It must be recognized that not all providers treating Medicare beneficiaries would be willing or able to serve this coordinating function. The Secretary of DHHS should design the particulars of how providers would be rewarded for serving this function, in addition to being eligible for rewards based on performance. The funding for this purpose need not come from the pay-for-performance reward pools discussed in Chapter 3, but could be drawn from the basic payment systems within Medicare.

Beneficiaries would have an important role in this process, in that they would work with their providers to identify a responsible source of care.

improve quality and value while reducing overall costs. These physicians might jointly purchase an electronic health information system, as well as discuss guidelines and the evidence base for best care practices at a monthly meeting. In joining this virtual group, the ten physicians would agree to share the costs associated with purchase and implementation of the electronic system as well as training in its use. In addition, the virtual group might agree to share the costs and administration of enhanced clinical support, such as the following:

  • Nurses who would serve as care managers for high-risk patients and visit patients living with targeted chronic conditions for all ten physicians.

  • Bidirectional data provided by a common laboratory vendor to reduce data entry costs.

  • “Service agreements” negotiated with an identified group of specialists who agreed to use methods approved by all the physicians and increase communication between primary and secondary care providers.

Example 3: Virtual Groups Convened by Health Plans

Health plans could play a convening role in the formation of virtual groups, for example, by providing a common information technology platform for gathering data across multiple solo or small group practices in return for a small fee. Practices would not have to be located in the same geographic area, as they would be linked by common financial and communication systems. As part of their services, plans could also track a minimum number of patients with chronic conditions and send out prompts and reminders for recommended preventive services. Reward sharing could occur through reaching of thresholds on selected performance measures (including clinical effectiveness and efficiency) for chronic conditions determined by CMS.

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