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Strategic Alignment in Health Care

Presented to

CAJPA Fall Conference9/15/16

Transforming Care Delivery

Value-Based Pay for Performance

Oncology Practice of the Future

Maternity Care Focus - C-Sections

Choosing Wisely

Narcotic Safety Initiative

Transformation to value-based care

Principles of Value-Based CarePay for VALUE, not volume

Rewards and incentives for quality, health outcomes, and patient satisfaction

Providing doctors and hospitals with tools and real-time patient data to transform their practices

Integration of patient care across the care continuum

Helping consumers to become active in their healthcare through transparency and technology

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Health Care todayProviders are fragmented and unable to coordinate care well

Fee for service payment systems drive

fragmentation, rewards unnecessary care

Inconsistent quality with no line of sight for member care across the continuum

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Studies estimate

30 cents of every

healthcare dollar goes

to care that is ineffective

or redundant.

Evidence clearly shows that more does

not equal better care.

The Challenge

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Today

He

alth

ca

re C

ost

s Drivers of Cost:• Fragmentation• Lack of accountability & coordination• Narrow focus of providers• Waste/redundancy• Difficult system for consumers to

navigate

Shifting paradigms

Fragmented health care based on fee for

service model

Coordinated

experiences

founded on pay

for performance

Passive involvement

Member is

empowered

and actively

engaged

Brief History of Value-Based Pay for Performance

(VBP4P)

A shared savings incentive program to stem the commercial HMO

cost trend in CA while continuing to improve quality.

Statewide collaboration:

The Integrated Healthcare Association (IHA)

Health plans

Physician organizations (POs).

Pay for Performance (P4P) launched in 2001 and expanded to

include Valued-Based Incentives in 2013 to address utilization and

cost management.

10 health plans and more than 200 California Provider

Organizations caring for 9 million Californians in commercial HMOs

or POS.

What Does VB P4P Look Like at BSC?

BSC began participating in 2003.

VB P4P closely tracks with Our mission as a not-for-profit health plan, to ensure all Californians have access to high-quality health care at an affordable priceOur Values: creative solutioning and agility, while acting with integrity to get results.

Our Strategic Truths: To Change the Game and to Be Bold and Think Big

Reinforces that providers can impact the highest dollar care services

while actively maintaining quality standards.

To date, BSC has awarded over $137M to participating Provider Organizations.

VB P4P Goals

VB P4P incentivizes Provider Organizations throughout the course of

the program while Blue Shield assesses the ability of each

participating Provider Organization to:

Improve population health outcomes in key clinical areas;

Ensure patient satisfaction;

Align with CMS’ meaningful use of health information

technology;

Manage the overall cost of care; and

Encourage patients to access appropriate care resources.

How Is Performance Measured?

Three domains in the VB P4P program design:

1. Quality:

Prevention and chronic care management measures

Patient experience measures from the Patient Assessment Survey

Meaningful use of HIT to improve patient care

2. Total Cost of Care (TCC):

The actual costs associated with care for members attributed to a PO

3. Appropriate Resource Units (ARU):

A set of efficiency measures to improve the delivery of appropriate and

quality care

Tomorrow’s healthcare starting today

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Specialty Care Management: Oncology

oncology practice ofthe future

cancer care today

• Rapid paradigm shift in diagnosis & treatment

approach, from cancer site to tumor genomic profile

• Scientifically advanced molecular

diagnostics & personalized therapy

• Care not evidence-based in up to 30% of

adult cancer patients

• Real-time clinical decision support to

promote evidence based medicine

• Patients not well informed of diagnosis,

treatment options, likely outcomes & cost

• Embedded shared decision making &

delivery of preference-concordant care

• Quality of cancer care not

well measured

• Robust quality metrics, including

patient-reported outcomes

• Provider and drug reimbursement

not aligned with rational care

• Reimbursement that rewards

quality and value

• Patient wishes for care at end of life not

documented/followed

• Respect for patient autonomy

throughout care & end of life

Oncology practice of the future

Ongoing processesto assess andaddress patient needs, with support that extends beyond the clinical setting

Compensation models reflecting quality and value

Delivery of evidence-based

medicine, and faster adoption

of it into practice

Shared decision making to align

treatment selection with patient’s preferencesand values

Whole-person, patient-centered care

Maternity Care Focus: C-sections

Blue Shield has joined Covered California, California Maternal Quality

Care Collaborative (CMQCC) and Leapfrog Group, among others, to

address the troubling trend of increasing C-section rates.

