Download - The Emerging Challenge of Chronic Care
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The Emerging Challenge of Chronic Care
Robert A. Berenson, M.D.
Senior Fellow, The Urban Institute
27 September, 2007
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Chronic Condition
• An illness, functional limitation or cognitive impairment that lasts (or is expected to last) at least one year
• Limits what a person can do
• Requires ongoing care
Source: National Academy of Social Insurance, “Medicare in the 21 st Century: Building a Better Chronic Care System,” January 2003.
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Projected Total Number of People
With Chronic Conditions
118125
133141
149
157164
171
100
120
140
160
180
1995 2000 2005 2010 2015 2020 2025 2030
(in millions)
Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment”; RAND Corporation, 2000.
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Chronic Conditions by Age Group
24%
38%
62%
84%
5%
13%
62%
35%
0%
20%
40%
60%
80%
100%
0-19 20-44 45-64 65+Ages
Per
cent
of
Pop
ulat
ion
One or MoreChronicConditions
Two or MoreChronicConditions
Source: Partnership for Solutions. “Disease Management and Multiple Chronic Conditions”; Agency for Healthcare Research and Quality, MEPS, 1998.
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Chronic Condition Prevalence By Race (Total Population)
65.7%70.6%
57.8%
20.6%21.4%24.2%
5.3%7.1%10.2%
3.6%5.9%7.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Caucasian African-American Hispanic
0 Conditions1 Condition2 Conditions3+ Conditions
Source: Hwang, W., et al., “Out-of-Pocket Medical Spending for Care of Chronic Conditions,” Health Affairs, December 2001.
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Proportion of Adults 50+ with Chronic Conditions, by Race
42
64
68
77
0 10 20 30 40 50 60 70 80 90
Asian American
White
Latino
Africa-American
Source: “Cultural Competence in Health Care,” Center on an Aging Society, Georgetown University. No. 5, February 2004.; K. Collins, et al., “Diverse Communities, Common Concerns; Assessing Health Care Quality for Minority Americans,” New York: The Commonwealth Fund, 2002.
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Chronic Conditions for Children
65
70
65
60
64
31
19
26
34
31
4
8
7
5
5
0% 20% 40% 60% 80% 100%
Disorders of Teeth and Jaw
Eye Disorders
Preadult Disorders
Asthma
Upper Respiratory Disease
Single Condition Condition +1 Condition +2
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Chronic Conditions for Adults
26
30
30
46
42
25
29
30
26
28
20
18
16
14
14
13
11
11
7
8
16
13
8
7
13
0% 20% 40% 60% 80% 100%
Arthritis
Hypertension
Mental Conditions
Upper RespiratoryDisease
Chronic RespiratoryInfection
Single Condition Condition +1 Condition +2 Condition +3 Condition +4+
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Chronic Conditions in Seniors
11
17
10
9
8
22
24
21
23
22
23
23
25
25
25
22
20
24
22
22
21
16
19
19
19
0% 20% 40% 60% 80% 100%
Arthritis
Hypertension
Heart Disease
Eye Disorders
Diabetes
Single Condition Condition +1 Condition +2 Condition +3 Condition +4+
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Multiple Chronic Conditions and Medical Service Usage
82%
69%
55%50%
0%
20%
40%
60%
80%
100%
Home HealthVisits
PrescriptionDrugs
InpatientStays
PhysicianVisitsP
erce
nt o
f Se
rvic
es U
sed
by P
eopl
e w
ith
Mul
tipl
e C
hron
ic C
ondi
tion
s
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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Hospitalizations by Number of Chronic Conditions
4%8%
12%17%
22%
32%
0%
10%
20%
30%
40%
50%
0 1 2 3 4 5+
Number of Chronic Conditions
Per
cen
t of
Peo
ple
wit
h I
np
atie
nt
Hos
pit
al S
tays
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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Hospitalizations for Ambulatory Care Sensitive Conditions
261236
219
9562
361870
169
131
0
50
100
150
200
250
300
0 1 2 3 4 5 6 7 8 9 10+
Number of Chronic Conditions
Hos
pit
aliz
atio
ns
per
100
0 M
edic
are
Ben
efic
iari
es
Sources: Partnership for Solutions. “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; Medicare Standard Analytic File, 1999.
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Activity Limitations by Number of Chronic Conditions
67%
52%
43%
28%
15%
4%
0%
20%
40%
60%
80%
0 1 2 3 4 5+
Chronic Conditions
Per
cen
t w
ith
Act
ivit
y L
imit
atio
ns
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Annual Prescriptions by Number of Chronic Conditions
0
10
20
30
40
50
0 1 2 3 4 5
Number of Chronic Conditions
Ave
rage
An
nu
al
Pre
scri
pti
ons*
*Includes Refills
Sources: Partnership for Solutions, “Multiple Chronic Conditions: Complications in Care and Treatment,” May 2002; MEPS, 1996.
