North Carolina BCBS seeks to keep primary care practices afloat, nudge to value-based care

Dive Brief:

  • Blue Cross Blue Shield of North Carolina, the second-largest payer in the state, has launched a novel two-year program to keep independent primary care practices solvent amid the COVID-19 pandemic and nudge them toward value-based care down the line.
  • Participating doctor’s offices will receive supplemental payments to stabilize flagging revenue for primary care services at their pre-COVID-19 levels beginning in September through 2021.
  • There are some strings. Providers have to commit to join the payer’s value-based program, Blue Premier, by Jan. 1, with the option of joining an existing accountable care organization within Blue Premier’s network or through Aledade, a company that helps independent physician practices transition to value-based models. Beginning in 2022, practices also have the option to receive fixed payments for keeping their populations healthy, a payment model known as capitation, in lieu of fee-for-service payments.

Dive Insight:

All providers are struggling amid widespread deferral of lucrative elective procedures for the past few months. But the pain is much more acute for independent practices, including family physicians and pediatricians, that already operate on razor-thin margins and lack the support of a hospital operator’s deep pockets.

A survey conducted in May by the Primary Care Collaborative and the Larry A. Green Center found roughly three-fourths of practices were operating under severe or near severe stress, 14% had temporarily closed and 1% had permanently closed, despite receiving some federal relief funding.

And the situation is unlikely to let up anytime soon. North Carolina is one of more than half of U.S. states that have seen their COVID-19 case counts increase over the past two weeks.

On Wednesday, Gov. Roy Cooper, a Democrat, paused the state’s reopening for at least three more weeks to fight the virus.

The new program from Blue Cross NC, called Accelerate to Value, is meant to help providers with the near-term financial situation while nudging them toward value-based payments in the long run. The 87-year-old payer, which covers some 3.8 million members, isn’t the first insurer introducing a program to help primary care practices stay afloat in the pandemic, but it is known for its bullishness on decoupling payment from volume.

Blue Cross NC will calculate payments to eligible providers by looking at the difference between 2019 payments for core primary care services provided to its members and 2020 payments year-to-date, according to Rahul Rajkumar, Blue Cross NC’s SVP and CMO.

Practices will get a payment for each member based on the difference, with the goal of getting their 2020 and 2021 revenues up to the same level they made in 2019. It’s an imprecise calculation, as the state of the pandemic could shift abruptly going into the back half of the year.

“We will calculate and make additional ‘catch-up payments,’ if necessary,” Rajkumar said. “If we overestimated the shortfall, providers get to keep what they received. We won’t claw back payments.”

Along with no clawbacks, the program has no new reporting requirements for participating physicians. 

CMS doesn’t have a primary care model structured this way. But its innovation center, CMMI, has run 11 models meant to improve medical quality and increase value-based payments in primary care, though only five are currently active.

It’s still unclear what the impact of the pandemic could be on the decades-long shift to paying for value. Ex-CMMI official Lisa Bari cheered the North Carolina program on Twitter, noting she hopes other Blues members follow and CMMI structures a model in the same way.

“Now is the time to change the way we pay for and deliver primary care,” Bari said.​

Independently owned doctor’s offices in North Carolina that are in-network with Blue Cross NC are eligible to apply for the program starting this week. The deadline to apply is July 31.