Archive for the ‘Healthcare Quality Ratings’ Category

BCBSM Physician Incentives Target 5 Root Causes of High-Cost Healthcare

February 17th, 2015 by Cheryl Miller

Designed to target underlying reasons for high-cost healthcare, Blue Cross Blue Shield of Michigan's (BCBSM) Physician Group Incentive Program (PGIP) rewards and incentivizes providers to enhance the delivery of care. To address poorly aligned incentives, for example, they developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level, says Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

How has the program evolved? The several root causes of high-cost healthcare within our system were readily apparent: poorly aligned incentives, a lack of population focus, very fragmented healthcare delivery, a lack of focus on process excellence or process improvement and a weak primary care foundation. As we’ve developed our Physician Group Incentive Program (PGIP) initiative, we were strategic and deliberate in how we were going to address the root causes of our high-cost system, keeping in mind the tenets and the philosophy of the PGIP program.

To address poorly aligned incentives, we developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level.

Tiered performance fees also addresses the lack of population focus and places emphasis on all patients and payor registries.

The one thing that really makes our PGIP program unique is that we are payor-agnostic. The incentive dollars we have distributed through the life of the program readily help and incentivize other payors in the state, because if these capabilities are implemented, they ultimately serve all the patients in our state. We’re very proud of that because we feel that that is part of the servant leadership we need to do for patients and members in our state.

To attack the fragmented healthcare delivery, we've organized our systems of care, aligning our incentives for primary care physicians, hospitals and specialists.

We also have collaborative quality initiatives, which help sharpen our physicians, specialists and care delivery people on the science of process improvement.

Our PCMH initiative is our pinnacle initiative, which we believe has strengthened our primary care foundation across the state.

generating medical home savings
Donna Saxton, field team manager of Blue Cross Blue Shield of Michigan’s (BCBSM) value partnerships program, currently oversees the team of representatives that support the statewide collaborative relationships with 44 physician organizations (PO) and 39 organized systems of care (OSCs) that participate in the BCBSM Physician Group Incentive Program (PGIP).

Source: Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures

Infographic: 10 Things You Should Know About PQRS for 2015

January 21st, 2015 by Melanie Matthews

CMS’ Physician Compare website has begun listing physician participation in its Physician Quality Reporting System (PQRS), which could potentially mean a loss of new patients based on nonparticipation in the program, according to a new infographic by HealthFusion.

The infographic lists 10 key features of the PQRS program.

Physician Value-Based Reimbursement: Quality Rewards for Population Health With more than a quarter-century of experience with value-based reimbursement models, Humana is ideally positioned to help physician practices navigate the transition from fee for service to fee for value. The payor's multi-level Accountable Care Continuum rewards physician practices for care coordination of Medicare beneficiaries along the population health spectrum.

Physician Value-Based Reimbursement: Quality Rewards for Population Health describes the four tiers of Humana's Physician Quality Rewards program as well as the support, training, technologies and outcomes associated with these pay-for-value relationships.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

Infographic: Physician Quality Transparency

January 12th, 2015 by Melanie Matthews

Independent and objective public quality data are only available for 16 percent of U.S. physicians, and in some states no data is available, according to the second annual State Report Card on Transparency of Physician Quality Information report from the non-profit Health Care Incentives Improvement Institute (HCI3).

HCI3 has released an infographic on the study results that details the importance of transparency as the growth of high-deductible health plans for healthcare consumers continues, along with details on the availability of quality information.

Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry From collaboration and consolidation to the inevitable acceptance of a value-based system, the state of healthcare continues to stimulate health plans, providers and employers.

Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry, HIN's eleventh annual industry forecast, examines the factors challenging healthcare players and suggests strategies for organizations to distinguish themselves in the steadily evolving marketplace.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

The Year in Healthcare Intelligence: Reimbursement, Value-Based Results Resonate with Readers

December 29th, 2014 by Patricia Donovan

Newswise, fee-for-value healthcare initiatives eclipsed fee-for-service models.

When survival of healthcare providers hinges on payment for services rendered, it's not surprising our 2014 readers closely tracked news of emerging payment models and results from patient-centered, quality-based initiatives.

Here is a retrospective of stories that dominated our readers' news feeds over the last 12 months:

  • We reported on results from many accountable care organizations (ACO) over the last year, but few generated interest like the Anthem Blue Cross-Healthcare Partners accountable care collaboration that saved more than $4 million. The program succeeded by sharpening its focus to those with two or more chronic diseases—the population that research shows can most effectively be helped by coordinated care, officials state. A dedicated staff of care managers and care coordinators identify hospitalized ACO patients, coordinate transitions of care, and ensure patient care and healthcare resources are accessible.