3.7
10.4
17.9
24.1
33.3
49.2
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Utilization of Physician Services by Number of Chronic Conditions
7.811.3
14.9
19.5
37.1
13.8
8.16.55.24.01.3 2.0
0 1 2 3 4 5+
Number of Chronic Conditions
Unique Physicians
Physician Visits
Sources: R. Berenson and J. Horvath, “The Clinical Characteristics of Medicare Beneficiaries and Implications for Medicare Reform,” prepared for the Partnership for Solutions, March, 2002; Medicare SAF 1999.
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Breakdown of Total Health Care Spending
78% Health Care Spending for People with Chronic Conditions
22% Health Care Spending for
People without Chronic Conditions
Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.
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Health Care Spending by Number of Chronic Conditions
$11,500
$8,900
$5,600
$3,400
$1,900
$800
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000
5+
4
3
2
1
0
Nu
mb
er o
f C
hro
nic
Con
dit
ion
s
Average Per Capita Health Care SpendingSources: Partnership For Solutions. “Disease Management and Multiple Chronic Conditions”; Agency for Healthcare Research and Quality, MEPS 1998.
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Medicare Spending Related to Chronic Conditions
22.1%
0.9%
15.1%
3.5%
16.3%
6.8%
14.8%
10.3%
11.3%
12.7%
20.3% 65.8%
Percent of MedicarePopulation
Percent of Medicare Spending
5+ Conditions
4 Conditions
3 Conditions
2 Conditions
1 Condition
0 Conditions
Source: Partnership for Solutions, “Medicare: Cost and Prevalence of Chronic Conditions,” July 2002; Medicare Standard Analytic File, 1999.
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Medicare Spending on Beneficiaries with Chronic Conditions
4 Chronic Conditions
12%
5+ Chronic Conditions
68%
3 Chronic Conditions
10%
1 Chronic Condition
3%0 Chronic Conditions
1%
2 Chronic Conditions
6%
Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.
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Growth of Medicaid Spending
$73
$168
$49 $54$60
$34
$142
$124$120
$91
$0
$50
$100
$150
$200
1992 1995 1997 1998 2000
In B
illi
ons
Disabled Beneficiaries All Beneficiaries
Sources: J. Crowley and R. Elias. “Medicaid’s Role for People with Disabilities,” The Kaiser Commission on Medicaid and the Uninsured, August 2003; Urban Institute estimated based on HCFA-2082 and HCFA-64 Reports.
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Projected Total Medicaid Spending Per Enrollee
$16,300$17,200
$1,400$2,300
$11,200$12,300
$2,000$3,200
Children Adults Disabled Elderly
FY 2001FY 2006
Note: Includes federal and state spending on benefits.
Sources: J. Crowley and R. Elias. “Medicaid’s Role for People with Disabilities,” The Kaiser Commission on Medicaid and the Uninsured, August 2003; KCMU analysis based on CBO baseline for Jan. 02.
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Private Health Insurance Spending on Individuals with Chronic Conditions
0 Chronic Conditions
13%
2 Chronic Conditions
15%
3 Chronic Conditions
14%
5+ Chronic Conditions
31%
4 Chronic Conditions
13%
1 Chronic Condition
14%Source: G. Anderson, “Hospitals and Chronic Care”, PowerPoint Presentation to the American Hospital Association. Partnership for Solutions. 16 June 2004.; MEPS 2000.
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Incidents in the Past 12 Months
1. Been told about a possibly harmful drug interaction
2. Sent for duplicate tests or procedures
3. Received different diagnoses from different clinicians
4. Received contradictory medical information
Sometimes or often
54%
54%
52%
45%
Among persons with serious chronic conditions, how often has the following happened in the past 12 months?
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Barriers to Improvement
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Barriers to Implementing Change in Most of Medicare
• The nature of medical education and the resultant professional culture and orientation of clinical practices
• Traditional Medicare is based in traditional indemnity insurance
• Major benefit limitations and restrictions in the Medicare statute
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Professional Issues
• Hard to influence by public policy• Based on an orientation to identifying and caring
for acute illnesses and injuries, not chronic conditions
– “find it and fix it” – solve, rather than manage problems– “the tyranny of the urgent”– Failure to find the unusual and the life-threatening is
worse than overlooking the common and considering quality of life
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Professional Issues (cont.)
