Posts Tagged ‘Incentives’

PHOs Let Quality, Cost Guide Them Toward Value-Based Reimbursement

April 16th, 2015 by Cheryl Miller

Instead of focusing on volume, physician-hospital organizations (PHOs) are concentrating on value-based care, says Travis Ansel, senior manager with the Healthcare Strategy Group. The once revenue-based organizations are now focused on quality and cost, realizing that if they can’t manage those two things, their reimbursement will go down.

Why is the PHO model going to work now? We always get this question. This comes more from doctors than it does from administrators: why are PHOs going to work now, when they didn’t work before? The simple answer is that before, PHOs were revenue-focused. They were about getting the biggest number of physicians into the model regardless of their quality. It was run by the hospital as a methodology for increasing rates. Then fee-for-service (FFS) didn’t really give anybody the incentive to work together.

They gave everybody the incentive to sign their name on the contract and hope for better rates. What we’re seeing PHOs focus on now is quality and cost, with the idea that if they can’t manage those two things, their reimbursement is going to go down. We have clinical integration guidance from the Federal Trade Commission (FTC), which gives everybody the framework for developing joint contracting capabilities and defines legally how we can work together. What we’re seeing now, since there’s more of a clinical than a revenue focus for PHOs, is that they are more dominated by physician leadership. The hospital keeps control over the purse strings, but gives the governance of the group to physicians. They are letting them take the leadership on the cost and quality protocols that they need to develop to be successful.

There is also the way that payment reform is transitioning the incentives. They’re focused on getting quality and cost across populations or across episodes of care. They’re giving the right incentives for collaboration, which the PHO model provides the forum for.

Source: Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement

Home Visits

Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement describes the relevance of the PHO model to today’s healthcare market, offering strategies to leverage the physician-hospital organization for maximum clinical outcomes, competencies and value-based reimbursement.

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

Incentives Advance PCP-Specialist Communications in Value-Based Health System

January 6th, 2015 by Cheryl Miller

In a value-based reimbursement model, primary care physicians need to be quarterbacks for their patients, taking an additional interest in their care and following them to the end zone, or to other specialists providing care, says Chip Howard, Humana’s vice president of payment innovation in the provider development center of excellence. This will foster communication between physicians and specialists, a fundamental problem of the classic fee-for-service model.

Question: How can you manage and reward the complex interactions between primary care physicians (PCPs) and sub-specialists?

Response: (Chip Howard) That’s a pretty common question in the industry these days. If you think back to the old model, the classic fee-for-service model, the PCP potentially loses track of the member as they go to a specialist. The volume-based model is very fragmented. You don’t have communication, a fundamental problem of the model. But I think we’re on a discovery to potentially address that. Some thoughts that come to mind are putting incentives in place that will promote communication between PCP and specialists.

At the end of the day in a primary care model, we’re encouraging the PCPs to be the quarterback of the member’s care, to take that additional interest and follow the member through the path to other specialists that are providing care. There are also obligations on the specialist’s part that you would have to engage because it’s a two-way street.

Some other thoughts: we are starting to explore specialist engagement programs, whether it’s looking at bundled payments or at other sorts of programs that incentivize the specialist to achieve the Triple Aim: higher quality, lower cost, best outcomes. Then, putting data and analytics into the hands of PCPs that will enable them to potentially steer those members to specialists that are proving that they can work to achieve the Triple Aim on behalf of the patient.

There are also some ideas about how to promote interactions between PCPs and sub-specialists and start the ball rolling. That is a lot easier in an integrated system-type environment where there is one system that owns the continuum of care for the most part from PCP to specialist, to outpatient, inpatient, etc.

value-based reimbursement
Chip Howard is vice president, payment innovation in the Provider Development Center of Excellence, Humana. He is responsible for advancing Humana’s Accountable Care Continuum, expanding its Provider Reward Programs, innovative payment models and programs that enable providers to become successful risk-taking population health managers.