  • Heads also turned when the Centers for Medicare and Medicaid Services (CMS) proposed updated penalties and incentives for its Medicare Shared Savings Program (MSSP), an accountable care initiative for Medicare beneficiaries. The proposed rules are designed to strengthen MSSP by placing greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. CMS is also suggesting a third ACO model," track 3," which integrates some elements from the Pioneer ACO model.

  • The patient-centered medical home (PCMH) model, a stepping stone to an ACO, garnered its share of readership, especially when the National Committee for Quality Assurance (NCQA) added five measures to its medical home criteria, the gold standard for patient-centered measurement.

    In its third iteration of PCMH standards since 2008, the NCQA added behavioral health integration and care management for high-need populations, among other new criteria.

  • The patient-centered model suffered a setback, however, when one of the first, largest, and longest-running multipayor trials of PCMHs in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department (ED), or ambulatory care services or total costs of care over three years. Research by Rand Corporation and colleagues centered on patient-centered activities in the Southeastern Pennsylvania Chronic Care Initiative.

  • There was good news on the medical home front, however: A study published in September, 2014 attributed reductions in emergency room visits, principally by patients with chronic illness, to the PCMH approach. Research by Independence Blue Cross (Independence) and CTI Clinical Trial and Consulting Services (CTI), and published by Health Services Research, found that transitions to a medical home were associated with a 5 to 8 percent reduction in ED utilization. This finding is specific to patients with chronic illness(es) having one or more ED visits in any given year. These reductions were most evident among patients with diabetes.

  • Readers also paid attention when Geisinger Health System, an early adoptor of care coordination for chronic illness, announced that its all-or-none or “bundled” approach to primary care for patients with diabetes produced better health outcomes, and the benefits happened quickly for the more than 4,000 patients in the study. The system-wide approach was not easy, warned Geisinger: the model requires constant evaluation, and must be scalable across a variety of practice settings.

  • Also raising the bar for physician practices was Highmark, which shared six requirements for the "best practices" element of its successful pay-for-performance initiative. Physician practices can earn additional rewards for completion of an office-based best practice project, essentially a small pilot, that involves measurement and reporting.

  • On the flip side, reporting of some questionable hospital pricing strategies rated some page views as well. Data released early in 2014 by National Nurses United (NNU) and the Institute for Health and Socio-Economic Policy (IHSP) found that some U.S. hospitals charge more than 10 times their cost, or nearly $1200 for every $100 of their total costs. Public oversight or regulation seems to help constrain excessive pricing, researchers found; Maryland, probably the most regulated state in the United States, has the lowest average charges of all the states among its 10 most expensive hospitals.

  • Cost savings aside, readers seemed especially attuned to new approaches or technologies designed to streamline healthcare delivery and enhance the patient experience, such as an uptick in remote monitoring.

    One hundred percent of respondents to the Telehealth in 2013 Survey by the Healthcare Intelligence Network monitor weight and vital signs, up from a respective 79 and 77 percent in 2010. The health conditions monitored remotely remain the same from 2010, the top three being heart failure, COPD and diabetes.

  • And finally, as all eyes focus on care management interventions that span the healthcare continuum, many readers responded to a story on a CMS pilot that would give hospice patients more options in the type of care they wish to receive at the end of life. Under the Medicare Care Choices Model, individuals who meet Medicare hospice eligibility requirements could receive palliative care services from certain hospice providers while concurrently receiving services provided by their curative care providers.

Were these stories on your news radar in 2014? Stay up-to-date in 2015 with the latest healthcare news, trends and benchmarks with a free subscription to the Healthcare Business Weekly Update.

Humana Physician Quality Rewards Boost Population Health across Accountable Care Continuum

December 23rd, 2014 by Patricia Donovan

Humana offers primary care physicians a four-tiered value-based rewards program.

You can't argue with the data: the total cost of care for Humana's Medicare Advantage members treated in accountable care settings in 2013 was 19 percent lower than MA members receiving care in traditional Medicare fee-for-service (FFS) environments.

Humana's successful approach is honed from twenty-six years of experience with value-based reimbursement, explained Chip Howard, Humana's vice president of payment innovation in the provider development center of excellence, during a December 2014 webinar on Physician Quality Rewards for Population Health Management.

Today, Humana not only offers physicians four levels of participation and rewards in fee-for-value programs but supports their shift from an episodic to population health mindset with training and reporting.

