Posts Tagged ‘Specialists’

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Infographic: Are Specialty Practices Prepared for MACRA?

September 18th, 2017 by Melanie Matthews

A growing number of specialty physicians, comprised mainly of oncologists and urologists, recognize that clinical, financial and operational changes are needed to be successful under value-based healthcare reimbursement models stemming from MACRA regulations. However, the majority has not yet invested in organizational, IT, or service improvements needed to achieve them, according to a new study by Integra Connect.

A new infographic by Integra Connect highlights the survey findings, including details on the barriers to MIPS success and practices’ plans to optimize MIPS success.

Under CMS’s “Pick Your Pace” choices for Year 1 Quality Payment Program participation, physician practices may opt for the minimum activity necessary to avoid a payment penalty in 2019 by simply submitting some data in 2017.

However, instead of delaying MACRA participation to the later part of this year, physicians should prepare and better position themselves today for MIPS success by analyzing their existing CMS data on their practices’ performance and laying a path now toward performance improvement.

Physician MACRA-Readiness: Mining QRUR and Other CMS Data to Maximize MIPS Performance describes the wealth of data analytics available from the CMS Enterprise Portal–Quality Resource Use Reports (QRURs) and other reports providing a window into practice performance under the Merit-Based Incentive Payment System (MIPS). MIPS is one of two MACRA reimbursement paths and the one where most physician practices are expected to align.

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Posted in Healthcare Quality Reporting, Healthcare Trends, Infographics, MACRA, Physician Practices, Specialists, Value-Based Reimbursement | Comments Off on Infographic: Are Specialty Practices Prepared for MACRA?

Horizon Episodes of Care Program Prototype for Value-Based Specialty Care and Reimbursement

April 21st, 2016 by Patricia Donovan

Horizon BCBS-NJ's Episodes of Care program engages specialists across a suite of nine episodes.

Imagine a value-based healthcare payment model in which the sole financial hazard to specialist providers is the risk of amassing additional revenue.

Further, envision a scenario in which these specialists are invited to design their payment program, from the model’s intent to key quality metrics.

Those are some highlights of Horizon Blue Cross Blue Shield of New Jersey’s Episodes of Care (EOC) program, a value-based model designed to focus specialists on the provision of quality- and value-based care across nine separate episodes, from joint replacement to hysterectomy to oncology.

Hailed as a national leader in advancing the episodes model as a prototype for value-based specialty care, Horizon is careful to distinguish its EOC program from a bundled payment initiative, for two key reasons.

“First, our EOC program is a quality-based program; it’s not only about the payment or payment structure,” explained Lili Brillstein, director of the Horizon Episodes of Care program during a recent webinar, Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship.

Secondly, bundled payments typically refer to a prospective model in which a bundled amount of money is paid to a provider or group of providers in advance of services being delivered, while Horizon’s retrospective model pays providers after services have been provided.

The upside-only nature of Horizon’s retrospective model contributes to the program’s collaborative nature, Ms. Brillstein added. “If the metrics are met, savings are shared. If the metrics are not met, we’re not punishing our partners.”

There is other evidence of collaboration and of Horizon’s desire to see the providers succeed in the EOC program. One example is the payor’s use of case mix-adjusted budgets at the practice level rather than the prevalent member-specific risk-adjusted budgets. “This budgeting allows Horizon to create an opportunity for providers to move the needle [on a metric], and benefit from that. The opportunity for cost savings and shared savings also is dramatically improved.”

Another case in point is Horizon’s invitation to prospective providers to talk through the episode’s construct, intent and design prior to its launch.

Horizon’s engagement of providers in the EOC program has “changed the spirit of the relationships between the payor and the provider,” Ms. Brillstein noted. “It’s like nothing I’ve ever seen before. Our provider partners have become our ambassadors for the program.”

Select EOC results presented during the webinar indicated that outcomes are better for EOC partners—in the area of reduced readmissions, for example—than they are for physicians not in the EOC program.

Horizon expects to launch at least three more episodes in 2016, including a Crohn’s Disease episode that will take into account behavioral health services for those members. While the payor fully expects to move to a prospective model, it believes its current EOC model is preparing them for that eventuality, softening the transition from fee for service to prospective payments.

“[That transition] doesn’t just happen. You don’t sign the paper, and suddenly know what to do. It is an evolutionary transformative process,” concluded Ms. Brillstein.

