A new analysis from IHA and Purchaser Business Group on Health (PBGH) evaluating provider organization performance on person-centered care measures for Californians with Medicare Advantage coverage
The delivery of person-centered care — defined as a holistic approach oriented around an individual’s goals and preferences — is an important consideration for supporting health care system transformation. Prior research revealed that people whose preferences were not taken into account had fewer doctors’ visits, were less likely to use home care, and were less likely to take prescription drugs; quality measurement and payment structure were suggested as health system and health policy levers that could help lead to more person-centered care.1 For clinicians to deliver high quality, evidence-based care in an effective manner, where patients’ and caregivers’ individual preferences, needs, and values are reflected, payments need to enable this.
Supported by a grant from The SCAN Foundation, the Integrated Healthcare Association (IHA), and Purchaser Business Group on Health (PBGH) evaluated the relationship of provider organization (PO) performance on person-centered care measures for their Medicare Advantage population for 2020 with the payment model under which POs are paid – specifically the financial risk arrangement. This is consistent with the Health Care Payment Learning & Action Network framework push toward more risk through population-based payment.2 The hypothesis for this study was that being paid under a flexible population-based method like capitation will allow innovation and customization to support more person-centered care, as demonstrated by better patient experience, higher quality, and lower total costs.
What is person-centered care?
Two decades ago, the Institute of Medicine (IOM) named patient-centered care as one of six aims for a 21st century health system. The IOM defined patient-centered care as “respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”3 The American Geriatric Society also defined person-centered care as eliciting individual values and preferences to guide all aspects of health care and support realistic health and life goals.4 The Picker Principles of Person-Centered Care reflect very similar themes: effective treatment delivered by trusted professionals; coordinated care; support for self-care, family and caregivers; involvement in decisions and respect for preferences; emotional support, empathy and respect.5
Is there a relationship between person-centered care and financial risk arrangement?
Measuring person-centered care
A set of patient experience, clinical quality, and total cost of care measures were selected with guidance from subject matter experts from PBGH and IHA’s measurement committees.
Patient experience measurement is an integral piece of person-centered care because it incorporates the patient’s unique viewpoint of their care. Gathering information directly from patients manifests the person-centered concept that patients know best how well their care is meeting their own needs,6 including the extent to which care is respectful and responsive to their preferences and values.7 The patient experience measures are based on PBGH’s annual statewide survey, the Patient Assessment Survey (PAS), which is based on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey.
Receiving the right clinical care at the right time is also an essential part of person-centered care. The Picker Principles of effective treatment, as well as continuity of care and smooth transitions, can be assessed through clinical quality measures. And, the amount someone needs to pay for healthcare services is also a part of person-centered care, as it can affect how accessible care is. Since copayments are often a fixed percentage of the allowed amount, higher total cost of care is generally associated with higher patient cost sharing. With this in mind, clinical quality and cost measures produced through IHA’s Align. Measure. Perform (AMP) program8 were also included in the analysis.
The following measures were selected to assess person-centered care:
- Patient Experience:
- Overall Ratings (average of Rating of Doctor and Rating of Care)
- Access to Care
- Provider Communications
- Care Coordination
- Office Staff
- Clinical Quality:
- Concurrent Use of Opioids and Benzodiazepines
- HbA1c Poor Control >9%
- All-Cause Readmissions
- Breast Cancer Screening
- Colorectal Cancer Screening
- Controlling Blood Pressure
- Osteoporosis Management for Women Who Had a Fracture
- Total Cost of Care
Financial risk arrangements
Provider organizations (POs) are groups of health care providers organized to contract with health plans. In California, POs participating in a capitated, delegated model of care assume responsibility and financial risk for managing the care of their assigned patients. One hundred fifty-one (151) POs were categorized by level of financial risk/risk arrangement at the Plan-PO contract level (n = 406). The financial risk categories included:
|Financial risk category||Description||Number (%) of Plan-PO contracts|
|No risk||all services paid fee-for-service||4 (1%)|
|Facility risk only||capitation paid for facility services, but fee- for-service for professional services||1 (<1%)|
|Professional risk only||capitation paid for professional services, but fee-for-service for facility services||62 (15%)|
|Full risk||capitation paid for both professional services and facility services||339 (84%)|
Assessing the correlation between person-centered care and financial risk
To assess the correlation between financial risk and performance on person-centered care measures, a multivariate regression analysis was run. The analysis included risk arrangement and PO size since the distribution of PO size was found to be different by risk arrangement, with professional risk contracts more often with smaller POs and full risk arrangements with larger POs. By adjusting for PO size, these results show to what degree the performance on the measure for a Plan-PO in a full risk arrangement is better or worse compared to those in a professional only risk arrangement.