• Oriented to those who present for care, rather than to populations who inhabit their chronic conditions
• Little division of labor – M.D. as captain of the ship
• Underuse of information management and decision support tools
• Resistance to change, even in the face of demonstrable failures
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Specific Structural and Organizational Deficiencies
• Residency training takes place in hospitals• Shortage of geriatricians• Guidelines (even when followed) usually ignore co-
morbidities – may conflict or produce overwhelming compliance burden
• Disease management and primary/principal care are not well coordinated
• Lack of integrated care orientation (also fostered by siloed payment systems)
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Medicare Statute Based on Indemnity Insurance of the ’60s
• Kenneth Arrow in 1963: for people with chronic illness, “insurance in the strict sense is probably pointless.”
• Why? Moral hazard• Yet, 80% of beneficiaries have one or more
chronic condition and 20% have 5 or more and account for two-thirds of program spending
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Example of the Problem: Should Medicare Pay for E-mails?
• Why not phone calls, while you’re asking?
• In a fee-for-service payment system, there are a number of concerns:
– Relatively high transaction costs relative to the value of the underlying service
– Substantial program integrity concerns
– “Nuclear force” moral hazard
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Problems in How Traditional Medicare Pays for MD Services
• Many Medicare payment systems have evolved from FFS to prepayment for episodes of care – physician payments is the main exception
• Physician payment is for discrete, narrowly defined services or transactions
• Partly fails to account for complexity• Pays based on resources expended, whether serve a
useful purpose or not• And doesn’t pay differently for quality
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Medicare Benefits Need to Be Improved and Upgraded
• Now, reasonable coverage for prescription drugs (although still 4 million not in)
• Sensory loss support devices not covered (eyeglasses, hearing aids)
• DME and home health limitations, e.g., the “homebound” definition
• Program interpretation that rehabilitation services require prognosis of improvement, and not maintenance or slowed deterioration
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Various Models of Enhanced Chronic Care Management
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Disease Management
• I use the term to refer to third parties attempt to influence patients directly, bypassing physicians
• Relies on predictive modeling, decision-support software, and remote monitoring devises to complement core nurse-patient communication, which focuses on patient self-management (diabetes) and early detection of clinical deterioration (CHF)
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Case Management
• Targeted to a subset of patients who are typically the most complex – with a combination of health, functional, and social problems
• Approach is more customized to needs of particular patients
• Relies mostly on telephonic interventions
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The Wagner Chronic Care Model
• Pioneered by Wagner and associates at Group Health Cooperative of Puget Sound and The MacColl Institute
• Offers a multidimensional approach to a complex problem
• Identifies 6 essential elements: community resources, health care organization, self-management support, delivery system redesign, decision support, clinical information systems
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Delivery System Redesign
• Specialized assessment tools to identify patients at risk
• Multi-professional team responsibility and delineation of roles
• Active promotion of patient self-management
• Proactive follow-up/communication, outside of the anachronistic office visit
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Chronic Care Strategies That Bypass Physicians Make No Sense
• From 30 years of Medicare demos -- approaches
that are supplemental to the patient/physician relationship have had little impact – the MMA disease management demo seems to be failing; in commercial and Medicaid settings D.M. may have some, but limited, usefulness.
• In contrast, CMS just announced modest positive results from the Medicare physician group practice demo, which incentivizes, rather than bypasses, practices – mostly, but not only, large groups
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Challenging the Status Quo in Chronic Disease Care: Seven Case
Studies Robert A. Berenson, M.D.
September, 2006
Available on California Health Care Foundation website
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Seven Case Studies
• Sutter Health Sacramento Sierra Region• Park Nicollet Health Services• Integrated Resources for Middlesex Area (Ct.) • Billings Clinic• Care Level Management• Washington Hospital Center Medical House Call • MDxL
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Case Study Finding 1
• Physicians and hospitals can do much more to manage patients with chronic conditions
• Physicians and hospitals do not think third-party disease and case management has worked because of the absence of physician engagement
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Finding 2
• Viable models of chronic care management fall between the Chronic Care Model and third-party approaches
• Case study sites do not attempt to redesign traditional practice of frontline primary care physicians
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Finding 3
• Although third-part D.M. remains the dominant framework for chonic care improvement, some health plans also support innovative approaches that more closely relate to patients’ regular sources of care
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Finding 4
• Provider-based programs carefully distinguish among patients based on their specific clinical conditions and other assessments
• Differentiators include: whether patient home-bound, have limitations in activities of daily living, and specific conditions, e.g. CHF vs. diabetes vs others
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Finding 5
• Approaches to case management for medically complex patients vary more than do disease management programs for patients with one or more specific chronic conditions
• For the former, programs rely more on point of care decision-making by clinicians
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Finding 6
• Capitation is more compatible with chronic care programs and their populations than fee-for-service reimbursement
• Capitation provides greater flexibility and organizations can benefit from reduced expenditures
• The Medicare “shared savings” approach used in the PGP demo also may be a practical approach
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Finding 7
• Current Medicare payment rules greatly influence the configuration of chronic care programs, e.g., how to get reimbursed for diabetes education or the “incident to” rules.
