Posts Tagged ‘PFP’

5 Requirements for Highmark Pay-for-Performance Participation

October 28th, 2014 by Patricia Donovan

Highmark Inc.’s well-established physician pay for performance program, Quality Blue, continues to evolve, providing its 6,300 enrolled primary care physicians the opportunity to earn bonus payments across a variety of measure sets. Here, Julie Hobson, RN, BSN, manager of provider engagement, performance and partnership at Highmark Inc., describes minimum requirements for physician participation in the program.

Our program is open to all the primary care providers (PCPs) in our network. However, there are some participation requirements. The incentive payment is rewarded to the practices based on their total score and is in addition to their fee-for-service (FFS) schedule.

There are over 113 evaluation and management (E&M) claims, both outpatient/inpatient, that we provide the incentive monies to. The quality scores are calculated on a quarterly basis and the incentive payment that the practice receives is paid for on that particular quarter.

There are five requirements that must be in place to be able to participate in our program. First, there has to be a participating provider agreement signed and in Highmark’s hands; second, an incentive participation agreement must be completed as well.

The third requirement is IT capabilities: the practice must have a Web-based provider application in their office. This is the Web-based application that we choose and it allows for real-time transactions. It is HIPAA-compliant and allows for sending and receiving of information to us and from us, as well as to them and from them.

Fourth, the practice must meet certain thresholds of E&M claims and electronic claims submission in a 12-month period.

And finally, they must achieve a minimum total score within the program.

Source: Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance

http://hin.3dcartstores.com/Guide-to-Value-Based-Reimbursement-Profiting-from-Payment-Bundling-PHO-Shared-Savings-and-Pay-for-Performance_p_4689.html

Julie Hobson, RN, BSN, is a manager in Highmark Inc.’s provider engagement, performance, and partnership department, which is accountable for advancement and deployment of strategic design and development of provider driven health management transformation.

Payment Bundling Requires Suspension of FFS State of Mind

March 25th, 2013 by Patricia Donovan
payment bundling shared savings

Webinar Replay: Moving Forward with Payment Bundling

Four hundred healthcare providers — about a tenth of all hospitals in the United States — can’t be wrong, can they?

That’s the number signed on to participate in a Medicare payment bundling pilot run by CMS, their biggest payor. And while it’s too early to know if the reimbursement concept will stick, one thing’s for certain, noted Jay Sultan during a recent webinar on Moving Forward with Payment Bundling: there’s a growing body of proof that the payment model works.

As an example, Sultan, associate vice president and chief product portfolio architect for TriZetto® shared some data from California’s Hoag Orthopedic Institute, formerly two surgical groups who have collaborated in a bundled payment model and “reengineered every aspect of care, from beginning to end, significantly lowering its common cost structure.” In one proof point shared by Sultan, Hoag reduced infection rates for knee replacements to 0.1 percent, significantly below the national 2 percent average, Sultan explained during the advice-filled session. The savings per avoided infection is about $60,000, he said.

While the federal payor has yet to report, early feedback from CMS’s recently concluded ACE bundled payment demo is largely positive in terms of revenue for participating payors, hospitals, physicians — even the patients in the pilot received a rebate from CMS, he added.

Based on Sultan’s own research, he is “not aware of any prospective payment, bundled payment program that was not beneficial for the providers, the payor and the members.” He contrasted prospective payments with retrospective payments, which he characterized as similar to fee-for-service (FFS) but with the possibility of receiving a bonus afterward.

There is a place for both payment types, but prospective does a better job of transforming care, Sultan noted.

Sultan went on to outline the general challenges for both payors and providers of crafting an episodic payment program, which could take up to 12 months. A strong analytics framework for both health plan and provider use is essential. What is also required is a mind shift on the part of entities unused to working together and sharing data, who need to realize that “under payment bundles, the provider and the payor have an opportunity to collaborate, instead of competing against each other in a zero sum way.”

For payors, some prickly areas early on might include provider contracting, claims administration, and impact on member responsibility.

Providers, for their part, must become adept at managing risk. Providers “need to be able to get the data, to develop analytics, and to develop methods for collaborating with each other — including the fact that some providers are going to lose,” he emphasized.

Sultan offered a wealth of advice for each entity contemplating a shift to bundled payments. For all stakeholders, what will be required is a paradigm shift away from FFS, the foundation for much of the industry’s day in, day out day out operations. “We measure our utilization by it, we evaluate our quality by it, we do all these things based on fee-for-service.

“When you change that, whether you’re changing it for shared savings ACOs, moving from FFS to capitation, or going from FFS to payment bundling, it has profound impacts throughout the entire organization.”

Sultan provides more advice on bundled payments, from two key factors to keep in mind when trying to engage physicians in the model to the major decision facing primary care now that CMS has introduced bundled payments for care coordination tasks, in this expanded interview.