This stepped approach has paid off for the payor and its Medicare Advantage (MA) members in other areas as well, including higher HEDIS® scores, fewer ER visits and hospital admissions, and improved clinical management and screening compliance levels for Medicare Advantage members.

Howard walked webinar participants through the four models, from Humana's Star Rewards program that incents providers who meet a subset of NCQA HEDIS goals, to its Medical Home program for high-functioning physician practices with a well-developed infrastructure, a physician population health champion and a robust team approach.

Each value-based option across Humana's Accountable Care Continuum supports the Triple Aim objectives of improving care, improving health outcomes and lowering cost—with the bonus of enhancing the overall patient experience, Howard noted.

Participating physicians are exposed to Humana's population health management initiatives, including the Humana at Home program for high-risk patients, with its goal of keeping MA members healthier, out of the hospital and safe in their homes; a 30-day Transitions program that reduced readmissions by 39 percent less than expected; and a bank of technologies and data tools that help providers become better population health managers.

Encouraged by gains from its pay-for-value strategy at the primary care level—the payor recently distributed $76.8 million in quality awards to approximately 4,700 physician practices— Humana is exploring programs to engage and incentivize specialists to achieve similar Triple Aim goals.

The intent would be to then promote interactions between the primary care physician, which Humana views as the "care quarterback," Howard noted, and sub-specialists that result in high-quality, efficient healthcare delivery.

Click here to listen to an interview with Chip Howard on the value of care coordination in Humana's Accountable Care Continuum.

Infographic: Variations in Maternity Care Quality Measures

December 10th, 2014 by Melanie Matthews

Hospital performance on four measures of maternity care — low-risk C-section rates, episiotomy rates, rates of exclusive breastfeeding before discharge, and VBAC (vaginal birth after C-section) rates — varied widely by hospital in California, according to an analysis by the California Hospital Assessment and Reporting Taskforce.

This infographic illustrates how two first-time expectant mothers, each with a low-risk pregnancy, can have very different delivery experiences depending on the hospital.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and ProfitabilityIn today's value-based healthcare sphere, providers must not only shoulder more responsibility for healthcare outcomes, cost and quality but also align with emerging compensation models rewarding these efforts—models that often seem confusing or contradictory. The challenges for payors and partners in creating a common value-based vision are sizing the reimbursement model to the provider organization and engaging physicians' skills, knowledge and behaviors to foster program success.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability examines a set of provider compensation models across the collaboration continuum, advising adopters on potential pitfalls and suggesting strategies to survive implementation bumps.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you'd like featured on our site? Click here for submission guidelines.

4 Factors Driving Resurgence in the Physician-Hospital Organization Model Today

October 10th, 2014 by Cheryl Miller

As healthcare organizations seek the infrastructure to respond to emerging payment models like accountable care organizations (ACOs), bundled payments, narrow networks and direct contracts, the physician-hospital organization (PHO) model is experiencing a resurgence nationwide.

But will it work this time? Four factors make the PHO attractive, says Travis Ansel, senior manager with the Healthcare Strategy Group, during Preparing for Value-Based Reimbursement Models: PHO Development for ACOs, Bundled Payments and Direct Contracting, a 45-minute webinar from the Healthcare Intelligence Network (HIN) now available for replay.

The first most immediate driver is independent physician alignment, says Mr. Ansel. While most markets are mature in terms of employment, there are still a number of markets where there are a significant number of independent physicians in key specialties. In these areas, the PHO model is more of an initial catchall type of alignment model, one that creates a loose tie between the hospital and the physicians in the market, and provides value to the physicians in terms of being protected as part of a larger group without having to become employed. One benefit for the hospitals is that they can align independent physicians en masse and create common incentives, instead of having to negotiate alignment models or arrangements with all independent physicians in their market.

The second driver is the increasing mutual accountability for quality and cost across providers. In the wake of transitioning payment models under payment and insurance reform, insurers and payors are trying to drive mutual accountability for patient costs to physicians and hospitals. The PHO is an appropriate response for those providers to work together to manage the cost of a population and of an episode of care in order to make sure everybody’s successful.

The third factor driving resurgence in PHO activity is the consolidation and distribution of resources that will allow providers to be successful in managing quality and cost. As healthcare reform and payment reform mature, information technology (IT) competencies, clinical competencies, care coordination practices, and exploring the patient-centered medical home (PCMH) concept are often unrealistic at the individual practice level. The PHO gives physicians and hospitals the platform to work on those care competencies together, build them in one place and then distribute them to PHO members — a “win-win for everybody,” Mr. Ansel says.

