Transforming Health Care: Moving from Volume to Value Dr. Joseph Cunningham Vice President of Health Care Management and Chief Medical Officer Blue Cross and Blue Shield of Oklahoma This presentation is a high-level summary and for general informational purposes only. The information in this presentation is not comprehensive and does not constitute legal, tax, compliance or other advice or guidance. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2009 State Health Rankings
2012 City Health Rankings Source: Commonwealth Fund Scorecard on Local Health System Performance, 2012.
Identifying the Problem Age-adjusted Death Rates 1,050 1,000 950 900 850 Tulsa US 800 1980 1985 1990 1995 2000 2005 Some Factors 1. Economic downturn: Healthy people and jobs left Oklahoma 2. Poverty remained 3. Heart Disease (Diabetes) 4. Cancer 5. Access to Care 6. Obesity Past 25 Years
Identifying the Problem
The Current State of Health Care in the U.S. The cost of health care in the U.S. is high. 17.2% of GDP in 2012 Health care reimbursement is focused on volume. Health outcomes are less than optimal. Move focus to Quality Difficult to define More difficult to measure 6
Transition Within Primary Care Physician Practices Requires changes in the care delivery model Team based care Development of milestones Access to and sharing with community data exchange Creation of scorecards to report Quality measures 7
Value Equation Value = Quality Cost 8
Reimbursement Strategies Fee-for- Service Pay for Performance Medical Home Accountable Care Organization (ACO) Shared Risk HMO Global Payment or % of Premium Population Health Provider Accountability Bridges to Excellence OK Hospital Infection Control Program Re-Admission & Surgical Complication Reduction Program Medical Homes CPC Initiative Pilot w/cms Discussions beginning with some OK health systems Overlapping Medical Mgmt. Delegated Medical Mgmt.
Value-Based Care Solution Guidelines Bring Care Management closer to the patient through the primary care physician Greater patient engagement Improved program adoption Care Management tools designed for care coordinators within a PCMH practice Enable stakeholders with information via Health Information Exchange Interoperable standards Flexible data storage models (federated and/or centralized) Use Analytics to turn data into actionable information Population based lists Care Gaps Identify patients with chronic conditions (or potential chronic conditions) 10
Value-Based Payment Innovative payment strategies gradually shift accountability for quality outcomes and cost onto provider. Current System (Guaranteed Increase) Future System Shift to Increasing Shared Savings and Quality-Related Incentives Fee Schedule % Fee Schedule % Fee Schedule Shared Savings Quality Incentives Fee Schedule Shared Savings Quality Incentives Fee Schedule Shared Savings Quality Incentives Fee Schedule
Looking to the Future Health Care Model Outcomes- Focused Health Management PROVIDERS Value-based provider reimbursement aligned to optimal health management PAYERS Critical Enablers Access to care Engaged consumers Advances in health information technology Evidence-based care standards Trust PATIENTS Personal Health Responsibility Benefits and services aligned to promote member engagement in optimal outcomes 12
Keys to Success Technologies Partnerships Reimbursement Strategies 13
Comprehensive Primary Care Initiative A four-year initiative developed by the CMS Innovation Center A collaboration between multi-payers that seeks to strengthen free-standing primary care capacity by testing a model of comprehensive, accountable primary care Approximately 140,000 participating Oklahomans
Goal of CPC Initiative Transform health care at the point of delivery: Better health. Better care. Lower costs. 15
Location Seven regions across the country Oregon Colorado Oklahoma Arkansas Ohio New York New Jersey 16
Program Participants Primary Care physicians Public and private payers Patients of all ages Medicaid members 17
BCBSOK Participation BCBSOK Fully Insured Federal Employee Program ASO accounts 18
CPC Initiative Support Tools Enhanced risk-stratified, non-visit based payment system Shared Savings program Ongoing education Systematic data sharing 19
Data Aggregation Practices participating in bi-directional data exchange with community based HIE Payer claims data flowing into the HIE Quality reporting generated out of HIE utilizing both EHR and claims data 20
Early Successes Over 70 care managers hired and embedded in participating practices. Statistically significant increases in preventive screening over baseline year Mammography Cervical Cancer Colorectal Cancer 21
` Thank You 22