John T. Berthiaume, MD; L. Allen Dobson, Jr, MD; George K. Heuser, MD; Peter Salgo, MD; and Jed Weissberg, MD
COMMUNITY CARE OF NORTH CAROLINA (CCNC)Background
CCNC is a statewide provider organization that has existed for about 10 years. Since its inception, CCNC has concentrated on quality. The CCNC patient roster includes approximately 1.5 million Medicaid recipients.Approach
CCNC takes a population-based approach. Primary care providers belong to community organizations (provider communities or communities). The provider communities partner with hospital specialists and other providers and are accountable for improving quality and lowering costs. The initiative, which began with Medicaid, is progressing to an all-payer model.
The CCNC program offers communities incentives and staff resources for care coordination and the additional primary care resources necessary for medical homes. The program is centered on providing support, enhanced capability, and resources, and does not pay direct financial incentives.
CCNC measures statewide quality/performance on most diseases. Although not required to do so, CCNC bases its measurements on HEDIS.
HEDIS is used by more than 90% of US health plans to measure performance on vital dimensions of care and service. Managed care companies must use HEDIS to report to accrediting agencies.
Comments From Allen Dobson, MD, President/CEO, CCNC
Providers have become willing participants; the additional resources provided have lowered their operating costs.
All HEDIS scores are in the top 10%.
An independent report from Millman in 2011 found that over 4 years, the CCNC initiative saved nearly $1 billion statewide, representing approximately 10% of CCNC’s total program cost, and $1000 per Medicaid recipient.
Private payers are recognizing that the CCNC approach is translatable, and have started working with CCNC.
“This is not socialized healthcare, it’s privatization. The providers have accountability and responsibility. We’ve established an infrastructure that gives them trusted data, uniformity of effort, and resource support to improve, and confidence that the payer (the state) is willing to partner with them sensibly.”
“Accountability is key. Even though CCNC is not at risk, we’re accountable to the budget. Ultimately, if we don’t help the state meet its Medicaid budget goals, then the choice is cutting rates or cutting benefits for recipients who will, regardless, still live in the community. It’s the ultimate accountability in a public program.”
Kaiser Permanente is an IDS organized into 8 regions and aligned with a financing arm. Kaiser Permanente has a 70-year history.Approach
As an IDS, Kaiser Permanente’s objective is “to align everyone around providing the best care at the best price to people and employers in the community,” said Jed Weissberg, MD (SVP Hospital, Quality, and Care Delivery Excellence).
Kaiser Permanente collects its own data, and compares them against its own standardized quality, service, and safety measures, as endorsed by Kaiser Permanente’s Board of Directors. In support of its fiduciary obligations, the Board engages third-party experts to assess the results and holds Kaiser Permanente’s management, and the delivery system overall, accountable for consistent improvement.
Over time, Kaiser Permanente has assimilated national standards into its quality measurement protocol, and all 8 Kaiser Permanente regions are now held to national standards.Results
Comments From Jed Weissberg, MD
Metrics demonstrate that quality of member care has improved. Those metrics are backed by patient testimonials.
Costs at Kaiser Permanente are increasing at a lower rate than the rest of the industry.
HAWAII MEDICAL SERVICE ASSOCIATION (HMSA)–BLUE CROSS/ BLUE SHIELD OF HAWAIIBackground
“Because we have a financing arm, we have a built-in efficiency: we don’t have to pass money back and forth.”
“Introducing third-party, national standards has helped us discern not only who is best among us but who is best in the country, and how good can we actually get.”
“Kaiser Permanente has been following this basic accountability and quality-improvement approach for a long time. We like to describe ourselves as the mother of all ACOs, and in that sense, we’re already aligned with the current reform movement. We have a great chance to avoid some of the paradigm shifting and scrambling that may befall other HCOs.”
HMSA is a nonprofit mutual benefit association that was founded in Hawaii in 1938. HMSA covers more than half (700,000) of the approximately 1.3 million covered lives in Hawaii.Approach
HMSA seeks to promote primary care, and follows the patient-centered medical home (PCMH) model. HMSA has adopted the Joint Principles of the Patient-Centered Medical Home, developed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association.
HMSA has made appreciable investments in patient management and provider incentives. In 1999, HMSA initiated “Pay for Quality,” a P4P program for primary care physicians (PCPs). During the last 2 years, all lives in HMSA’s PPO and HMO plans were rolled into a single P4P program. PCPs are held accountable based on HEDIS measures.
In its 2011 quality program for commercial members, providers receive patient management fees and incentive payments based on performance, in addition to fee-for-service (FFS) payments. During 2012, the maximum quality payment has increased from $2 per member, per month to $4 per member, per month.
In April 2012, and to support its P4P program for PCPs, HMSA rolled out Cozeva, a web-based, system-side platform developed by Applied Research Works for presenting data and other crucial quality information that allows doctors to track patient care for key quality measures, generate report cards to evaluate their own performance, and communicate securely with their patients and other medical professionals. HMSA provides incentives to PCPs to adopt and use Cozeva.
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