P4P program rewards providers for quality
Hospitals, physicians can earn extra reimbursement
With the goal of boosting outcomes for health plan members, BlueCross Blue Shield of South Carolina has developed a pay-for-performance program open to hospitals and physician groups in the network.
"We are focusing our attention on physicians and hospitals around quality initiatives and improving outcomes for our members. This ultimately will lead to better quality and lower costs," says John Little, MD, vice president of health care services and chief medical director for the Columbia-based insurer.
Officials at the health plan have been studying the pay-for-performance movement in the health care industry and decided to bring its own program into the market, calling it "performance recognition," he says.
"One goal for this program is to make hospitals and physicians comfortable with the idea of pay for performance and what it could ultimately mean. We want them to understand that we and other commercial payers are joining Centers for Medicare & Medicaid Services [CMS] in moving in that direction and that we plan to focus on rewarding providers who improve quality and ultimately lower costs," Little says.
The program is voluntary and open to any physician group or hospital in the network.
"Our intent is that the program will evolve as time goes on and we get better reporting and better data. We have made it clear to the provider community that this is not a static program and that this pilot project will evolve in the next 18 to 24 months," Little says.
Designing the program
In designing the program, the health plan looked at initiatives that would be meaningful to its members and have an impact on its population. Because South Carolina has a high prevalence of heart disease, diabetes, and stroke, the physician initiatives focus on those three diagnoses.
Under the program, physicians will receive a one-time cash award of up to $5,000 for achieving either National Committee for Quality Assurance (NCQA) accreditation for diabetes or cardiovascular disease or certification in hypertension management by the American Society of Hypertension.
"We chose NCQA because they focus on the disease areas we are interested in; the accreditation program is nationally developed and administratively doable for physician practices whether or not they have a sophisticated computerized medical record in their office. We added the American Society of Hypertension program to fit in with the South Carolina Hypertension Initiative," Little says.
The hospital portion of the performance recognition program has three parts:
- Hospitals will receive an increase in reimbursement (around 0.5%) for a year if they achieve the 90th percentile nationwide for any four of the 10 quality measures tracked by CMS quality initiative program.
- Hospitals that participate in the Leapfrog Group Hospital Quality and Safety Reporting Program will receive a similar increase in reimbursement.
- Hospitals that fully implement a computerize physician order entry (CPOE) system will receive a one-time reward of $50,000.
While most of the interest in the physician recognition program has come from primary care physicians, the health plan offers the reward to a physician of any specialty who is accredited by one of the programs or passes the test.
In the first three months of the program, nearly 20 physicians and physician practices qualified.
"We have seen a moderate amount of interest from other physicians. We’ve gotten some comments that it is more appropriate for primary care physicians and doesn’t cover every specialty. We knew that going in but wanted to start with something that is broadly applicable and meaningful to our membership," Little adds.
Accreditation from the NCQA involves reporting and chart-audit functions. To receive the designation of Clinical Specialists in Hypertension from the American Society of Hypertension, physicians have to take a course and pass an exam.
"These initiatives do take some effort. We made the reward high enough to catch the attention and interest of the physicians and to give them an economic incentive to cover the administrative cost of accreditation," Little says.
So far, one hospital has met the criteria for the CMS Core Measures performance, and there has been a substantial increase (from five to 14) in the number of network hospitals that report the Leapfrog quality and safety measures.
"This initiative got the attention of the hospitals and encouraged them to make a decision about reporting the Leapfrog measures," Little says.
So far, no hospital has completely implemented its CPOE system according to Leapfrog standards.
The health plan chose the quality measures because they would be administratively simple to track and wouldn’t add to the workload of the providers or the health plan.
"We didn’t want to create an industry of measurement that would require physicians and hospitals to do a lot of reporting and the health plan to do a lot of data analysis," he says.
The health plan chose national recognition measures, rather than a measurement system developed locally, so physicians and hospitals would feel confident about the nationally known standards.
"We wanted to leverage off existing quality initiatives for diabetes and cardiovascular disease," he adds.
Before embarking on the program, the health plan mailed a description of the program and an agreement to every hospital with which it contracts. The material outlines what the hospital must do to qualify. If they choose to participate the hospitals send in a signed agreement and list what criteria they met and the dates they met it.
The health plan’s staff go to the CMS and Leapfrog web sites and ensure that the criteria have been met.
Physicians received a similar mailing and must send in a signed agreement along with an accreditation certification certificate. As an alternative, physicians may send in the date they were certified and the insurer will check the NCQA or American Hypertension Association web site.
Once the health plan receives a confirmation that the criteria have been met, it implements the process for the provider to receive the cash award.
With the goal of boosting outcomes for health plan members, BlueCross Blue Shield of South Carolina has developed a pay-for-performance program open to hospitals and physician groups in the network.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content