CareFirst BlueCross BlueShield prioritizes quality care over the traditional ‘fee-for-service model’

CareFirst BlueCross BlueShield, the largest not-for-profit health plan in the mid-Atlantic region, is transforming the way health care is financed and delivered by embracing a “value-based care” model that puts patients above everything else.

Value-based care ties health care provider revenue directly to improved health outcomes and the value of services rather than the volume of office visits.

Such arrangements have the ability to improve the overall quality of care and can potentially expand access, improve affordability and address equity.

“We contract with a doctor’s office, for example, in order for our members to be able to go to that doctor’s office and use that service, and we contract for a rate and the quality that we expect,” said Brian Wheeler, vice president of provider collaboration and network transformation at CareFirst.

The company is contracting on behalf of millions of its members with offices, physicians, hospitals and large-scale health systems.

Those contracts govern what happens when CareFirst members visit a particular provider.

“We’re trying to change from the old way of contracting – which was a fee-for-service model – and reframe the nature of the way we’re financing health care to payment for value and outcomes,” Wheeler said. “It’s a completely different world.”

Changing the model

Under the previous model, CareFirst would typically hold contract negotiation meetings with its health care delivery partners once every three years or so.

Now, the company is hosting meetings monthly or even weekly to discuss how patients are doing and what can be done to improve outcomes.

“I think we actually change as we move further away from that fee-for-service model,” Wheeler said. “The new payment models we’re focused on not only change the set of incentives for providers, but also free them up so they aren’t tied to just visit-based revenue.”

CareFirst’s ultimate goal is to take the existing model and add systems around it in order to better measure the quality of care and identify where specific needs are in the population.

The United States economy produces more than $20 trillion per year in goods and services, and health care is responsible for roughly 20% of that.

That amounts to more than $12,000 per American on an annual basis.

Still, the U.S. has lower life expectancies and higher infant mortality rates when compared to other industrialized nations, such as Canada, France, Germany and the United Kingdom.

In those countries, about $5,000 is spent on health care per person annually.

“We’re not getting the value that we should be getting, and that has a lot to do with the financing and delivery system that has evolved over the years,” Wheeler said. “As we are able to change to a new economic model for healthcare, we will see the healthcare delivery system change in a way that is productive for society.”

As a health insurer, CareFirst has access to information straight from patients that can be used to identify areas where improvements can be made in order to increase the quality of care.

In the near-term, the company plans to focus on getting more of that information to its health care delivery partners.

“It’s about providing data and providing insights that help our partners understand where the opportunities are to improve,” Wheeler said.

Over the longer term, the company wants to see the growth in healthcare costs slow down.

“All of these things contribute to better health outcomes for society,” said Wheeler. “That’s what we hope to see and how we would define success.”

How the pandemic accelerated change

Lessons learned from the COVID-19 pandemic have, in many ways, led to greater access to care and better outcomes for patients.

The healthcare delivery system moved from an almost entirely in-person experience to one that allowed people to access care from the comfort of their own home through telehealth.

“Now people can access the expertise of their physician or another health care practitioner via video or audio link,” Wheeler said. “When you expand access to someone who has a chronic disease or an acute illness, they do a better job of managing their condition and have better outcomes overall.”

Additionally, the nation’s mindset changed due to the nature of the pandemic, which had an impact on the entire population.

It forced providers to view the concept of health on a larger scale, focusing on the population as a whole rather than an individual patient in front of them.

“In that way, the pandemic accelerated what we’re doing in partnership with the healthcare delivery system,” Wheeler said. “It’s been a huge change.”

Federal News Network Logo
Log in to your WTOP account for notifications and alerts customized for you.

Sign up