Global payments create strong incentives for transforming the way health care is organized and delivered. While episode-based, fee-for-service reimbursement tends to encourage fragmented care, global payments can liberate providers to focus on delivering integrated, coordinated care that is more effective and efficient.

In order for provider organizations to succeed with global payments, however, they require systems, tools, and resources that enable them to manage costs and improve quality, both for individual patients and for the entire population of patients for whom they accept financial risk. For example:

• Organizational culture: Transforming provider organizations requires strong physician leadership and a commitment to engagement, collaboration, peer-to-peer feedback, and data-driven quality improvement. On the business side, groups need new and different administrative and financial management resources.
• Data reporting and analysis: Provider groups have to be able to use insurer and provider data for tracking cost and utilization trends, finding unexplained variations in practice among providers, and identifying patients who would benefit from outreach or care management.
• Medical management: Groups will need to employ or contract with disease management specialists, case managers, clinical pharmacists, social workers, and other clinicians to offer programs that improve outcomes for their patients, along the entire continuum of care.
• Health information: Ideally, providers should have easy access to a complete picture of their patients' diagnoses, treatments and follow-up, wherever they occur. At Atrius Health, for example, all of our sites use electronic medical records that include medical histories, encounter and medication records, e-prescribing, order-entry capabilities, and access to evidence-based clinical guidelines, to enable more coordinated and reliable care.

Caring for the "Whole Patient"

With the right systems, tools and resources in place, global payments can stimulate positive changes in many aspects of medical practice. Providers are better able to focus on improving the health of the “whole patient” rather than simply on what happens during office visits or other individual episodes of care. For example:

• Reaching into the space between visits: Much of what most affects people's health occurs, not in the doctor's office, but in the home, the workplace, the community – all the places where we make decisions that protect us from, or put us at risk for, chronic conditions, infectious disease, and injury. With global payments, providers can offer programs that don't rely on traditional, reimbursable office encounters. Web-based support, e-mail exchanges and in-home monitoring are just a few examples of how clinicians can influence patients where life is actually being lived – in the "space between visits.”
• Managing transitions of care: Research confirms that some of the best opportunities to reduce waste and improve patient safety can be found in the “hand-offs” that take place across medical specialties and between clinicians – from primary care physician to specialist to hospital to home, for instance. Global payments reward providers for planning and ensuring safe and efficient transitions of patient care. Fee-for-service payments, on the other hand, provide no incentive for planning transitions and rewards poor quality (avoidable office visits or hospital readmissions) with payment.
• Focusing on high-risk, high-cost patients: Global payments also make it easier for provider groups to care for high-risk patients with chronic conditions and complex medical needs by using interventions and care management services that would not normally be reimbursed under fee-for-service.
• Becoming patient-centered: Global payments, especially when they are linked to quality incentives that include patients' assessments of the care experience, encourage “patient-centered care” that respects patients' needs and preferences and that helps them to make decisions about, and participate in, their own care.

Well-designed global payment systems reward provider organizations for making long-term investments in developing the infrastructure, organizational capacity, and clinical programs that support these kinds of practice improvements.

October 7, 2009

This article is for general information purposes only and is not intended as legal or other professional advice. ©Atrius Health. All Rights Reserved.

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PRIOR ISSUES
Part 1: Introduction

Part 2: How Payments and Quality Incentives Are Determined

IN THE NEWS
Gene Lindsey, MD, President & CEO of Atrius Health, offers his perspective on payment reform.

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