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Finding 8
• The negative business case for hospitals to support chronic care management does limit the robustness of programs
• However, in some circumstances, there are offsets to the negative ROI
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Finding 9
• Communications, monitoring, and data-sharing technologies enhance chronic care programs but, state-of-the-art, “high tech” technologies are not essentail.
• EMRs, disease registries, PDAs, yes
• Sophisticated telemonitoring devices, not really
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Some Final Thoughts on Physician Payments to Support All of This
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We Should Not Expect Pay-for-Performance to Solve the Problem
• It focuses on marginal dollars and ignores the incentives in the basic payment system -- which drive behavior
• A lot of what we want physicians to do is not easily measurable. Are we looking under the light for the keys lost in the bushes?
• P4P can’t easily address “overuse” and “misuse” quality dimensions, much less cost.
• We are still learning about P4P. Don’t overload it.
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The Bottom Line
• A one-size fits all, RBRVS fee schedule no longer makes sense as physicians increasingly do very different things
– Perhaps, PCPs need mixed FFS and prospective monthly payments (with a dash of P4P)
– Surgeons could be paid for episodes (but addressing the bias to inappropriate surgical episodes)
– Other specialists who perform one-time, discrete services might still be paid FFS for their services
• The payment system should promote integrated care, including multi-specialty groups, but not single specialty consolidation
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Continuum of Approaches for Paying for “Medical Home” Services
• Aggressive, politically difficult RBRVS/fee schedule revaluations
• New CPT codes for targeted medical home activities
• A new payment, i.e. pmpm or pppm, for chronic care management activities to the practice on top of FFS payments
• Bundled payment for medical services and medical home activities – either a more improved pmpm or a hybrid FFS/bundled payment approach
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FFS Revaluations
• Hope that better payment for E&M services cross-subsidizes medical home activities (as some are already included in pre and post service work, according to the RBRVS methodology
• Avoid difficult design issues of a formal medical home --
• Who qualifies for payment, e.g. primary care or principal care?
• The physician or the practice? • Is there a formal patient lock-in – hard or soft?• No obligation to hold any one accountable and all that
that entails
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FFS Revaluations -- Cons
• No obligation to hold any one accountable and all that that entails – in a FFS system, it might be putting good money after bad
• Politically difficult to redistribute within a fee schedule context
• A CPT code based payment system that pays for specific services cannot really accommodate the set of “soft” activities we want to promote
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New CPT Codes for Particular Medical Home Activities
• Or particular services in the Chronic Care Model• As examples, palliative care family conferences,
“email consultations,” geriatric health assessment• These should be included in CPT and paid for,
but can’t really include most medical home or care coordination activities on a FFS payment basis, as discussed before
• Even here, face political obstacles to adoption from vested interests who are involved in CPT
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PPPM Payment for Medical Home and/or Chronic Care Management
• Assumes there is a definable and designated subpopulation that “qualifies” for additional activities supported with additional payment
• Would small practices reengineer their processes for a small subset of patients which may make up a highly disproportionate share of health spending but not a relatively small share of their time and attention?
• Compounded if not an all-payer approach
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An Add-on PPPM Payment (cont.)
• Which raises the fundamental question, do all patients benefit from a medical home or should the approach be targeted to only some, for efficiency?
• How would eligible patients be selected – physician referral (then self-referral issues), history of high costs, data mining re conditions and co-morbidities – the issues that are relevant to eligibility for case management?
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Bundled (“Capitated”) Payments for All
Services and All Patients or a FFS Hybrid
• The advantage is that all patients are included, so no practice dissonance for different patients and risk adjustment handles the fact that different patients have different needs for chronic care management
• But should medical home services be provided to everyone? Do they all want a home? Is this efficient? (But some of us think FFS sends wrong signals for all patients)
• Can we correct the execution errors of 1990s capitation approaches related to: insurance risk, absence of risk adjustment, mechanical actuarial conversion of pmpms under FFS to a situation when more is expected of the practice?
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A FFS/Bundled Payment Hybrid
• Some very smart people, e.g., Joe Newhouse, have recommended a mixed approach to soften the effects of capitation and FFS payment incentives
• Some European primary care payment models, e.g. Denmark, is a hybrid
• But surely more complex operationally for the payer and maybe the practice and may negate some of the appeal of bundled/“capitated” payments