Source: Physician Value-Based Reimbursement: Quality Rewards for Population Health

HealthFitness Refines Population Health via Engagement, Tools and Technology

November 19th, 2013 by Jessica Fornarotto

Integrated health coaching continues to move the needle on population health management with interventions that keep the healthy, healthy without compromising the clinical support needed for high-risk, high utilization individuals. Dr. Dennis Richling, chief medical and wellness officer for HealthFitness, and Kelly Merriman, vice president of service delivery for HealthFitness, believe coaching offers a great opportunity to change the health status of a population.

In HIN’s special report, Integrated Health Coaching: Reducing Risk and Empowering Change across the Health Continuum, these industry experts detail HealthFitness’ move toward integrated health coaching, including the rules of participant engagement, the role of technology, and the range of self-management tools provided for participants.

Question: What strategies reach the population and increase engagement in health and wellness coaching?

Response: (Dr. Richling) One of the key strategies has been the use of an incentive that draws people toward the program. Incentives are fairly effective in getting people to do certain kinds of activities. If we provide an incentive for taking a health assessment, for instance, then we can engage them in a health advising session. We can take that external incentive and try to leverage it into an intrinsic motivation to go into our health coaching program. We see a better engagement rate when we offer an HRA, and when we provide screenings and advisement.

(Kelly Merriman) Engagement is also how long participants are choosing to engage with their coach. One of the main reasons we created our EMPOWERED Coaching program, or coaching across the continuum, is to more appropriately assign those individuals who have a chronic condition that is being well managed with somebody specially trained in lifestyle engagement techniques. Individuals working with our advanced practice coaches are much more likely to remain engaged with their coach because they’re focusing on those things that are most important to them.

Question: What is the role of technology in the various levels of health and lifestyle coaching?

Response: (Dr. Richling) We have developed a sophisticated algorithm that uses claims data and HRA data to decide which coach would be the best coach for the participant. The algorithm evaluates whether the individual has the appropriateness of care compared to chronic care guidelines, whether they are compliant to those guidelines, if they are having trouble with functions of daily living, and it also evaluates the risk for high cost in the future. These all go into identifying which professional coach would be the best fit for an individual. Technology continues to play a role after a person and coach are matched:

  • Assessment of risk is ongoing; HealthFitness’ data and technology platform can reassess a participant’s health status whenever new data becomes available.
  • Health coaches access a unique dashboard of participant-specific information via a proprietary HealthFitness technology platform. The technology populates a record with personal health risk factors, claims data, biometric screening results and previous contact with the coach and other program personnel, as well as complete activity and program information feeds.
  • The platform also displays a 360-degree interactive view of client-specific program options so the coach can reference participants to health management activities and programs from their employer, whether HealthFitness provides the services or not.

Question: What tools do you provide to your coaching participants to help them self-manage their conditions?

Response: (Kelly Merriman) We have a series of educational and self-management tools available for participants via their wellness Web site and/or the mail. For example, a coach can share documents and resources with a participant through a toolbox, which then integrates with the wellness portal. Additionally, participants are able to set up and track their focus area goals of interest. The coaching program has a mobile phone interface that allows users to track their progress remotely and stay in touch with their coach.

Risk Assessment, Case Management Help to Improve Dual Eligibles’ Health

April 30th, 2013 by Jessica Fornarotto

“When you look at some of the characteristics of the dual eligibles, in the under 65 population, 66 percent have only a chronic condition and have no functional impairments. But as you move up to the older ages, there’s fewer frailty and a bit more of the chronic conditions,” according to Dr. Timothy Schwab, chief medical officer of SCAN Health Plan. SCAN has a strategic approach to serving the dual eligible market, and Dr. Schwab recently discussed how they get this population to complete health assessments as well as the role of case managers in deciding who needs nursing home services. He also discusses how case managers work with the most extreme health condition cases.

Question: SCAN-risk stratifies individuals to determine those at highest risk, using HRAs, claims data and other assessment tools. How does SCAN encourage or incent completion of HRAs and other assessments in what can sometimes be a transient or hard-to-reach population?

