Interview: Behind WellPoint's $1B primary care initiative

Dina Overland

Dina Overland

WellPoint recently launched a major new initiative to increase reimbursement for primary care physicians who keep patients healthier and lower costs. The insurer is investing $1 billion to increase doctors' fees by about 10 percent and pay them for services that currently aren't covered. To learn more about the decisions driving WellPoint's new primary care program and goals for the program, FierceHealthPayer turned to Jill Hummel, WellPoint's vice president of payment innovation.

FierceHealthPayer: What motivated WellPoint to make such a large investment in primary care? Are there specific goals you hope to achieve as a result of the increased doctor payments?

Jill Hummel

Jill Hummel

Jill Hummel: As the healthcare benefits company for over 34 million people--1 in 9 Americans--we feel obligated to drive the solutions that can transform the current system to a patient-centered care model that promotes coordinated care across the continuum, disease management for patients with chronic conditions, wellness and prevention and, importantly, shared-decision making and accountability with patients and their caregivers.

We know that primary care physicians are uniquely positioned and anxious to provide this type of patient-centered care. However, by 2020, it is predicted that our country will have a shortage of more than 40,000 primary care physicians. [Source: American Academy of Family Physicians]. Therefore, if we want to drive improvements in health status and affordability through a patient-centered primary care model, we need to improve primary care access and effectiveness.

FHP: How does Wellpoint intend to improve access and effectiveness?

JH: Our program is designed to do that in a number of ways. First and foremost, we do that by helping to make primary care a specialty that is rewarding, both financially and professionally. Financially rewarding because we appropriately compensate primary care physicians for the service and value they deliver to our members. Professionally rewarding because we give primary care physicians more tools to be the kind of physicians they went to medical school to become. This includes payment for important clinical services that occur outside of a traditional office visit, meaningful and actionable information that helps them identify and manage their high-risk or chronic patients, and education and clinical support for the care planning they do with those patients.

All of these tools enable physicians to improve the health status of their patients by reducing or eliminating gaps in care and empowering them to manage their patients' care across the delivery system. And this in turn will improve affordability of healthcare by reducing the cost associated with avoidable ER visits, admissions and readmissions. So our goals for this program are big but simple: to improve patient health and healthcare affordability through increased access to primary care physicians who are best equipped to deliver patient-centered care.

FHP: What type of services must doctors perform to earn the additional payments?

JH: To participate in our program, physicians must agree to adhere to patient-centered principles of care. These include ensured access, physician-led, risk-stratified care management for their patients, shared decision-making and accountability with their patients and their patients' caregivers and a strong focus on wellness and prevention. In addition to these foundational commitments, in order to be eligible to receive shared savings, participating physicians must meet plan quality requirements, which include quality standards established by organizations, such as the National Committee on Quality Assurance, the American Diabetes Association, the American Academy of Pediatrics and others. Examples of these standards include percentage of people receiving recommended preventive care screenings, such as mammograms, cervical cancer screenings and immunizations, management of chronic diseases such as diabetes and high blood pressure, and appropriate use of antibiotics.

FHP: Can you provide examples of "non-visit" services of which WellPoint will reimburse doctors?

JH: Initially, we will be providing compensation for activities related to approved care management planning and follow up. Over time, physicians will earn additional revenues through shared savings. Our payments for care management-related activities, together with amounts earned through shared savings, are intended to cover a host of non-visit-based activities, such as responding to patient emails, phone calls or text messages.

FHP: What steps will WellPoint take to enhance resources to physicians?

JH: We will be doing a number of things. Most importantly, we will be using our tools that perform predictive modeling and find potential gaps in care to identify, for participating physicians, those patients within their unique panel who may benefit from a care management or disease management program, or those who may not have received the evidence-based care important to effectively manage their disease or promote wellness and prevention. 

Primary care physicians don't have access to this information today on a population-health basis because they often lack both the technology and the access to information regarding care that their patients are receiving (or in some cases not receiving) outside of their office. We will also be working with physician extenders within the primary care practices to help them by providing direct care management support. Likewise, we will increase our internal clinical support so that practices can tap into a wealth of clinical resources, including pharmacy and behavioral health guidance, that is not generally feasible for a small- to mid-size practice to provide. Finally, physicians will have access to a transformation consultant who can help them analyze and interpret the information they receive from us as part of this program.

FHP: How will the initiative affect patients? Could they see lower copays or deductibles?

JH: Members will benefit from better outcomes, more personal and continuous interaction with their primary care physician, enhanced care management support and information and, ultimately, savings. If we eliminate unnecessary costs in the system, everyone benefits. This program has no impact on members' premiums. However, if we are successful in reducing medical spending in the long term, this could potentially result in slowing the growth of premiums.

FHP: Do you think other insurers may take on similar reimbursement initiatives? Is this something that could fundamentally change the healthcare market?

JH: Yes, and I will go further and say that it is our hope that others will follow. We know from our discussion with the many primary care physicians who have partnered with us in our patient-centered medical home programs, that it takes a village to drive change. 

To best drive change in a primary care practice and move away from an episodic, intervention care model, we must maximize the percentage of a physician's revenue that is value based. That said, as the nation's leading health benefits company by membership, representing more than 34 million Americans, we have the responsibility to lead. And we can't afford to wait; we know from our work with our affiliated health plan patient-centered medical home pilots, that strengthening the primary care relationship makes a meaningful difference in patient quality, outcomes and cost. Some of our pilots have experienced an 18 percent decrease in acute inpatient admissions and a 15 percent decrease in total ER visits.

Given the volume of patients, in most markets, that receive their health coverage through our affiliated health plans, we believe our move toward value-based compensation and a collaborative relationship that recognizes the unique role that an empowered, primary care physician can play in improving health and healthcare affordability, will drive positive change in quality and cost. So yes, innovations like this could, in time, significantly change the healthcare delivery system and landscape.

This interview has been edited and condensed for clarity.