The final driver is the need for an effective framework for clinical integration. While there are already a number of clinically integrated organizations around the country, “For the bottom 90 percent of healthcare organizations in the country, clinical integration is still that thing that’s on our to-do list, but it always gets bumped to the back of the to-do list; because, we have more immediate needs, or more immediate strategic priorities,” Mr. Ansel says. Clinically integrated models are needed as a strategy to respond to payment reform, to allow joint contracts between physicians and hospitals, and to enable sharing of payments effectively, whether those are shared savings payments, bundled payments, etc. Adds Mr. Ansel:

"The PHO model provides a great initial step to building that clinically integrated network platform, and gives providers and the hospital a great model for working together to start building the competencies towards a clinically integrated network."

Click here for an interview with Mr. Ansel.

2014 Value-Based Priorities: Population Health, Care Coordination, Integrated Care

July 3rd, 2014 by Cheryl Miller

From an early surge in Medicare accountable care collaborations (ACOs) to the problematic rollout of the nation’s historic health insurance exchanges during a 16-day government shutdown, healthcare in 2013 was nothing short of unpredictable. Respondents to HIN’s tenth annual Healthcare Trends and Forecasts survey identified a trifecta of value-based priorities for 2014, deeming population health management (56 percent), care coordination (51 percent) and integrated care delivery (42 percent) initiatives most worthy of their attention in 2014.

In tandem with these Triple Aim priorities, respondents also selected the accountable care organization (ACO) as the care delivery model most likely to transform healthcare, from both cost and care delivery perspectives. The patient-centered medical home has held this distinction for the last two years.

Some key findings from the survey include the following:

  1. The top business areas affected by the 2013 economy were growth (65 percent, still the top area but down from 72 percent in 2012); hiring and recruitment (65 percent); capital improvement (48 percent); and service expansion (43 percent).
  2. The top five factors impacting healthcare business in 2013 were not limited to purely financial issues as they have been in recent years: budget constraints (42 percent), the Affordable Care Act, or ACA (30 percent), reimbursement (28 percent), care transitions (27 percent), and the economy (25 percent).
  3. Beyond the ACO and the patient-centered medical home (PCMH), the care delivery systems with the most transformational potential were comprehensive primary care (19 percent) and bundled payments (11 percent).
  4. Beyond population health management, care coordination and integrated care delivery, the areas of healthcare most ripe for development are e-health and telehealth (39 percent), access to healthcare (33 percent), health and wellness (26 percent) and dual eligibles (25 percent).
  5. Impacts from continued rollout of ACA initiatives in 2014 include (in respondents’ own words): expansion of customer base from implementation of physician ACO and bundled payment programs; reduced reimbursement, requiring more efficiency and cost reductions; the challenge of delivering primary care services with improved outcomes and transparency in reporting; and revenue streams created by exchanges, along with a need to add primary care practitioners.

Excerpted from Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry.

Narrow Networks Top Payor Product Innovations List for 2014

June 17th, 2014 by Patricia Donovan

If recent market data is any indication, employers are gravitating toward narrow networks in greater numbers. For instance, a March 2014 Wells Fargo Insurance survey of more than 70 insurance companies placed narrow networks among the top three employer product innovations in 2014, along with are accountable care organizations (ACOs) and increased wellness programs.

In just one example, Harvard Pilgrim HealthCare this week introduced ElevateHealth℠, a partnership with Dartmouth-Hitchcock and Elliot Health System that is a non-profit, high-performance, defined-network product offering access to premier hospitals and providers in New Hampshire.

With its emphasis on care coordination within the network, ElevateHealth insurance premiums on average offer 10 percent savings compared with Harvard Pilgrim’s similar full-network plans, the insurer said.

And last month, UnitedHealthcare announced it would cut 2 to 4 percent of the physicians in its Medicare Advantage network in some Virginia service areas.

In theory, narrow networks—and their close cousins, tiered, tailored and high performance networks—sound like a good thing: health insurance products that group providers into tiers based on their cost or efficiency of care, then steer patients to choose these providers through lower premiums or cost sharing.

In practice, however, some consumers served by narrow networks are balking at the difficulty of obtaining appointments with network providers. Earlier this month, the Wall Street Journal reported that insurers in several states are expanding hospital and physician networks for plans sold through the Affordable Care Act's health insurance exchanges amid gripes from patients and state officials about limited provider choices.

