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A Blue Cross and Blue Shield Association Presentation
National Pay for Performance SummitNational Pay for Performance SummitFebruary 7, 2006Los Angeles, CaliforniaLos Angeles, California Nat KongtahwornNat Kongtahworn
Manager,Manager,Network StrategiesNetwork Strategies
Recognizing Physician Excellence: Recognizing Physician Excellence: The Health Plans’ PerspectiveThe Health Plans’ Perspective
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
53.5% 56.1% 54.9% 49.5%
0%10%20%30%40%50%60%70%80%90%
100%
Acute Chronic Preventive Preventive -65+
Gaps in CareGaps in Care
Closing the gaps in care is the primary objective for Closing the gaps in care is the primary objective for recognizing physician excellencerecognizing physician excellence
Patients Receiving Evidence-based Care
Source: McGlynn et al, “The Quality of Health Care Delivered to Adults in the United States,” NEJM, 2003; To Err Is Human, Institute of Medicine, 1998
$ $ $ $
Source: Pham et al, “Delivery of Preventive Services to Older Adults by Primary Care Physicians ,” JAMA, July 27, 2005
Note: Coverage is for a family of four.Source: Calculated based on “Employer Health Benefits 2005 Annual Survey,” (#7315), The Henry J. Kaiser Family Foundation and Health Research and Educational Trust, September 2005This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.
Average Annual Premium Contribution for Family Coverage 1999-2005
$1,543$1,619
$1,787
$2,137
$2,412
$2,661
$2,713
$8,169$7,289
$6,656$5,866
$5,274$4,819
$4,248
73.3% 73.4%
75.1%
74.7%
73.4%
74.9%
73.3%
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
1999 2000 2001 2002 2003 2004 2005
Co
ntr
ibu
tio
n f
or
Fa
mily
Co
ve
rag
e
70.0%
71.0%
72.0%
73.0%
74.0%
75.0%
76.0%
77.0%
% E
mp
loy
er C
on
tribu
tes
Employer Contribution Employee Contribution % Employer Contributes
Unsustainable Rise in PremiumsUnsustainable Rise in PremiumsUnsustainable Rise in PremiumsUnsustainable Rise in Premiums
Savings from better outcomes and reduced waste will make insurance more affordable
Rising Premiums
• Differentiated Networks
• Consumer-directed Health Plans
• Incentives for Better Practice & Outcomes
• Differentiated Networks
• Consumer-directed Health Plans
• Incentives for Better Practice & Outcomes
Plans Responses
Plans responses promote greater accountability for physicians and members
• Affordable, Quality Affordable, Quality HealthcareHealthcare
• Members Paying Greater Share
• Greater Transparency
• Value-based Purchasing
• HIT Adoption & Use
• Affordable, Quality Affordable, Quality HealthcareHealthcare
• Members Paying Greater Share
• Greater Transparency
• Value-based Purchasing
• HIT Adoption & Use
Market Expectations
Market DynamicsMarket Dynamics
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
Recognizing Physician ExcellenceRecognizing Physician Excellence
Incentive programs complement Blue Plans’ efforts to engage Incentive programs complement Blue Plans’ efforts to engage key stakeholderskey stakeholders
EmployersEmployers
• Arkansas Fitness Arkansas Fitness ChallengeChallenge
• Concierge Service Concierge Service Delivery PlusDelivery Plus
ConsumersConsumers
• Blue Health CoachBlue Health Coach
• Smoking Cessation Smoking Cessation QuitlineQuitline
• Men’s Health Program Men’s Health Program
ProvidersProviders
• Collaborative Collaborative Appropriate Antibiotic Appropriate Antibiotic Prescribing InitiativePrescribing Initiative
• Out of the ER: The Out of the ER: The Tulare ProjectTulare Project
• Bridges to ExcellenceBridges to Excellence© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
Recognizing Physician ExcellenceRecognizing Physician Excellence
Blue Plans have implemented incentive programs across Blue Plans have implemented incentive programs across every region of the U.S.every region of the U.S.
• Large focus on PCPsLarge focus on PCPs
• Specialties include:Specialties include:
– OB / GYNOB / GYN
– CardiologyCardiology
– OrthopedicsOrthopedics
– EndocrinologyEndocrinology
• Programs for additional specialties are under developmentPrograms for additional specialties are under development
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
250459© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
Core values guide…Core values guide…
Recognizing Physician ExcellenceRecognizing Physician Excellence
• Measures approved by nationally recognized groupsMeasures approved by nationally recognized groups
• Relative ease of data collectionRelative ease of data collection
• Breadth of measures to ensure a valid, comprehensive picture of physician performanceBreadth of measures to ensure a valid, comprehensive picture of physician performance
• Credible and actionable to clinicians & transparent to patientsCredible and actionable to clinicians & transparent to patients
MeasurementMeasurement
• Report by tertiles/quartiles rather than rank orderReport by tertiles/quartiles rather than rank order
• Reward commitment to improvementReward commitment to improvement
• Promote environment for practice transformation Promote environment for practice transformation
RecognitionRecognition
Recognizing Physician ExcellenceRecognizing Physician Excellence
• Urban Area:Urban Area: 4 million population4 million population2 million covered 2 million covered
liveslives
• 6,000 Primary Care Physicians6,000 Primary Care Physicians
• 10 X 10 grid of primary care quality 10 X 10 grid of primary care quality measures – 20% completedmeasures – 20% completed
• 30% profiled30% profiled
Chicago
Challenge:Challenge: Limited claims data can preclude broader Limited claims data can preclude broader participation by network physicians, e.g.,participation by network physicians, e.g.,
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
250459© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
Approach:Approach: Condition-specific, self-assessment programs Condition-specific, self-assessment programs complement Plans’ claims-based reporting capabilitiescomplement Plans’ claims-based reporting capabilities
Recognizing Physician ExcellenceRecognizing Physician Excellence
• Licensees of Bridges to Excellence: CareFirst BCBS & BCBS of GeorgiaLicensees of Bridges to Excellence: CareFirst BCBS & BCBS of Georgia
• Adoption into recognition programs: BCBS of South CarolinaAdoption into recognition programs: BCBS of South Carolina
• 7 more Plans exploring implementation7 more Plans exploring implementation
NCQA Physician Recognition ProgramsNCQA Physician Recognition Programs
• Adoption into recognition programsAdoption into recognition programs
• Self-directed improvement modulesSelf-directed improvement modules
Maintenance of Certification & Practice Improvement ModulesMaintenance of Certification & Practice Improvement Modules
ConclusionConclusion
• Savings from better outcomes and reduced waste will make Savings from better outcomes and reduced waste will make insurance more affordableinsurance more affordable
• Bridges to Excellence complements existing and developing Blue Bridges to Excellence complements existing and developing Blue Plans’ strategies to improve quality and affordabilityPlans’ strategies to improve quality and affordability
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.
Closing the gaps in evidence-based care is not enoughClosing the gaps in evidence-based care is not enough
ContactContact
Nat KongtahwornNat KongtahwornManager, Network StrategiesManager, Network StrategiesOffice of Clinical AffairsOffice of Clinical AffairsBlue Cross and Blue Shield AssociationBlue Cross and Blue Shield Association312.297.6210312.297.6210nat.kongtahworn@[email protected]
© 2006 Blue Cross Blue Shield Association. All Rights Reserved.© 2006 Blue Cross Blue Shield Association. All Rights Reserved.