Built upon the core principles of our triple aim - improve health care quality, lower costs and enhance the patient experience - Provider Performance Improvement (PPI) programs support the creation of a high performance network to improve the overall quality of care provided to our members and the communities we serve.
As the health plan continues to support our provider partners in all sectors of healthcare, we strive to provide programs and venues that help decrease fragmentation, improve care coordination and allow for collaboration of comprehensive patient-centered care with higher quality and lower costs.
Value Based Payment
PPI consulting services are designed to drive improvement in population health, including preventive health, acute and chronic disease care, and patient safety through application of system level processes and delivery of patient-centered care. Hierarchical in nature and based on ability and/or tolerance for financial risk, the programs are built using a consistent framework for determining quality performance, using established and tested measures that align with national measure sets with level of risk being the primary variable. These programs support providers in their efforts to improve patient safety outcomes while improving fiscal performance through means other than increases in payment rates. The PPI consultants provide additional ad hoc support to hospital quality teams and physician practices through: (1) targeted and focused interventions as opportunities are identified; and (2) accreditation and regulatory program activities.
Accountable Cost and Quality Agreements (ACQA) are innovative payment programs designed to drive improvements in patient experience, cost trends, and quality of care. Similar to an Accountable Care Organization (ACO), the programs establish a new relationship between the health plan and partner integrated healthcare systems or large primary care physician groups based on healthcare quality and financial gain share. ACQA, administered with the integrated healthcare systems, is a full innovative payment program with both upside and downside risk. Savings generated by exceeding the budget target is shared with the system based on overall quality performance. Should financial performance result in a loss, the proportion of the loss passed to the system is moderated by the overall quality performance score.
The RPE Program is a performance improvement incentive program for primary care physicians. This program is designed to introduce practices to both quality and cost improvements through a focus on both high quality and efficiency performance. The program also serves as a foundational step in a hierarchical portfolio of innovative payment programs, and is set up as a foundation for seamless transition into more robust ACQA arrangements.
This pay-for-performance program is rolled out as hospital contracts open for negotiation. The menu-driven incentive program utilizes all payer data, rather than just our own, for measurement and applies it to all lines of business contracted with the hospital. The program exists best as a componenet of multi-year agreements and models a prospective payment methodology. Annual performance targets using nationally recognized measures are established to define expectations for improved performance, and if the hospital achieves the target outcomes agreed upon jointly, the negotiated extra payment for quality applies the following year.
Getting patients in for a well care visit (WCV) is the primary focus for the Pediatric Quality Incentive Program. Recognizing that the majority of preventive recommendations are provided during the well care visit, encouraging completion of all age appropriate screenings at the well care visit is the subsequent focus of the program. Providers are given a list of their attributed members and are requested to schedule and complete the WCV providing all necessary preventive screenings, counseling, lab work, and immunizations as appropriate. Incentive rewards are earned both for completing the comprehensive WCV, which is defined as the visit and all age appropriate specified preventive care services. Rewards are also administered for achieving improvement in the practice aggregate overall WCV performance as calculated through paid claims.
Health Plan Performance
Healthcare Effectiveness Data Information Set (HEDIS®)
HEDIS is a set of standardized performance measures developed and maintained by the National Committee for Quality Assurance (NCQA) which are the most widely used set of health care performance measures in the United States. These measures specify how organizations collect, audit and report performance information across the most pressing clinical areas, as well as dimensions of patient satisfaction and experience.
HEDIS is updated annually and consists of five domains of care. HEDIS allows for standardized measurement, reporting and accurate, objective side-by-side comparisons. The health plan uses its HEDIS results to continually improve the quality of care for its members.
The New York State Department of Health collects health care data through an annual reporting system called Quality Assurance Reporting Requirements, or QARR. QARR measures are largely adopted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data Information Set (HEDIS), with specific measures added to address public health issues of particular importance in New York.QARR is used to determine health plan performance on the areas of provider network, access and utilization, child and adolescent health, women's health, adult health, behavioral health and satisfaction with care.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
CAHPS is a program administered by the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency involved in developing and distributing standardized, evidence-based surveys and related tools used to assess patient experience with the United States health care system (AHRQ CAHPS Program Brief). There are many different CAHPS surveys for ambulatory care and facilities. The health plan contracts with a certified vendor to administer the CAHPS health plan survey.
The CAHPS survey gives health plan members the opportunity to report on and evaluate their health plan and tell us about their experiences with their health care. Survey topics include access to care, test preauthorization, communication with doctors and health care providers, accurate claims and service received from customer care. There are commercial, Medicaid and Medicare versions of CAHPS.Survey results are used for National Committee for Quality Assurance (NCQA) accreditation and by other regulators.
The health plan's Provider Quality Improvement programs are unique and innovative, as no other health plan in upstate New York has invested in programs of this type. These programs can be used by regional leadership to support collaborative activities and build significant relationships. Joint planning occurs to determine which program offering best fits with a hospital's strategy to improve overall quality and cost. The health plan provides supportive funding to providers when they join a collaborative; the amount varies by program. Since program inception, about 90% of network hospitals have participated in at least one program collaborative. The programs are viewed as employer/health plan investments that seek to align and integrate performance improvement programs with the goals of generating return on investment, impacting affordability, and improving quality of care for the communities served. Availability of these programs has become generally known in the provider community and important linkages have also resulted with the Hospital Performance Incentive Program (HPIP)/Small Hospital Incentive program (SHIP) programs, further supporting these initiatives by focusing improvement efforts on the reduction of hospital-acquired infections, surgical complications, and other adverse patient safety events.
Excellus BlueCross BlueShield established a pilot program to reduce hospital-acquired infections in seven upstate New York hospitals in late 2005, titled the Upstate New York Hospital Quality Initiative (UNYHQI), provided by CareFusion/MedMined Services. This pilot experience has shown an approximate 2:1 return on investment to Excellus BCBS/employers and a 12:1 ROI to hospitals, along with reduced number of infections resulting in better patient outcomes, reduced exposure to unnecessary medical tests, reduced lengths of stay, and lowered costs.
The American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) is a nationally validated, risk-adjusted, outcomes-based program that measures and improves the quality of surgical care, with the goal of improving surgical outcomes and reduce the costs associated with them. Eighteen hospitals across upstate New York are currently participating. Since the program's inception, the UNYSQI participants have made notable improvements in surgical care. The 30-day post-operative complication/morbidity rate results are 58% below the expected rate. The reduction in total aggregate complications represents an estimated 721 avoided surgical complications, saving the hospitals approximately $8.3 million through 2015.
Created in response to our provider partners' requests for such forums, provider alliances provide a venue where participants are able to share best practices, learn from community subject matter experts in the quality field, exchange information related to common or uncommon concerns, network with each other, and build trusting relationships. The alliances meet throughout the year in varied locations in order to allow for network-wide participation and topics covered are determined mutually by participating providers and the health plan. Current Provider Alliances include:
Primary Care Quality Alliance (PCQA) - supporting outpatient quality improvement
Health Systems Alliance (HSA) - supporting coordination of an effective "medical neighborhood"
For more information or for requests for support, please contact Provider Performance Improvement. A nurse consultant will contact you to discuss resources available to support your practice's quality improvement activities. You may also contact Teresa Murray, the Director of Value Based Payment - Clinical Consulting at (585) 238-4323.