Click here to listen to an interview with Lili Brillstein: Horizon BCBSNJ Episodes of Care: No-Risk Retrospective Model Paves Way for Value-Based Migration

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Posted in Affordable Care Act, Bundled Payments, Disease Management, Physician Practices, Post-Acute Care, Reducing Readmissions, Risk Stratification, Value-Based Reimbursement | Comments Off on Horizon Episodes of Care Program Prototype for Value-Based Specialty Care and Reimbursement

Guest Post: 7 Ideas to Improve Communication and Coordination between Care Sites

September 22nd, 2015 by Richard A. Royer, CEO, Primaris

With access to some of the most highly educated and trained medical professionals in the world, providing Americans with the best patient care possible should be simple. Unfortunately, that’s not often the case. Poor communication between specialists, duplicate tests and unnecessary procedures are frequently the norm rather than the exception, leading to costly, dangerous and sometimes deadly consequences. With so many specialists and resources readily on hand, how is this happening?

The problem is a lack of care coordination. Simply put, care coordination is the idea that all specialists treating a patient should communicate and share information to ensure that everyone acts as a team to meet patient needs. This includes reporting all results back to a primary care practice or to someone coordinating patient care, and ensuring that labs, specialists, hospitals, and long-term care facilities work together to communicate information quickly and appropriately. It’s about primary care physicians, nurses, technicians, specialists, and caregivers collaborating on patient care rather than working as separate entities.

The average Medicare beneficiary interacts with seven physicians in four different practices during a single year, according to the New England Journal of Medicine. For those with chronic conditions, the numbers can be even higher. And, nearly one-fifth of Medicare patients who are hospitalized are readmitted within 30 days of discharge, and 75 percent of these readmissions could have been prevented by improved care coordination.

Too often, patients discharged from hospitals don’t get the support and encouragement they need to take their medicine, follow their diets, and adhere to the regimens doctors have prescribed during their stay. Many of these problems can be solved by improving care coordination, and that starts with communication between care sites.

Here are seven suggestions for improving communication between care sites—as well as across the care continuum:

  • Start the dialog: As a rule of thumb, improving communication between care sites begins with healthcare providers asking themselves what they know that others need to know, and sharing that information with the patient’s care team. What do patients need to know when they’re referred to a specialist? What do the specialists that patients are being referred to need to be aware of, e.g. what tests have already been completed? Has the primary care physician been informed?
  • Create a team and make it accountable: Organizations should start by assigning a team of people to be accountable for managing patient care. Define the extent of their responsibilities for key activities such as following up on test results and communicating information to other physicians. Establish when specific responsibilities should be transferred to other care providers—whether that means specialty physicians, long-term care facilities, or home care providers.
  • Designate care coordinators: Designate staff that will act specifically as care coordinators can help to reduce hospital readmissions. Before patients leave the hospital, care coordinators should meet with them to make sure they understand the treatment plans they need to follow at home as well as any changes to their medication regimens. The hospital care coordinators also must follow up on any pending labs and imaging studies and contact primary care physicians to communicate updated medications, treatment plans, and test results for their patients. The likelihood of readmission drops significantly when patients leave with a clear understanding of their treatment plans and when their primary care physicians know what is necessary during follow-up care.

    This same communication protocol should also apply to patients who leave the hospital for long-term care facilities. In this instance, the hospital care coordinator should communicate discharge instructions to the long-term care staff. As soon as residents return to the long-term care facility, staff there should meet with residents to review their discharge instructions, answer their questions, and communicate with the hospital if any further clarification is needed. Long-term care staff should also follow up regularly with these residents to ensure they continue to comply with instructions the doctor has recommended and intervene if any problems arise.

  • Standardize communication processes: Create a protocol for filling out patient charts in a standard way so they are easy to interpret and key elements aren’t overlooked. You also should standardize communication by using structured forms to ensure primary care providers, specialists, and long-term care providers all have the same and necessary information.
  • Develop a referral tracking system: Creating a system to internally track and manage referrals and transitions— including consultations with specialists, hospitalizations and ER visits, and referrals to community agencies—can go a long way towards improving communication between care sites. It will help to ensure patients are well prepared for their referral visit and know what to expect afterwards. And, it simplifies follow-up with referral providers about findings, next steps and treatment plans.
  • Follow up on referrals: When a primary care physician refers a patient to a specialist, for example, office staff should follow up to make sure the appointment was made and completed. In addition, office staff needs to ensure the specialist shares his findings with the primary care physician so he can be well versed on the patient’s progress and any additional steps to be taken.
  • Notify providers in the patient’s medical neighborhood: Similarly, when patients visit the emergency room or are admitted to the hospital, communication should be a priority. In this instance, hospital staff should notify the primary care practice so the primary care doctor can follow the patient’s progress through discharge and institute a care plan to prevent future admissions. In addition, the practice can reach out to patients when they leave the hospital to make sure they understand discharge instructions and schedule follow-up appointments. When the patient comes in for follow-up care, the primary care physician should have a complete history of specialists seen during the hospital admission, their recommendations, and tests performed, along with the results.

