presentation material (powerpoint)

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


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.


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


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…


• 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


• 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.,


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


• 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


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]


presentation material (powerpoint)

Economy & Finance

blue plans strategies

blue plans efforts

quality of health care

physician excellence

health plans incentives

health plans perspective

primary care physicians

evidencebased care source