Our goal is to lower the nulliparous term singleton vertex (NTSV) cesarean

section rate to the Healthy People 2020 target of 23.9%, the emerging

standard.

How will we do this? Five pronged approach involving the member,

physician and hospital in a collaborative environment.

Maternity Care Focus: C-sections

• Member Engagement: Our Prenatal Program features collateral and telephonic coaching that educates women that C-section is major surgery. Our program also promotes text4baby, a free text messaging service for pregnant women and new moms.

• Physician Engagement: Our Provider Education Program – a collaboration of Quality Improvement and MCS Enhanced Clinical Programs – is under development and will provide to providers with key messages and evidence-based practice guidelines from expert sources.

• Hospital Engagement: Our plan to address low-performing hospitals in targeted rating regions (managed by the Regional Delivery Network team) will use Maternal Data Center tools as well other elements that are under review.

• Contracting: We’re working to align incentives for POs and hospitals. We have piloted blended case rates in two hospitals and are reviewing the data for possible expansion.

• Data: Key to measurement and improvement using the “Plan-Do-Check-Act” model is key. Blue Shield has encouraged its hospital partners to participate in the Maternal Data Center and 90% of ACO hospitals are now participating

To access the free Consumer Reports materials:

ConsumerHealthChoices.org/Choosing

• 100+ campaign topics

• Specialty society endorsed

• All in Plain English and Spanish

• Support conversations

• PDFs, for easy printing

• Suited for email, linking, hosting

• Suited for clinic display/handouts

• Great for social media posting

What is Choosing Wisely

Source: Consumer Reports

Examples of Choosing Wisely Materials: Pregnancy Care

Source: Consumer Reports

Examples of Choosing Wisely Materials: Cancer Care

Source: Consumer Reports

How Is BSC Supporting The Choosing Wisely Campaign?

National Grantee

In 2015 BSC helped form a collaborative including the Institute for

Healthcare Improvement, Sharp Rees-Stealy Medical Group, Sutter

Health and California chapter of the American College of Physicians.

The goal of the collaborative is to leverage the Choosing Wisely materials

to reduce overuse by 20% in 5 key areas within 3 years:

• Avoidance of antibiotics for adults with acute bronchitis

• Imaging for uncomplicated headache

• Don’t perform repetitive CBC and chemistry testing

• Imaging for nonspecific low back pain

• Preoperative stress testing

Our collaborative is one of only 14 collaboratives nationally to receive

grant funding from ABIM Foundation and the Robert Woods Johnson

Foundation.

BSC also takes part in the California State Workgroup on Reducing

Overuse co-chaired by CalPERS, the California Department of Health

Care Services and Covered California, to address overuse of selected

medical care across public and private payers.

How Is BSC Supporting The Choosing Wisely Campaign?

Statewide Policy Development

BSC takes part in the California State Workgroup on Reducing Overuse

co-chaired by CalPERS, the California Department of Health Care

Services and Covered California, to address overuse of selected medical

care across public and private payers.

Collectively the workgroup covers 15 million California consumers.

The charter of the workgroup is to develop, initiate, monitor and evaluate

approaches to reducing the overuse of selected unnecessary and

wasteful medical services in CA.

The statewide workgroup is primarily focusing on reducing:

• Cesarean section for low-risk, first-time birth

• Diagnostic imaging for low back pain

• Opioid overuse