The healthcare industry can no longer simply “discharge” patients. Providers must now work collaboratively with all others across the continuum of care to transition and coordinate the ongoing care of every patient. That’s what care coordination is all about.


Richard Royer

About the Author: Richard A. Royer has served as the chief executive officer of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006 he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the board of directors as treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience he has held positions as chief executive officer at Cuyahoga Falls, Ohio, General Hospital; executive director of Columbia Regional Hospital in Missouri; and founder and president of Avalon Enterprises, a medical financial consulting firm.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

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Posted in Avoidable ER Use, Care Coordination, Care Transitions, Chronic Care Management, Guest Posts, Hospital Readmissions, Hospitals, Physician Practices, Primary Care Practice, Transitions in Care | Comments Off on Guest Post: 7 Ideas to Improve Communication and Coordination between Care Sites

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

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Multi-Specialty Telehealth Collaborative Offers One-Stop Healthcare for Underserved, Remote Patients

October 24th, 2014 by Cheryl Miller

It’s all about the patient.

That’s what prompted Blue Shield of California and Adventist Health, both not-for-profit organizations, to collaborate on a telehealth program that could afford quality care to all Californians, when and where they need it, says Lisa Williams, senior director of strategic integration and execution, healthcare quality and affordability, Blue Shield of California, during Creating a Virtual Multi-Specialty Physician Network: A Payor-Provider Telehealth Collaborative, an October 15th webinar, now available for replay.

The presentation also featured Robert Marchuk, vice president of ancillary services at Adventist Health, and Christine Martin, director of operations, Adventist Health; all three shared the inside details on the collaboration and the shared mission and values that has led to the program’s success.

Located in largely rural markets, access to specialists is especially critical for the program’s success, Ms. Williams says. The nine-site program, which launched in March, includes 11 specialties, ranging from cardiology to dermatology to orthopedics and rheumatology, which account for the majority of volume in pre-op and post-op care. Specialists are all board-certified and credentialed. The program will expand to an additional 16 sites by the end of this year, with plans to add telepsychiatry, she says.

Central to the program is its care coordination center, a full-service, virtual, multi-specialty physician practice with robust patient and provider supporting services, says Mr. Marchuk. Similarly to a one-stop shopping site, when patients enter a site, clinicians make one phone call regarding that patient to the center, which coordinates all aspects of that patient’s care, from scheduling an appointment with the provider and the clinic itself, ensuring all patient records are available and uploaded to their electronic medical record (EMR), to scheduling follow-up ancillary services and physician appointments and billing. “It’s been very successful,” says Mr. Marchuk, “and really sets us apart from other programs.”

Identifying gaps in their markets, and then finding the right specialty and specialist for that market are big parts of the process, Mr. Marchuk continues. “There are physicians out there that can be wonderful on a face-to-face visit and very, very good clinically, but don’t necessarily lend themselves well to a video interaction, so we screen very carefully.”

Clinician engagement, extensive training, and communication at all points of contact are also important, says Ms. Martin. “You can never over-communicate,” she says. Patients, staff, local providers and specialty providers all need to know what’s going on, so the experience can be as seamless as possible.

Reimbursement for telehealth is still on the negotiation table, Mr. Marchuk adds. But ultimately, it pays to invest in the technology now for the future.

“It’s one of the fastest growing growing fields. It’s affordable, accessible, and cost-effective. Telehealth really can enhance the physician and patient relationship.”

Listen to interviews with Robert Marchuk and Lisa Williams.

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5 Features of the Patient-Centered Medical Home

October 23rd, 2014 by Cheryl Miller

Patient-centered medical homes (PCMHs) are not about pigeon-holing certain diseases or illnesses, says Terry McGeeney, MD, MBA, director at BDC Advisors, but about delivering acute and chronic care prevention and wellness. Dr. McGeeney reiterated the five essential features of the medical home as the groundwork for a medical neighborhood.

