outcomes Framework: QOF-Transforming
General Practice, 2016;147.
107. O’Malley AS, Rich EC, Maccarone A, DesRoches
CM, Reid RJ. Disentangling the linkage of primary
care features to patient outcomes: a review of current literature, data sources, and measurement
needs. J Gen Intern Med 2015;30:576 – 85.
108. Casalino LP, Gans D, Weber R, et al. US physician
practices spend more than $15.4 billion annually to
report quality measures. Health Aff 2016;35:401– 6.
109. Saultz JW. Defining and measuring interpersonal
continuity of care. Ann Fam Med 2003;1:134 – 43.
110. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family physicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med 2015;13:206 –13.
111. Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics
and emergency department use in a Medicaid managed care organization. Med Care 2005;43, 792–
800.
112. O’Malley AS, Rich EC, Maccarone A, DesRoches
CM, Reid RJ. Disentangling the linkage of primary
care features to patient outcomes: a review of current literature, data sources, and measurement
needs. J Gen Intern Med 2015;30:576 – 85.
113. Stange KC, Nutting PA, Miller WL, et al. Defining
and measuring the patient-centered medical home.
J Gen Intern Med 2010;25:601–12.
114. Anderson KM, Marsh CA, Flemming AC, Isenstein
H, Reynolds J. Quality measurement enabled by
health IT: overview, possibilities, and challenges.
Rockville (MD): Agency for Healthcare Research
and Quality; 2012.
115. Berenson RA, Pronovost PJ, Krumholz HM.
Achieving the potential of health care performance
measures. Princeton (NJ): Robert Wood Johnson
Foundation; 2013.
604 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org
on 24 February 2022 by guest. Protected by copyright. http://www.jabfm.org/ J Am Board Fam Med: first published as 10.3122/jabfm.2018.04.170388 on 9 July 2018. Downloaded from

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