Value Based Programs Overview

Transcription

1 Value Based Programs Overview

2 What are Value-Based Programs? A data driven, innovative way to incentivize collaboration between physicians, consumers and employers to improve quality, cost, and patient satisfaction. Florida Blue is leading the way Over 30% of Florida Blue commercial medical spend flows through a value-models 90% of members have access to value based providers in their region Providers in these models are designated on Florida Blue s provider directory 2

3 Value Based Programs at Florida Blue Current State Population Based Accountable Care Organizations Patient Centered Medical Home (PCMH) Comprehensive Primary Care Program Regional Primary Care Program Bundled Payments/Episode Payments Collaborative Care Models for Medicare Advantage Oncology ACOs Hospital Pay-for-Performance In process: Oncology Medical Homes, Comprehensive Cardiology Initiative 3

4 Value Based Program Goals Provide physicians with measurement analytics that are pertinent to their practice Improve integration and quality of care Improve member experience Avoid waste and duplication of care Bring cost trend in line or below inflation Facilitate infrastructure to enable new generation based insurance products 4

5 Value Based Methodologies Patient-Centered Medical Homes (PCMH) The primary care physician coordinates a team that takes collective responsibility for patient care and, when appropriate, arranges for care with other qualified physicians. Include bonus funding for meeting and exceeding defined cost and quality measures. Accountable Care Models Includes PCMHs and other providers to deliver coordinated care for a population. Populations can be global or condition specific Uses a Total Cost of Care benchmark to fund efficiency incentives with a quality gate. Currently up-side only for commercial business. Episode-based / Bundled Payments Defines an episode of care and pays providers with a single payment for all clinically related services. Providers assume clinical risk for items such as complications and readmissions. Creates accountable care for the episode. Pay-for-Performance / Quality-Based Incentive Programs Rewards healthcare providers for achieving improvements in multiple areas including process, efficiency, clinical quality outcomes, infrastructure and patient safety measures. Improved performance impacts future FFS. Collaborative Care Models A Primary Care Physician centric model that uses a prospective, risk-adjusted revenue concept to fund proactive care for Medicare Advantage patients with an emphasis on high-risk conditions. Physicians focus on the Triple Aim concept of improving cost, quality, and access / member satisfaction. CCMs can be gain-share, full-risk or global risk. 5

6 Value-Based Programs S a n ta R osa W al t on Holmes B a y Jackson Gulf Libe r t y G adsden L eon F r an k lin W a k ulla Accountable Care Organizations (ACO)s 1. Baptist Miami/AMS (Oncology) 2. NCH Healthcare (Naples) 3. BayCare Physician Partners 4. Holy Cross Physician Partners 5. H. Lee Moffitt Cancer Center (Oncology) 6. Cleveland Clinic 7. Brevard APO 8. Orlando Health Physician Partners 9. First Coast Health Alliance (Flagler Hospital) 10. Memorial Health Network (Memorial SFL) 11. Baptist Health Quality Network (Baptist Miami) 12. Physician Health Partners at Munroe Regional 13. Advantage Health Network (Tenet) 14. Baptist Health Care Corporation (Pensacola) 15. University of Florida Health (Jacksonville) 16. University of Florida Health (Gainesville) 17. Hospital Corporation of America (Northeast Florida) 18. Integrated Care of Sarasota (SMH) 19. Florida Physicians Integrated Healthcare Network Medical Homes (PCMH, CPCP, & RPCP) >300 Physician Groups >2,000 Physicians Participating PCPs M adison T a ylor Hamil t on Laf y et t e Dixie Gilch r ist L e v y Baker A lachua C itrus He r nando P as c o H illsbo r ough M an a t ee M a r ion Nassau D u v al Cl a y P utnam P olk Ha r dee S a r asota D eso t o Cha r lot t e L ee Lake F lagler V olusia S eminole O r ange Os c eola H ighlands Glades Hend r y C ollier I ndian R i v er St. L ucie P alm B each B r o w a r d M iami- Dade M a r tin Medicare Collaborative Care Models (CCM) 1. Blue Water Doctors 2. Bond & Steele Clinic 3. Diagnostic Clinic 4. Florida Medical Clinic 5. Gessler Clinic, PA 6. Gulf Coast CHS Management 7. Holy Cross Physician Partnersa 8. InterAmerican Medical Centers 9. Intercoastal Medical Group 10. Internal Medicine Associates 11. Martin Memorial Physician Corp 12. Melbourne CHS Management 13. Millennium Physician Group 14. North Broward Hospital District 15. Orlando Family Physicians 16. Osler CHS Management 17. PBC, Plus LLC 18. Physician Associates 19. Physician Trust MSO 20. Prime Health Physicians 21. Professional Health Choice 22. ProHealth MSO 23. Richard Hays 24. Rockledge CHS Management 25. Senior Medical Associates 26. South Florida Multispecialty 27. Total Medical Management 28. Shands and University of Florida Health Care Network (SUFHCN) 29. My Medical Access 30. Mario Almeida Suarez, MD 31. St. Lucie Medical Specialists (HCA) 32. Ocala Health Primary Care (HCA) 33. West Florida Physician Network (HCA) 34. West Florida Primary Care d/b/a Pensacola Primary Care (HCA) 35. verimed IPA 36. Santa Rosa CHS Mgmt. 37. Lakeview Internal Medicine 38. Health Point Medical Group 39. Morton Plant Primary Care 40. SC Physicians 41. St. Anthony s Primary Care 42. Baptist Health Quality Network Bundled Payments 1. Mobile Surgical Services 2. Florida Ortho Institute 3. Mayo Clinic 4. Coastal Orthopedics and Sports Medicine 6 Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association.