Given many of the initiatives of the Centers for Medicare and Medicaid Services (CMS), coupled with the Triple Aim, many have gotten bogged down and probably overly focused on the name: patient-centered medical home (PCMH). What’s important are the features or attributes of the PCMH: first, its patient-centeredness, a partnership among practitioners, patients and their families that ensures and respects the decisions of the patients and ensures patients have the education and support they need.

Secondly, in a PCMH, the care needs to be comprehensive. It’s a team of care providers who are wholly accountable for a patient’s physical and mental healthcare needs, including prevention and wellness, acute care, and chronic care.

Third, you will hear discussions about the PCMH being about a certain disease or illness. Please note that it’s acute and chronic care prevention and wellness. Pigeon-holing conditions, while important, is more of a chronic quality improvement initiative and not PCMH.

Fourth, under the PCMH, care needs to be coordinated. Care is organized across all elements of the broader healthcare system, including specialists, hospital, home healthcare, community service and support. There’s a lot of debate now about what we call ‘post-acute care’ or ‘transitions in care.’ Jonathan Blum, principal deputy administrator of CMS, recently spoke on the importance of post-acute care. This is what coordinated care particularly is all about.

Care has to be accessible. Patients are able to access services with shorter waiting times, after-hours care with access to EHRs, etc., and there has to be a commitment to quality and safety. Clinicians and staff need to enhance quality improvement with the use of health IT and other tools that are available to them.

We also need to be very careful that quality care is not equated with lower cost of care. Sometimes those two have a tendency to get muddled.

Source: Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs

http://hin.3dcartstores.com/Blueprint-for-a-Medical-Neighborhood-Building-Care-Coordination-Between-Specialists-and-PCPs_p_4967.html

Blueprint for a Medical Neighborhood: Building Care Coordination Between Specialists and PCPs provides a framework in which to evaluate the patient-centered medical neighborhood (PCM-N) model. Pictured here is Terry McGeeney, MD, MBA, director of BDC Advisors, who navigates the landscape of the medical neighborhood, from the value-based payment realities of healthcare today to identifying and engaging specialists in a medical home neighborhood.

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WellPoint Referral Preparedness Tools Support Physician-Specialist Care Compacts

October 2nd, 2014 by Cheryl Miller

With the help of care compacts that drive accountability between primary care physicians and specialists, WellPoint has launched a medical neighborhood pilot for three specialties with clear care coordination alignment opportunities with primary care medical homes. Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses how Wellpoint supports the care compact model with Referral Preparedness Tools— add-ons devised for physician/specialist patient handoffs.

One thing we found interesting was the uniform request from physicians for what we call ‘Referral Preparedness Tools.’ That’s a name we made up. These are add-ons to care compacts that call out common conditions for a given specialty, the conditions for which they often get referrals or consult requests from PCPs. It specifies for that condition what the specialist would like to see for the initial consult or regular repeating referral, and what they want the PCP to do first and send to them and specifically, what they want the PCP not to do—that is, things to avoid before sending the patient over.

On the flip side, the tool lists for that condition what the specialist intends to send back to the PCP. The practice will work on this together for common conditions. The tool doesn’t list everything that could possibly happen, but rather specifies the patient flow for common conditions.

We didn’t initially include this tool in our care compact expectations. The practices asked us for this; they see this as a true opportunity to drive improvement and efficiency in the system, to avoid unneeded care and to make sure that the correct care is provided for all patients.

We’re going to monitor development of these tools throughout the pilot to determine common themes so we can provide a good template starting place on this run as well as for future pilot practices in this program. We’re excited that specialists have made this template their own. They’re hard at work identifying what they’d like to see in these scenarios.

dual eligibles care
Robert Krebbs is the director of payment innovation at WellPoint where he has accountability for the design, development and rollout of value-based payment initiatives. He works directly with network physicians and facilities on innovative performance measurement programs aimed at delivering healthcare value by promoting high quality, affordable care.

Source: Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination

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Communication Key to ‘Healthy Handoffs’ in Medical Neighborhood

June 26th, 2014 by Cheryl Miller

Consultations and referrals have long been a source of frustration for physicians and specialists; physicians refer patients to specialists without the necessary tests or pre-work, or a physician refers a patient to a specialist, but hears nothing back from that specialist, says Robert Krebbs, director of payment innovation at WellPoint, Inc. There needs to be better, effective communication between the two, and established processes for consultations and referrals between physicians and specialists to ensure “healthy handoffs,” a key component of care coordination.

