Payment Reform Strategies. Ann Thomas Burnett BlueCross BlueShield of South Carolina

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1 Payment Reform Strategies Ann Thomas Burnett BlueCross BlueShield of South Carolina

2 Disclosure I have no relevant financial relationships with commercial interests to disclose.

3 The Current Market Landscape Increased Financial Pressures Complex Regulatory Environment Network and Product Complexity Shift to Lower Cost Settings Rising Retail Marketplace

4 Effective Health Care Reform Through Quality ALIGNMENT: Health plans contract with and reimburse providers based on the outcomes and value of care rather than on units of service or price. TRANSPARENCY: Consumers are engaged in health care decision making and use clear, meaningful information to routinely select their healthcare providers on the basis of value. PATIENT-CENTEREDNESS: Health benefit designs reward healthy behavior, encourage engagement in self management of chronic disease while creating disincentives for low value services and poor lifestyle choices. COLLABORATION: Payers, hospitals and providers work collaboratively to transform care delivery systems to be patient focused, evidence based, measurable, reliable and safe. = CARE DELIVERY REFORM 4

5 BCBSSC Innovation Philosophy Innovative programs developed as PARTNERSHIPS We can t do it alone! Depends on a shared vision for improving health outcomes in South Carolina Listening to our partners and responding to their needs Providing appropriate resources, expertise and financial support to achieve shared goals Providing easy access to robust actionable data Collaborating with other stakeholders invested in improving health outcomes in South Carolina Aligning performance measures whenever possible to prevent provider measurement fatigue Developed statewide committees to obtain consensus and support

6 The Path Toward Accountability Fee For Service Pay for Performance/ Incentives Episodic Bundling Shared Savings Capitation Full Risk

7 What are we doing to address the need for payment reform? Developed and implemented provider alternative payment models Pay-For-Performance (P4P) Rewarding Excellence Patient Centered Medical Home (PCMH) Episode-based Care/Bundled Payment Accountable Care Models Benefit Solutions BlueCross BlueShield Association Moved from a pilot stage to a large-scale deployment A leader executing payment reform initiatives in South Carolina and among other Blue Plans

8 Rewarding Excellence: Hospitals (P4P) Rewards top-performing hospitals with increased payments for the quality of care they provide Quality measures include key safety and efficiency measures, as well as patient experience. GOAL: To compensate hospitals for the quality of care provided to patients, not just the quantity of procedures performed.

9 Rewarding Excellence Development Key Values Input from hospitals for the best available metrics Incorporate Rewarding Excellence into contract negotiations Easy to reproduce by hospitals Third party data validation Align with CMS and state-wide initiatives Reward improvement Timeliness of data

10 Rewarding Excellence for Physicians The Rewarding Excellence for Physician Program consists of three components: Quality Measures Reporting and Transparency Physician Recognition Practice Patient-Centered Medical Home Recognition Practices have the opportunity to earn points in each of the three components for an overall score and increase to their reimbursement.

11 Transparency Display nationally recognized performance measures with comparison results on national and local websites Star ratings are assigned for each measure by comparing the practices score to the NCQA National benchmarks (75th, 50th and 25th percentile). The National percentile benchmarks correspond to a 1 Below Average, 2 Average or 3 Above Average Star rating. The 50 th percentile (Average) is used for the comparison percentage. Star ratings are shared with the practice for review. Star ratings are not displayed on web sites without approval. Star ratings are displayed at the practice level. All physicians have the same star ratings.

12 Blue Physician Recognition Program "The Blue Physician Recognition (BPR) designation means the physician has demonstrated a commitment to delivering quality and patient-centered care by participating in a local, national, and/or regional quality improvement and/or recognition program" and was developed by the BlueCross BlueShield Association Physicians/practices that participated in our original physician recognition program received this icon beginning in Criteria to receive the icon will now change to participation in the Physicians Rewarding Excellence Program. The Blue Physician Recognition icon will be displayed in addition to any other recognitions that the physician/practice has achieved such as NCQA Diabetes or NCQA Patient-Centered Medical Home.

13 Patient Centered Medical Home Continue to support and recognize PCMH practices throughout South Carolina Currently 702 physicians with 206 practices Membership state-wide: 202,990 Implemented BlueChoice Medicaid PCMH Network Collaborate regarding Healthcare Effectiveness Data and Information Set (HEDIS) benchmarks and other quality initiatives

14 Cornerstone for Success: PCMH Reimbursement Methodology Blended Payment Methodology FFS Fee-for- Service Payment Traditional PLUS Nontraditional services Prospective Payment Monthly payment Such as case coordination proactive outreach services technology and infrastructure Pay For Results Bonus Payment for Quality Outcomes Improved Patient Outcomes Reporting quality measures to support transparency initiatives and rewards for achieving quality recognition programs NCQA & PCMH

15 Robust Data Collection Structured and Unstructured Transforms disparate data into Claims Member Eligibility Pharmacy Practice EMR Population Health & Reporting Platform Practice Schedulin g System Practice Manageme nt System Progress Notes meaningful, actionable data: Instant robust patient view individual and pop level Gaps-in-care Performance tracking Robust data for enhanced reporting and analytics such as risk stratification and predictive modeling Easy to share and integrate: Instantly shared with our practice partners Easily integrated into other platforms such as DM/CM Direct Data Entry Transcriptio n (Word, etc.) Collects all types of patient data. Natural language processing

16 Episode-based/Bundled Payment Case rates are developed to define a patient specific budget for an entire episode of care Encourages shared decision making, care coordination and potentially improves quality April 2013 issue of H&HN magazine Does not penalize providers for caring for sicker patients due to risk adjusted budgets

17 Accountable Care Organization Models Integrated Organizations of Care Composed of primary care physicians, a hospital, and specialists Members of the healthcare team work together to improve the health of a designated population Key Components: Provider Risk Sharing Care Coordination and Integration Financial Incentives to Improve Quality Goals: Effectiveness Efficiency Quality of Care

18 Benefit Solutions Developed Client Specific Narrow High Performance Networks and custom benefit designs that encourage employees to choose care appropriately, for example: Large Integrated Delivery Systems 3 Tier Benefit Structure: Tier 1 Narrow Network Tier 2 Standard BCBSSC network Tier 3 Out of network State Health Plan Initiative PCMH Tier Benefit Structure with Narrow High Performance Network

19 BlueCross BlueShield Association (BCBSA) Implementing system-wide capabilities for PCMH, ACO and Bundled Payments payment models for BlueCard and National Accounts Creating guidelines on workflow, procedures and timelines regarding Episode of Care/Bundled Payments platforms.

20 In Closing Payment Reform is a Priority Directly through fixed base payment models, such as Accountable Care Models and Episode-based Payments Indirectly through reimbursement that improves quality, such as PCMH and Rewarding Excellence BlueCross BlueShield of South Carolina is committed to exercising leadership and working with stakeholders to make payment reform a reality

21 Questions Ann Thomas Burnett Vice President Provider Network Innovations and Partnerships BlueCross BlueShield of South Carolina (o)

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