Risk arrangement matters: Full risk POs performed slightly better than professional risk POs on all but two measures.
Full risk POs slightly outperformed professional risk POs on most measures, with the differences being statistically significant for three of the seven clinical quality measures, as well as two of the five patient experience measures. Access to Care and Total Cost of Care were exceptions where full-risk POs performed slightly worse than those with professional risk.
Size also matters: Large POs outperformed small/medium POs on all but two measures.
Large POs outperformed small/medium POs – sometimes by a wide margin – across all measures except Access to Care and Total Cost of Care. For all seven clinical quality measures and four of five patient experience measures, the differences were statistically significant.
Bringing risk arrangement and size together: Large, full risk POs outperformed small/medium POs that are full risk or professional risk on almost all measures.
The multivariate regression analysis – assessing the association between risk type and performance on person-centered care measures after adjusting for PO size – found statistically significant results for two measures. After adjusting for PO size, performance for Plan-POs in full risk arrangements show:
For all other measures, the relationship between risk type and person-centered care performance, after accounting for PO size, was not statistically significant, but there was a clear pattern that large, full risk Plan-POs generally outperform other categories of Plan-POs.
Limitations and future opportunities for advancing person-centered care
This research indicated that there is a positive relationship between delivering person-centered care and being paid under a more flexible, population-based payment model with greater financial risk. However, the analysis could not compare performance of POs with no financial risk since only 1% of Medicare Advantage PO contracts were categorized as no risk or facility risk only. Previous work by IHA showed that populations cared for by providers with any financial risk sharing received better quality care at a lower total cost than populations cared for by providers with no financial risk sharing.9 Assuming that finding would apply to this study, performance on person-centered care measures would be lower for providers with no financial risk. This should be confirmed in future analysis by including traditional Medicare, where many providers are still paid fee-for-service.
Using a subset of measures already being collected to produce baseline measurement of person-centered care in California, and assessing its relationship to provider financial risk arrangement, is an important foundation. There is opportunity to continue to expand measurement to other areas important to person-centered care, such as shared decision making,10 cultural sensitivity, and person-driven outcome measurement.11 Any expanded person-centered measurement efforts should be incorporated into existing measurement initiatives to avoid increasing burden on providers.
Determining the type(s) of payment model(s) that can support the trust and relationship building necessary for person-centered care is a worthwhile endeavor, and this study suggests that financial risk arrangements such as population-based payment may allow the flexibility and innovation needed. In California, there is limited opportunity for further increasing risk-based contracting in Medicare Advantage because providers already nearly universally take risk through professional, facility, or global capitation in their Medicare Advantage contracts. Increased risk-based contracting could be pursued in other scenarios.
As the health care industry strives to increase equity and decrease disparities, person-centered care should be a focal point. The use of provider financial risk arrangements through population-based payments is a key consideration in advancing person-centered care.
For the full report, click here.
- https://www.healthinnovation.org/resources/publications/body/Person-Centered-Care-Infographic_Jan- 2021.pdf
- Alternative Payment Model (APM) Framework (hcp-lan.org)
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001 https://pubmed.ncbi.nlm.nih.gov/25057539/
- Person-Centered Care: A Definition and Essential Elements. JAGS, 64:15-18, 2016.
- IHA, “Atlas, Measurement Year 2018 Financial Risk Findings.” https://www.iha.org/wp-content/uploads/2020/11/20-0701-Atlas-MY18-Risk-Summary.pdf
- http://www.glynelwyn.com/collaborate.html; https://www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-decisionmaking-cg30-adult.html
- Amy Maciejowski, NCQA Blog, “Person Driven Outcomes: Opportunities for Your Quality Measurement.” August 2, 2021. https://www.ncqa.org/blog/person-driven-outcomes-opportunities-for-your-quality-measurement/