Care coordination is important to us and is the main pillar of our Patient-Centered Specialty Care program. What we mean by that is that care coordination is about effective communication. Practices need to establish communication timeliness expectations, agree on core default patient information regardless of the condition, and make sure the information flows back and forth between the two practices that are exchanging the patient or experiencing the care transition for that patient.

We actually refer to those as ‘healthy handoffs.’ That’s what we’re shooting for, care exchanges in which the patient moves between practices in a healthy fashion and everything moves back and forth between the practices in an ideal and efficient manner. It’s about establishing data exchange; that is, how is the information going to get back and forth between two practices?

Every practice is different. Every practice has different capabilities in terms of data exchange. We’re looking for practices to make sure that they understand each other’s capabilities so there are no assumptions to cause missed care opportunities for patients.

It’s about establishing processes for requests in consultations and referrals in the first place and expectations around interactions related to those referrals. It’s about agreeing on the types of consultations that are available: face to face, phone, e-mail from patient to provider. It’s making sure that the entire landscape of consult or referral is clear for both parties.

Excerpted from Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination.

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Care Coordination Compacts: Establishing Accountability, Clarity between Physicians and Specialists

May 22nd, 2014 by Cheryl Miller


It’s a scenario that occurs time and time again, and is a deep source of frustration for all involved: a physician refers a patient to a specialist, but hears nothing back from that specialist. In fact, they learn that the visit happened only when the patient returns for his primary care visit, but without any necessary information.

Or, a specialist receives a patient who has none of the pre-work or test results necessary for an effective visit, which ends up delaying care for the patient. Or, on the flip side, the specialist receives patients that had numerous unneeded and avoidable tests done prior to the referral.

The culprit? Lack of accountability and clarity, the foundations of the Care Compact, an agreement between two practices that outlines the roles and responsibilities of each in order to promote patient-centered care, says Robert Krebbs, director of payment innovation at WellPoint, Inc., during Care Compacts: Forming the Foundation of Care Teams with PCPs and Specialists, a May 2014 webinar now available for replay from the Healthcare Intelligence Network.

The Care Compacts (also known as Care Coordination Agreements and/or Referral Agreements) are key to WellPoint’s patient-centered medical home neighborhood (PCMH-N) pilot, Patient-Centered Specialty Care (PCSC). The program was launched in January 2014 with a select number of pilot practices, ranging in size from solo practices to large group practices in markets where there is a strong patient-centered medical home (PCMH) foothold, says Krebbs.

PCSC is a value-based reimbursement program developed for three types of specialties with clear care coordination alignment opportunities with PCMHs: cardiology, endocrinology, and OB/GYN. These specialists work with existing patient-centered medical home partners to improve quality and coordinate care guided by cost and efficiency measures, Krebbs continued, ensuring the following:

  • Effective two-way communication between primary and secondary providers;
  • Appropriate and timely referrals and consultations with prompt feedback of findings / recommendations;
  • Effective co-management of patients when necessary; and
  • Commitment to practice in a patient-centered fashion across all physicians delivering care to a patient.

The reason these care agreements work is because they provide a standard set of processes for roles in care coordination, truly defining what care coordination is between two practices. While many practices across the country agree they need care coordination, they don’t always agree on what the concept of care coordination is, Krebbs continues.

At their simplest, they help to clearly outline who’s going to do what in a referral or consult situation. By cutting out inappropriate duties and maintaining appropriate ones, they help to curb healthcare spend and improve patient care, Krebbs says.

“The care compact isn’t intended to solve all the world’s problems. It’s not going to make care coordination perfect, but it’s a starting point. Just like the patient-centered medical home (PCMH) provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It’s an essential starting point to further care coordination expectations across that medical neighborhood,” says Krebbs.

Listen to an interview with Robert Krebbs.

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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.

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Posted in Accountable Care Organizations, Avoidable ER Use, Disease Management, Electronic Health Records, Healthcare Quality Ratings, Healthcare Utilization, Patient-Centered Medical Home, Physician Practices, Value-Based Reimbursement | Comments Off on BCBS Michigan PGIP Value Partnership Translates to Quality Improvement, Cost Savings

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