Response: Getting completion of the HRA instrument is a challenge in any population, but more so in a very diverse population like the dually eligible. We initially mail our HRA to all new members. Then we follow up with reminder postcards. If we still don’t receive a response, we have a shortened risk assessment form that we ask them to complete through telephonic interactive voice response (IVR). Even with that, we still probably have a 30 percent failure rate to get the HRA done in a timely fashion.

We try to supplement that with information from our physicians. On the first visit to the physician, we can gather information and ultimately supplement it with our claims data on both the medical side and importantly the pharmacy side. We get a lot of valuable information, which makes up for people who don’t complete the HRA.

There are two groups that usually don’t complete it. The first is the group in long term institutions, like nursing homes. There’s a low response rate there. We also have a lower response rate in populations with mild dementia who are living on their own. But we also have a fairly low response rate from very healthy individuals. It’s important to recognize in the dual population that there are a group of duals that are relatively healthy. The only reason they’re a dual is because of financial conditions qualifying them for that. They could be out and about and just not concerned about completing the HRA.

We do not currently provide incentives for the general population to complete the HRA. We have tried some minor incentives with subsets of the population; for example, years ago with our diabetic population we offered a small gift of a foot care program if they completed a mini risk assessment. But in general, we haven’t found it effective.

Question: What percentage of your dual eligibles require disability support and what particular challenges would a case manager working with this subset of beneficiaries encounter?

Response: For our over 65 dual population, about 40 percent are what we classify as nursing facility level of care, or individuals who live in the community but have deficiencies in usually three or more activities of daily living (ADLs). They are frequently getting services for some of those deficiencies and are at high risk of ending up in a nursing home for long-term care, unless interventions are placed.

Of that 40 percent, probably about half are getting some sort of home-based services that are non-Medicare covered; things like personal care, homemaking, bathing assistance, and transportation assistance. For our case managers to make these assessments, do the in-home visits, and develop a care plan, we focus on hiring social workers, geriatric social workers and geriatric nurse practitioners. We spend a lot of time training them, both in how to identify the needs in the home, and how to identify the needs when talking with the caregiver, who is frequently an important part of this conversation.

We also offer on the job training for working with the rest of the team when they present these cases at our team meetings and the interdisciplinary care team meetings.

Question: How can care managers work with the most extreme cases that have multiple physical health and behavioral health, chronic and acute conditions?

Response: Those are the tough ones to work with. The first step is to find the right care manager for that individual. For example, if the primary issue is behavioral health, choose a care manager that excels in behavioral healthcare. That care manager then works with others to resolve the other issues. These people will require more time. You may also need to engage the help of the personal care workers or those in the home, so that they become both the physician and the care manager’s eyes and ears there. Teach them ways to pick up very subtle changes or differences in that person so that you can quickly provide new interventions if the person starts to show signs of deterioration. It’s a classic example of ‘one size doesn’t fit all;’ if your model says we will contact an individual monthly, some may need weekly and some may need daily contact. You may need to figure out ways to get that contact in an easy, efficient way for that individual.

Don’t Ignore ‘Reasonable Alternative Standard’ When Offering Outcomes-Based Incentives

March 15th, 2013 by Jessica Fornarotto

Companies contemplating outcomes-based health incentives shouldn’t ignore the portion of the population that can’t meet predetermined health standards, advises John Riedel, the president of Riedel & Associates Consultants, Inc. Reidel defines outcomes-based incentives, explains the role of risk-adjustment in these programs, and shares some recent data on incentives use among other companies.

We’re individualizing health goals based on where a person is on their health continuum as well as on their interest continuum. Based on behavioral economics principles, you also want to appeal to what people are most interested in, what will get them engaged in some sort of change. This is setting a risk-adjusted target. And so that you’re not presuming that all employees can meet a predefined set of health goals, you’re making this more individually targeted.

For instance, if someone is morbidly obese, or has cholesterol levels that are so high that it is unrealistic to bring them down to the health goal that you’ve already set, risk-adjust it and help people create the incentive program that will work best for them; get them on the right path.

When you offer outcome-based incentives in your company, you’re tying financial awards to whether or not the employees are within healthy ranges that you have set with them, which could be blood pressure, cholesterol, body mass index, or any other biometric measures.

