mhealth israel_dr dana safran_payment reform successes and challenges_nov 25, 2014

Payment Reform Successes & Challenges Lessons Learned from the Alternative Quality Contract (AQC)

Dana Gelb Safran, Sc.D. Senior Vice President,

Performance Measurement & Improvement

Presented at:

mHealth Israel

25 November 2014

2 Blue Cross Blue Shield of Massachusetts

Payment Reform:

The Economic Imperative


Average spending on health

per capita ($US PPP)

Total expenditures on health

as percent of GDP

Source: OECD Health Data 2011 (Nov. 2011).

Economic Imperative in a Global Economy

4 Blue Cross Blue Shield of Massachusetts Proprietary and Confidential – Do Not Distribute without Permission

The Increasing Cost of Health Care in MA

Compared to Other Public Spending Priorities

Billions of Dollars

Source: Massachusetts Budget and Policy Center


The Massachusetts health reform

law (2006) caused a bright light to

shine on the issue of unrelenting

double-digit increases in health

care spending growth (Health

Care Reform II).

The Alternative Quality Contract: Twin goals of improving quality and slowing spending growth

In 2007, leaders at BCBSMA challenged the company to develop a new contract model that would

improve quality and outcomes while significantly slowing the rate of growth in health care spending.

8.2%

15.9%

13.8%

13.1%

12.1%

13.3%

12.8%

12.5%

10.8%

10.7%

-2%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

BCBSMA Medical Trend Workers' Earnings General Economic Growth

Sources: BCBSMA, Bureau of Labor Statistics.


A Case Study:

AQC Model & Early Results


Global Budget

• Population-based budget

covers full care continuum

• Health status adjusted

• Based on historical claims

• Shared risk (2-sided)

• Trend targets set at

baseline for multi-year

Quality Incentives

• Ambulatory and hospital

• Significant earning potential

• Nationally accepted

measures

• Continuum of performance

targets for each measure

(good to great)

Long-Term Contract

• 5-year agreement

• Sustained partnership

• Supports ongoing

investment and commitment

to improvement

The Alternative Quality Contract


Results Under The AQC: Improvement of the 2009 Cohort of AQC Groups from 2007-2012

Op

tim

al C

are

These graphs show that the AQC has accelerated progress toward optimal care since it began in 2009. The first two scores are based on the delivery of

evidence-based care to adults with chronic illness and to children, including appropriate tests, services, and preventive care. The third score reflects the

extent to which providers helped adults with serious chronic illness achieve optimal clinical outcomes. Linking provider payment to outcome measures has

been one of the AQC’s pioneering achievements.

83.1 84.086.0 86.7

80.4 81.1 80.8 81.0

77.779.6

79.280.3

2007 2012

BCBSMA HEDIS National Average

Adult Chronic

Care

Pediatric Care

91.3 91.6 92.2 92.1

69.7 70.7 71.6 71.7

88.289.9

68.169.5

2007 2012


Adult Health

Outcomes

65.668.3

72.274.0

61.4 61.9 62.2 61.9

61.5 62.1

59.861.2

2007 2012


100

50


AQC Results: Formal Evaluation Findings

Source: Song Z, et al. Changes in Health Care Spending and Quality 4 Years into Global

Payment. The New England Journal of Medicine. 2014.


AQC Support & Improvement Analytics


Components of the AQC Support Model

Our four-pronged support model is designed to help provider groups succeed in the AQC.

Data and Actionable Reports

Best Practice Sharing and Collaboration

Consultative Support

Training and Educational Programming


New AQC Provider Dashboard

The updated dashboard provides actionable data, gives providers tools to more actively

manage the growth of medical trend and benchmarks them against other groups.


Daily Daily Census, Discharge, PCP Referrals and

Inpatient & Outpatient Authorization Reports

Weekly New Member Report

ED Utilization Report

Monthly AQC Member Call Tracking Grid

Monthly Ambulatory Quality Report

Monthly AQC Ambulatory Quality Measures

Group Comparison Report

Chronic Condition Opportunities Report

Quality Diabetic Composite Score

Bi-Monthly Case Management Report

Quarterly Ambulatory Care Sensitive Conditions Report

AQC Financial Dashboard

Non-Emergent ED Report

Top 100 Rx Report

Bi-Annually Practice Pattern Variation Report—Episode

Treatment Groups (ETG)

Practice Pattern Variation Report—Emergency

Department Use for Specific Conditions

Annually Readmission Report

AQC Ambulatory Quality Measures Score/Results

AQC Hospital Quality Measures Score/Results

Recurring Cost and Use Report

Site of Service Report

Data and Actionable Reports

We distribute reports that can be used to help organizations recognize opportunities,

develop goals and measure their success.


The results are

highly actionable

because they get to the

root of variations in

treatment costs for a

defined and highly-specific

clinical circumstance

among physicians of the

same specialty

Source: Greene RA, et al. Health Affairs 2008; w250-259

Practice Pattern Variation Analysis (PPVA)

Unpacking differences in the treatment components of specific episodes across clinicians in a

single, defined medical specialty.


The 12 primary care physicians in this group have

rates of ARB use ranging from 13% to 55%.

9 physicians have rates above the network average.

Benign Hypertension, With and Without Comorbidity

Individual Primary Care Physicians

Rate of ARB Use per 100 Episodes with ACE-I and/or ARB

2007

Rate = Episodes with ARB / Episodes with ACE-I and/or ARB

0

10

20

30

40

50

60

70

80

90

100

1 355 709 1063 1417 1771 2125 2479 2833

Individual Primary Care Physicians (N=3178)

Ra

te o

f A

RB

Us

e p

er

100

Ep

iso

de

s

wit

h A

CE

-I a

nd

/or

AR

B

The 12 primary care physicians in this group have

rates of ARB use ranging from 13% to 55%.

9 physicians have rates above the network average.


Staffing Models Approaches to

Patient Engagement

Data Systems & Health

Information Technology

Referral Relationships &

Integration Across Settings

Delivery System Innovation: Four Themes

There are four domains in which we see AQC Groups innovating to improve quality and

outcomes while reducing overall spending.


Summary

Payment reform gives rise to significant delivery system reform

Rapid, substantial performance improvements are possible in the context of meaningful financial incentives;

rigorously validated measures and methods; ongoing, timely data sharing and engagement; and committed

leadership

For payment reform, deep provider relationships and significant market share are advantageous

Expanding payment reform to include PPO presents unique challenges

Gaining strong employer buy-in and support will be important – and this means models must offer value from

day-1

Continued evolution of performance measures to fill priority gaps

Focus on outcomes, including patient reported outcomes (functional status, well being)

Continued delivery system reform, including:

Evolving the role of hospitals in the delivery system

Building deeper engagement of specialists

Bringing incentives (financial and non-financial) to the front lines

Advancing innovations in virtual care


[email protected]

Discussion

mhealth israel_dr dana safran_payment reform successes and challenges_nov 25, 2014

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