Abstract
BackgroundUpcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.MethodsWe performed a cross-sectional analysis of visits in the United States’ National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.ResultsAbout 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.ConclusionsPractices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.
Highlights
Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incor‐ porate capitated payments for chronic disease management
While the associations found in this study do not necessarily indicate causation, we find important differences in chronic disease quality of care by reimbursement type that complements prior literature
We found that Angiotensin converting enzyme inhibitor (ACEi)/ Angiotensin receptor blocker (ARB) use and statin use were suboptimal across practice reimbursement types, and dedicated quality measures for these medications tied to financial incentives should be considered in PCF and KCC
Summary
Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incor‐ porate capitated payments for chronic disease management. In the context of the Coronavirus Disease 2019 (COVID-19) pandemic, capitated payments provide a consistent revenue stream, leaving physician practices less financially vulnerable to decreases in visit volumes [10]. Two voluntary payment models through the Center for Medicare & Medicaid Innovation (CMMI) feature capitated payments as a central component: Primary Care First (PCF) [11] and Kidney Care Choices (KCC) [12]. In addition to a flat FFS primary care visit fee, PCF provides a capitated per beneficiary per month payment, tiered according to the average level of comorbidities in the practice. KCC provides a capitated payment quarterly to nephrology practices for aligned beneficiaries with CKD Stages 4 and 5
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