The Affordable Care Act (ACA) requires a ‘reasonable alternative standard’ because there are people who can’t meet an outcomes-based incentive. If they have an unreasonably hard time meeting a goal, you must provide them a reasonable alternative standard. The law on that is fairly open-ended. Incentives are becoming more common and the requirements are getting tougher. In other words, they’re being moved more toward outcomes-based incentives.

According to Towers Watson Staying@Work Survey, over half of U.S. respondents are currently providing financial rewards for participation in health programs. Rather than simply rewarding program enrollment, about a third of employers are requiring employees to complete multiple activities to receive a reward or avoid a penalty. That reward could be a progress-based incentive or an outcomes-based incentive. About 23 percent plan to impose this kind of requirement.

In other data, Hewitt Associates found that the use of cash payouts for HRA completion doubled between 2009 and 2010, up to almost two-thirds. Also, the Kaiser Family Foundation Annual Survey of Employee Benefits Plans shows that large employers are reducing premiums for engaged employees. For instance, a company with 1,000 to 5,000 employees will reduce premiums by 17 percent.

Clearly, incentives are becoming more common.

Data Analytics Drive Population Health Management Design, Success

October 1st, 2012 by Patricia Donovan

data analytics

HRA's don't tell the whole story of population health.

Even though most companies spend an average of $10,000 per employee on healthcare costs, two-thirds don’t measure specific outcomes from health promotion programs, notes Patricia Curran, principal in Buck Consultants’ National Clinical Practice. Data analytics can help to close this disconnect, suggests Ms. Curran, who shared these findings during a recent webinar on Population Health Management: Achieving Results in a Value-Based Healthcare System.

How should companies measure ROI from health improvement efforts? By gathering population-specific data and relevant costs before launching a population health management (PHM) program and setting specific goals, she advises.

“Identify what’s important to you that’s going to show that your program is successful; whether it’s a decrease in healthcare or trend, decrease in healthcare cost, improved productivity, absenteeism. Determine four or five areas where you’re going to look for successful outcomes. And then set up your program so that you’re collecting the data that’s going to tell you whether those things are happening.”

Robust data analytics are the main underpinning of a successful PHM effort, Ms. Curran noted. In laying out a blueprint for PHM, she defined population health management as the management, integration and measurement of all health programs offered by an organization — a set of interventions aimed across the health continuum, from the healthiest employees or health plan members to those with catastrophic illnesses.

There are six types of data analysis that should form the PHM foundation, Ms. Curran said. These range from clinical data (e.g. biometrics or aggregate health risk assessment, or HRA data) to humanistic data, which encompasses satisfaction with the PHM program. Companies shouldn’t base an entire PHM program on HRA data, she cautioned; this data is self-reported and doesn’t necessarily tell the whole story.

Instead, companies should analyze data to identify the ‘at risk’ population, which is about 20 to 25 percent of the population that accounts for about 20 to 40 percent of the cost, Ms. Curran recommends. “These folks are not getting preventive care. They’re obese, they smoke, and they have other healthcare risks.”

Once the PHM program is designed, how should companies motivate the participants? That answer will be different for each company, she says. “Figure out what motivates the population: is it plan design, wellness incentives, or purchasing incentives?” For example, the raffling of a pair of tickets to a NASCAR® event, which proved a popular incentive at a trucking company, might not motivate a different population.

Similarly, tailored to the appropriate population, technology such as dashboards and smartphone apps adds a ‘fun factor’ to programs, she says, and can boost PHM success.

Also motivating is the creation of a culture of health in which management supports and participates in the PHM effort — one that employs robust communications and tools that not only help individuals to control their health, but also clarify cost (such as comparison tools and calculators).

Incentives still play a role in health and wellness improvement, but that role is changing, notes Ms. Curran. On the horizon, more rewards for the healthy, for such things as completion of preventive care. The social and behavioral issues of a population come into play in the design of incentives, she notes. These can include such elements as a supportive network, be they colleagues or management, and a focus on loss avoidance. “How badly does the individual want the incentive?”

