Chronic Disease Management 101

I might be at an all-time backup on blog entries, but wanted to share this article quickly.  After doing two classes about this very example here at the UC in the last 24 hours, Lynn sent me this piece about the very example I use!  Way to go, Lynn.

From the Central Pennsylvania Business Journal:

Pay for performance: Health insurers seek money’s worth

Two years ago, nearly one out of every 10 patients at Eden Park Pediatric Associates
was overweight. About 1 percent of patients at the Lancaster County practice had hypertension and 28 percent had high cholesterol.

Those
are alarming numbers, especially in light of what they could lead to in 30 or 40 years. So Eden Park decided to do something about it.

The practice used Pittsburgh-based insurer Highmark Inc.’s pay-for-performance program, called QualityBlue, as a springboard to improve care.

“The
physicians are amazed,” said Lynn Cramer, the practice administrator and a board-certified pediatric nurse. “They never thought we would be able to impact (patients) positively to the degree that the program has allowed us to.”

Pay-for-performance programs, in which providers’ reimbursement is tied to patient care, have grown nationwide over the past decade and have been proposed as part of federal health
care reforms.

Capital BlueCross spokesman Joseph Butera said the Susquehanna Township, Dauphin County-based insurer plans to roll out its own pay-for-performance initiative this month.

“Capital BlueCross recognizes that pay-for-performance initiatives are increasingly becoming an important part of the business relationship between a health insurer and its providers,” Butera wrote in an e-mail.

He declined to elaborate on details of the program before its official launch.

The term “pay for performance” encompasses several types of initiatives,
said Lynn Leighton, vice president of health services for the Hospital & Healthcare Association of Pennsylvania (HAP).

For the past five years, Medicare has paid hospitals for reporting certain quality measures, she said. A few years after that, Medicare added a second piece to its pay-for-performance program by imposing reimbursement penalties for certain undesirable outcomes, such as high rates of hospital-acquired infections.

A third piece of the pay-for-performance puzzle, which has been proposed for Medicare but hasn’t been passed, is using increased reimbursements as incentives for achieving certain measures or for showing improvement.

Commercial insurers have taken similar approaches to pay for performance. Some pay
— and penalize — based on performance, others provide additional payment for improvements, and a third group mixes the two, Leighton said.

Pay for performance is growing among commercial providers, Leighton said, though she said she didn’t have exact numbers. She predicted other segments of the health care field, such as home health care agencies and nursing homes, increasingly will adopt these models as well.

The advantage of pay-for-performance programs is they ensure all parties are working toward the same goals, she said.

For
Highmark’s QualityBlue, providers get points based on how close to — or far above — they are compared to the local rate for a certain set of procedures, such as proscribing generic drugs, providing breast-cancer screenings or installing electronic medical records.

Providers also can earn points by using best practices to develop processes that target a practice’s trouble spots, such as childhood obesity at Eden Park Pediatric Associates. Points are then distributed based on progress made toward program goals.

The points translate to varying amounts of reimbursement above the set rate. Data is compiled and compared quarterly.

The program began in Western Pennsylvania in 2002 and reached Central Pennsylvania in 2006, said Dr. Carey Vinson, Highmark’s vice president of quality and medical performance management. Enrollment among physicians and hospitals is voluntary.

About 1,400 physicians in Central Pennsylvania — more than half of the region’s primary-care providers — are using QualityBlue, according to Highmark.

“We believe this does two things. Number one, it helps clinical care in all-round delivery of service. We want the standard of care to be promoted,” Vinson said. “It also helps primary-care providers who do a superior job to be recognized and get rewarded.”

Vinson said Highmark has seen encouraging results. For example, before QualityBlue, the generic prescription rate among Highmark’s Central Pennsylvania providers was 48 percent. By the last quarter of 2008, that rate had increased to 68 percent.

Highmark is seeking to improve the program, Vinson said. A few areas it aims to remedy are the facts that QualityBlue doesn’t take into account improved patient outcomes, doesn’t include specialists and, because it’s based on claims filed, in
some cases depends on whether patients take advice from providers.

At Eden Park, staff members used best practices to develop a formal protocol for combating childhood obesity, including measures such as scheduling regular appointments, charting patient information at every visit and using lab screening results.

At the end of the first year, 3 percent of patients with obesity had “problem resolved” written on their charts, Cramer said. None of the patients with hypertension
had their condition progress, she said. The practice is compiling more data on results next month, she said.

“Before, we thought we were addressing pediatric obesity, but it did not involve every person from the one who answers the phone to the pediatrician. It was not done in a coordinated manner where all problem issues were captured,” Cramer said. “Everyone thought we were doing it, but no one was doing it well.

The key is that Highmark’s program gives providers extra dollars to improve care, Cramer said.

“There has to be money there to establish good, preventative programs,” she said.

0 replies

Leave a Reply

Want to join the discussion?
Feel free to contribute!

Leave a Reply