Strategic Alignment in Health Care Presented to CAJPA Fall Conference 9/15/16 1
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 Health Care today Providers 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 Principles of Value-Based Care Pay 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 3
Evidence clearly shows that more does not equal better care. Studies estimate 30 cents of every healthcare dollar goes to care that is ineffective or redundant. 4
Healthcare Costs The Challenge Drivers of Cost: Fragmentation Lack of accountability & coordination Narrow focus of providers Waste/redundancy Difficult system for consumers to navigate Today 5
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 price Our 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 11
Specialty Care Management: Oncology cancer care today oncology practice of the future Rapid paradigm shift in diagnosis & treatment approach, from cancer site to tumor genomic profile Care not evidence-based in up to 30% of adult cancer patients Patients not well informed of diagnosis, treatment options, likely outcomes & cost Quality of cancer care not well measured Provider and drug reimbursement not aligned with rational care Patient wishes for care at end of life not documented/followed Scientifically advanced molecular diagnostics & personalized therapy Real-time clinical decision support to promote evidence based medicine Embedded shared decision making & delivery of preference-concordant care Robust quality metrics, including patient-reported outcomes Reimbursement that rewards quality and value Respect for patient autonomy throughout care & end of life
Oncology practice of the future Whole-person, patient-centered care Compensation models reflecting quality and value Delivery of evidence-based medicine, and faster adoption of it into practice Ongoing processes to assess and address patient needs, with support that extends beyond the clinical setting Shared decision making to align treatment selection with patient s preferences and values
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
What is Choosing Wisely 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 To access the free Consumer Reports materials: ConsumerHealthChoices.org/Choosing 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