Returning to the all-important factor of program ROI, Curran suggested that there are other areas to look at besides cost to determine the success of a PHM program. “Reduced cost is an important one, but it’s not the only metric. Other things may be increased efficiency, improved health status, outcomes and compliance, improved lifestyle behaviors, participation, changed opinions and interest, reduced turnover and improved company morale.”

“Programs for activities’ sake alone can’t and should not be sustained,” she cautioned.

More advice from Ms. Curran on population health management is available in this audio interview.

Health and Wellness Incentives in 2012: Participants Have to Hit Clinical Marks

September 13th, 2012 by Patricia Donovan

health incentives

Incentives in 2012: Rewarding Risk Assessment, Lifestyle Change

Showing up isn’t enough any more to earn a cash- or benefit-based incentive for health improvement, say respondents to HIN’s fourth annual Health & Wellness Incentives survey. Instead, employers and health plans are rewarding measurable achievements in health behavior change &#151 weight loss, smoking cessation, BMI reduction or other lifestyle changes that reduce an individual’s risk of developing or exacerbating a chronic (and costly) illness.

“That’s the future of population health management,” concurs Patricia Curran, principal in Buck Consultants’ National Clinical Practice. “Companies have developed incentive programs, but they’ve found that awarding incentives just for participating is not necessarily achieving the outcomes they want. Just taking the health risk assessment and the biometric screenings isn’t getting the results.”

While completion of a health risk assessment (HRA) remains the most heavily incented health improvement activity for the fourth consecutive year, according to two-thirds of survey respondents, more companies are incentivizing the lifestyle behavior changes of weight loss (57 percent) and smoking cessation (51 percent) than 2011’s favored activities of preventive screenings and participation in on-site wellness.

This makes sense, says Ms. Curran. “They’re making participants toe the mark. They have to meet certain health goals, and they’re going to be measuring that effort. They’re going to incentivize individuals for meeting those goals going forward. It’s a new trend — making people more aware of the importance of these health goals. [Companies] really want to see people getting results, so they’re going to be targeting things like weight management, tobacco cessation, BMI.”

In other survey findings, the use of texting to communicate incentive program details doubled in the last year, from 7 to 14 percent. Social networks and health portals also gained favor for this purpose. At the same time, more are relying on the more traditional communication modalities of work site flyers and table cards, a trend that has risen steadily from 61 percent in 2009 to 68 percent in 2011 to 84 percent this year.

“You have to leverage the right tools and techniques matched to those consumers or their preferences,” notes Jay Driggers, director of consumer engagement at Horizon Blue Cross Blue Shield. A key area of study for Driggers’s consumer engagement team is behavioral economics, which he refers to as “the carrots and the sticks, things that will motivate people to change their behavior or to do something.” Incentives fall into this category, he says.

The survey also identified a 2 percent increase in the awarding of incentives via contests and drawings, a practice reported by 57 percent of 2012 respondents. “In most cases, I think a lottery can be a cheaper option that will drive more participation than a one-to-one reward,” suggests Driggers, who recently outlined Horizon’s approach to consumer engagement in its patient-centered medical home initiative.

Other 2012 survey results:

  • The number of respondents reporting incentives program ROI of between 3:1 and 4:1 has doubled in the last 12 months, from 2.6 percent in 2011 to 5.3 percent this year. Program ROI of between 2:1 and 3:1 remained constant at 14 percent from 2011 to 2012.
  • The use of biometric screening to identify participants for incentive-based programs rose slightly in 2012 to 40 percent, up from 36 percent in 2011. Opt-in or self-registration remains the top identification tool, at 62 percent.
  • Group incentives lost some favor this year, in use by just 23 percent, versus 36 percent of 2011 respondents.
  • In new survey data this year, 20 percent extend eligibility for health and wellness incentives to domestic partners.

For more survey highlights, download the executive summary of Health & Wellness Incentives in 2012: Rewarding Risk Assessment, Lifestyle Changes. A detailed analysis of these metrics, including year-over-year trends, is provided in 2012 Healthcare Benchmarks: Health & Wellness Incentives.