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Sustained Participation in a Pay-for-Value Program: Impact on High-Need Patients
Dori A. Cross, BSPH; Genna R. Cohen, PhD; Christy Harris Lemak, PhD; and Julia Adler-Milstein, PhD
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Sustained Participation in a Pay-for-Value Program: Impact on High-Need Patients

Dori A. Cross, BSPH; Genna R. Cohen, PhD; Christy Harris Lemak, PhD; and Julia Adler-Milstein, PhD
Among Michigan primary care practices, sustained participation in a pay-for-value program appears to contribute to improved utilization outcomes for high-need patients.
A second potential limitation of our study is that our data sample, by design, only includes patients who were continuously enrolled with BCBSM throughout the study period, and assigned to PCPs who practiced in the same location for all years included in this analysis. Only one-third of commercially insured BCBSM enrollees met these criteria, which limits the generalizability of our findings. Because patients with multiple conditions have ongoing, and often complex, healthcare needs that benefit from provider continuity, we expect this population is more likely than healthy individuals to maintain stable coverage and physician care; however, our findings may not hold for patients who regularly switch PCPs or experience lapses in insurance coverage.

Finally, our results come only from the state of Michigan, and are specific to 1 commercial insurer’s pay-for-performance program. However, PGIP is a large and inclusive program; the program was established in 2005 and has nearly 20,000 physicians participating. The program also operates within the context of fee-for-service reimbursement, and program requirements and reimbursement structures are similar to those of other regional and national pay-for-performance programs.36,37 Thus, we believe our findings are generalizable beyond the PGIP program.

Policy Implications

As MACRA takes effect, provider payments will become increasingly tied to value through the Merit-Based Incentive Payment System and participation in alternative payment mechanisms (APMs), such as accountable care organizations, shared savings, or bundled payment initiatives. In early demonstrations, as well as currently operational new payment arrangements, these programs experience a lot of provider turnover.38

Although MACRA will compensate providers on an annual basis for APM participation, our findings about the benefits of sustained participation in these programs suggest that policy makers may want to consider conditional payments or additional incentives for providers who continuously participate in an initiative. In addition, the heterogeneous results across different outcome measures suggest that resources and support may be leveraged most effectively when targeted toward specific types of use that are more within practices’ direct control.


Given the large investment in pay-for-value programs to date, and their growing prominence, our findings offer reassurance that these initiatives appear to be effective in accelerating performance improvement among primary care practices caring for high-need patients. Our findings specifically point to the importance of sustained participation, which likely helps practices establish new care processes to improve outcomes under their control—in particular, ED use and readmissions, which are more prevalent among high-need patients. However, moving the needle on outcomes like total spending likely requires broader solutions that involve new approaches to health system organization and patient behavior change.

Author Affiliations: Department of Health Management and Policy, School of Public Health (DAC, JAM) and School of Information (JAM), University of Michigan, Ann Arbor; Mathematica Policy Research (GRC), Washington, DC; and Department of Health Services Administration (CHL), School of Health Professions, University of Alabama at Birmingham.

Source of Funding: The Commonwealth Fund.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DAC, GRC, JAM); acquisition of data (GRC, JAM); analysis and interpretation of data (DAC, JAM); drafting of the manuscript (DAC, JAM); critical revision of the manuscript for important intellectual content (DAC, JAM, CHL); statistical analysis (DAC, JAM); obtaining funding (GRC, CHL, JAM); administrative, technical, or logistic support (DAC, GRC, CHL); and supervision (CHL, JAM).

Address Correspondence to: Dori A. Cross, BSPH, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48108. E-mail:
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