7 Patient Centered Medical Home (PCMH) Mature enhanced primary care physician model. PCP reward based on quality and cost improvement. 2,400 physicians 1,200,000+ members treated, 400K attributed Third largest PCMH in US Quality advantage over peers on 28 quality metrics 15% lower Emergency Room utilization 6% fewer admissions than peers 7.8% fewer bed days 7

8 Population ACOs Shared savings arrangement for a population 20 currently covering >300,000 attributed members in Florida members, several more in pipeline Most partners are clinically integrated health systems with multispecialty care. Employed and affiliated physicians included Just beginning to get meaningful outcome data All to date have met full year quality gate Almost all ACO s are beating cost trend targets 8

9 Medicare Advantage Collaborative Care Model Primary Care Physician centric model with emphasis on quality and high risk conditions. Opportunities for increased payment based on meeting quality, access and care metrics Provides member level detail on cost, utilization and quality performance such as clinical gaps in care and can be accessed online through Physicians Florida Blue Portal. 41% of MAHMO membership aligned to a CCM partner 42 Statewide CCMs 1,225 PCPs statewide 9

10 Clinical Quality Metrics Quality performance is the gateway to receive any financial incentive awards from value based programs PCMH Program Metrics contain the following: 29 Physician HEDIS quality metrics, which are nationally approved and evidence based Results - PCMH physicians performed better than nonparticipating peers in 26 of the 29 metrics. Performance as expected the remaining 3 metrics ACO Program Metrics Contain the Following A combination of agreed upon HEDIS quality metrics, CMS process and readmission hospital measures, HCAHPS survey results Results - ACO entities met all quality performance measures 10

11 Clinical Quality Metrics CCM Program Metrics contain the following: Access Metrics: Seeing established patients annually Seeing new patients within 90 days Managing ER visits Following up with high-risk patients after discharge Quality Metrics (Star Ratings/HEDIS ): Breast Cancer Screening Colorectal Screening Cholesterol Management (for CAD, Previous MI) Diabetes Metrics (Renal Monitoring, A1C>9, Cholesterol) Adult BMI, High Risk Medication, Diabetes (ACE/ARB) Adherence: Oral Diabetic Medication; Hypertension Medication (ACE/ARB) Adherence: Cholesterol Medication (Statin) Generic Prescribing Rate 11

12 Physicians - HEDIS Based Quality Metrics Mammography Screening BMI measure only metric Use of Imaging Studies for Low Back Pain Annual monitoring for patients on persistent medication Proportion of days covered with Statins HbA1C Lipid Panel Diabetic Retinal Exam Screening for Diabetic Nephropathy Proportion of days covered - diabetes all class Long-term Control Rx Use Avoidance of Antibiotic Treatment of Adults with Acute Bronchitis Medication management for people with Asthma Post MI: Beta Blocker Persistence Appropriate Testing of Children with Pharyngitis Treatment of Children with URI One annual visit for children aged 3 6 for a well visit One annual visit for children aged 12 to 21 for a well visit Immunizations (12) 12

13 Hospital - Quality Metrics Hospital Quality Metrics Inpatient Measures Process of Care Measures Acute MI/Heart Attack Composite Score for all measures in the category Pneumonia Composite Score for all measures in the category Blood Clot/DVE Prevention & Treatment Composite Score for all measures in the category Readmission Measures Pneumonia (PN) Heart Failure (HF) Heart Attack (AMI) Patient Satisfaction Performance Question How do patients rate the hospital overall? Question How well did nurses communicate with patients? Question How well did doctors communicate with patients?( Facility Quality Registries Participation Status Measurement Baseline HOSPITAL performance as reported by CMS HOSPITAL meets or exceeds state average HOSPITAL meets or exceeds state average HOSPITAL meets or exceeds state average Measurement Baseline HOSPITAL performance as reported by CMS HOSPITAL has a 30 day readmission rate result of As Expected or Lower Than Expected, of state average HOSPITAL has a 30 day readmission rate result of As Expected or Lower Than Expected, of state average If HOSPITAL has a 30 day readmission rate result of As Expected or Lower Than Expected, of state average Measurement Baseline HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) as reported by HCAHPS If HOSPITAL meets or exceeds state average result of 7 or higher If HOSPITAL meets or exceeds state average result responding Always, Usually If HOSPITAL meets or exceeds state average result responding Always, Usually Measurement Baseline Hospital actively participates in the nationally recognized registry If HOSPITAL currently participates in the [sample-sts] data base reporting, then HOSPITAL shall meet this measure score 13