PCPs Paid Under Global Capitation Deliver Higher Quality Care

Global capitation payments provide strong incentives for primary care physicians to achieve key quality metrics, including cancer screening and medication review, UnitedHealth Group concluded from new research.

The research announced this week showed that primary care physicians paid under global capitation, which reimburses providers a set amount per month per patient, had higher rates of completing quality metrics from the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) compared to their peers paid via fee-for-service.

The quality metrics analyzed were related to preventative care and chronic conditions. UnitedHealth Group tracked the metrics across 5 million UnitedHealthcare Medicare Advantage enrollees and tens of thousands of primary care physician practices.

The analysis found that 80 percent of patients treated by primary care physicians under global capitation payment models were screened for breast cancer versus 74 percent of patients treated by fee-for-service providers.

More patients treated by primary care physicians under global capitation models were also screened for colorectal cancer compared to patients treated by fee-for-service providers (82 percent versus 74 percent).

The analysis also showed that global capitation payments were associated with higher controlled blood sugar levels (89 percent versus 80 percent), more eye exams (84 percent versus 74 percent), and higher rates of functional status assessments (96 percent versus 86 percent).

Finally, UnitedHealth Group reported that 97 percent of patients treated by primary care physicians reimbursed via global capitation payment models underwent a medication review compared to 92 percent of patients treated by providers under a fee-for-service system.

“Global capitation benefits patients, physicians and, more broadly, the health care system,” Richard Migliori, MD, chief medical officer at UnitedHealth Group, said in the announcement. “Patients benefit because their doctors prioritize preventive care to keep them healthy and out of the hospital. Meanwhile, providers can offer valuable services that may not be paid for under fee-for-service.”

Global capitation also better positions primary care physicians to spend more time engaging patients, use evidence-based clinical guidance, and avoid unnecessary patient interventions, UnitedHealth Group added.

“These findings underscore the importance of value-based care as a key element in building a better performing health care system for everyone,” said Migliori.

Value-based care models aim to improve care quality and patient experience while lowering the costs of care. The models accomplish value-based care goals by tying provider reimbursement to quality metrics and/or total care costs.

Global capitation payment models are sophisticated value-based care models that reimburse providers a single, fixed payment for all the healthcare services a patient may receive during a specific period of time.

Unlike less advanced models, like pay-for-performance, providers in global capitation must ensure total costs of care for a patient do not exceed the capitation amount, otherwise they incur a financial loss.

But adoption of global capitation models is low. Only about 5 percent of provider payments reimbursed by private and public payers in 2018 were considered population-based, which included global capitation payments, according to the Health Care Payment Learning & Action Network’s latest measurement effort report.

Greater adoption, however, would accelerate the value-based care transition while benefiting the overall healthcare system, the research from UnitedHealth Group and others indicated.

The alternative payment option may also help to support primary care physician practices suffering substantial losses from the COVID-19 pandemic.

Primary care practices are slated to lose $15 billion in 2020 after dramatic declines in both office visits and reimbursements during the COVID-19 pandemic, researchers from Harvard Medical School and American Board of Family Medicine recently projected.

These declines left one in five primary care providers surveyed by the Larry A. Green Center and Primary Care Collaborative ready to close practice doors in the spring. Visit volumes are starting to increase, more recent surveys from the groups have shown, but two in five providers still cannot say they have the billable services or cash on hand to stay open through August.

A more predictable and sustainable payment model, like capitation, would address financial losses among primary care practices, experts from the Larry A. Green Center and Primary Care Collaborative said.