Plans will pay for quality, but don't always know how

Practice Management. By Mike Norbut, AMNews staff. Dec. 23/30, 2002.

When six California health plans finalized their collaboration on "Pay for Performance," the Integrated Healthcare Assn. quality bonus initiative, there was one important question left unanswered.

How would physician groups be paid?

The answer, it seems, can be as elusive as some of those overdue claims payments.

When they announced the program last fall, organizers estimated bonus totals could reach $150 million for the state's largest medical groups, which represent about 40,000 physicians. However, while some of the participating health plans, like Blue Cross of California, Blue Shield of California, and PacifiCare Health Systems, have payment details down to the letter, others, like Aetna U.S. Healthcare, CIGNA Healthcare of California, and Health Net, would only say they were still devising how to pay quality bonuses.

Because of antitrust laws, the plans weren't allowed to devise a universal payment system, so it's not surprising that there will be differences in how the bonuses are paid. PacifiCare, for example, plans to pay up to $2 per member per month as an incremental add-on to the capitation rate, while Blue Cross has pledged to pay up to 10% of a group's capitated amount, which would be paid more in lump sums.

The insurers with plans already in place have said the bonuses would be paid on top of existing reimbursements, and even the ones without set details have said the intention is not to shift money away from capitation.

Still, there's a natural skepticism among physicians when it comes to managed care promises. And even after physicians took part in devising the bonus criteria -- 50% based on clinical measures, 40% on patient satisfaction, 10% on technological capabilities -- they have to sit back and wait for the insurers to figure out how to write the checks. [...]