Anthem Blue Cross, Blue Shield of California, Health Net and WellPoint are among insurers that have substantially expanded provider networks in its exchanges, the article stated. And more providers are slated to join Harvard Pilgrim HealthCare's ElevateHealth's network beginning in July.

Earlier this year, industry thought leaders analyzed what the proliferation of narrow networks means for healthcare. Steven Valentine, president of The Camden Group, talked about the impact on both providers and consumers.

"First of all, we anticipate an increase in the number of covered lives," Valentine said during HIN's annual healthcare trends forecast. "Providers are going to see an increase in patient volumes, especially primary care providers. And especially providers in states that have opted to stay in Medicaid."

However," he continued, "Many of the qualified health plans have narrow networks, so patients are probably going to be confused about which doctors are in their networks and probably will shift around until they can find the right place for them."

Providers in networks with bronze plans will probably have much higher increases in patient volumes, he predicted. "And other providers will probably see some shifting until patients can figure out where they need to go."

Regardless of the confusion, Valentine expects the trend of narrow networks to continue. "We clearly see narrow networks operating in conjunction with tiered benefit plans; that is, a lower premium, a more narrow network. We’ve clearly seen that in some of the exchanges as we look at the various medal options that are available. Narrow networks are here to stay; they are not going to go away."

Catherine Sreckovich, managing director in the healthcare practice at Navigant, concurs. "I agree 100 percent. We’re going to see [narrow networks] more and more. And to the extent there continues to be competition in the exchanges and more health plans trying to get involved, this trend will continue."

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

BCBS Michigan PGIP Value Partnership Translates to Quality Improvement, Cost Savings

May 6th, 2014 by Patricia Donovan

Donna Saxton: BCBSM's PGIP has resulted in primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend.

Blue Cross Blue Shield of Michigan's Physician Group Incentive Program (PGIP) is so studded with acronyms it's almost a separate language, jokes Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

And while not everyone speaks PGIP-tian, it's easy to translate the savings and benefits the medical home reward and incentives program portends for the insurer, its PCMH practices and its health plan members.

Ms. Saxton described PGIP's place in BCBSM's Value Partnerships program during Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, including the structure of rewards and incentives that have produced results for the plan, which operates the largest network in Michigan.

"PGIP incentivizes providers to enhance the delivery of care by encouraging them to be responsible and proactive in their behaviors, and ultimately driving better health outcomes and also increasing the fee for value that we also desperately need to get to," said Ms. Saxton.

In return, BCBSM provides financing tools and support for the nearly 18,500 primary care physicians and specialists who participate—more than half of BCBSM's physician population.

Aimed at some root causes of high cost healthcare, including a weak primary care foundation, PGIP, which Ms. Saxton described as the organization's "pinnacle" initiative, expects physician organizations (POs) to take responsibility for developing systems of care, motivating its physicians from within and adopting a culture of process improvement. In return, BCBSM places resources and a PGIP field team representative at the POs' disposal.

Some PGIP activities eligible for incentives range from e-prescribing and patient registries to specialist referrals and medical homes' linkage to community services, Ms. Saxton explained. Further, BCBSM has amped up three key medical home initiatives for its organized systems of care (OSC), "putting them on steroids," as Ms. Saxton said, to raise the performance bar and offer more chances for POs to earn incentives.

BCBSM coined the term OSC, which, while conceptually aligned with the goals of an accountable care organization (ACO) is designed to give providers more latitude in detemining their priorities, she noted. "The OSC is where the neighborhood concept comes into play, where you focus on implementation of PCMH neighborhood capabilities in your specialty offices to further address fragmented care." BCBSM specialists are eligible for one-time incentives plus enhanced fees for collaboration with primary care practices.

A counterpart to PGIP incentives is the PGIP PCMH designation program, an opportunity for practices to earn BCBSM's internally developed medical home designation and the added incentives that go with that distinction, such as increased reimbursement for PCMH office visits. The designation comprises 140 capabiities across a dozen areas.

To date, the biggest challenge of PGIP appears to be its extended access initiative, but practices who adopt more open scheduling often have much lower rates of ED and radiology utilization, noted Ms. Saxton.

Connectivity is also an issue for some, especially practices in rural areas of the state or organizations that have not yet adopted EHRs, which will ultimately be required for participation.

Compared to non-BCBSM-designated PCMHs, the organization's medical homes have produced some significant results, including an 11.2 percent decrease in primary-care related ED visits and a 6.7 percent reduction in low-tech radiology usage.

Ms. Saxton shares more on physician incentives and rewards and some outstanding primary care collaborations that have resulted from the engagement of specialists in BCBSM’s medical home program in this audio interview.