COMMUNITY CARE OF NORTH CAROLINA (CCNC)
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.
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
Kaiser Permanente is an IDS organized into 8 regions and aligned with a financing arm. Kaiser Permanente has a 70-year history.
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.
Comments From Jed Weissberg, MD
HAWAII MEDICAL SERVICE ASSOCIATION (HMSA)—BLUE CROSS/ BLUE SHIELD OF HAWAII
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.
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.
Comments From John T. Berthiaume, MD, VP/Medical Director, Quality Management
Optima Health (Optima) is a Virginia-based health insurance plan with more than 430,000 members. Optima is a subsidiary of Sentara Healthcare (Sentara), an integrated healthcare system.
Similar to most employers, the costs for providing healthcare to Sentara’s employees increased steadily during the late 1990s and into the 2000s. To restrain those increases, Optima Health rolled out Mission: Health, a new incentive-based wellness program for its benefits-eligible employees. Participation was voluntary.
The program began in 2008 and is still in place. Optima published the results of the program in 2010 and again in 2012.
Participating employees complete a personal health assessment (PHA), including blood pressure and cholesterol testing, height and weight measurements, and questions about exercise frequency and tobacco use over the prior 3 months. Using the PHA data, the health status and risk factors are determined for each employee.
Employees with 0 to 1 risk(s) receive a premium reduction (currently about $600). Employees with 2 to 5 risks are required to receive health coaching via telephone in order to receive a similar discount. Employees with certain chronic diseases such as diabetes, coronary artery disease, or congestive heart failure become eligible for additional incentives by participating in a condition management program.
In 2010, Sentara engaged AonHewitt to independently review the program data. AonHewitt concluded that the reported results were based on an appropriate methodology and could be regarded as an unbiased assessment of outcomes. The following results were reported for the 5-year period 2007 to 2011. For the last 3 years, the results are reported for a study population of 5000 employees who participated in all 5 years of the program.
Of members continuously enrolled since inception, although that population had aged 5 years, 87% improved or maintained critical health risk measures (blood pressure, body mass index [BMI], cholesterol, tobacco use, and level of exercise). Improvements were statistically significant for all risks except BMI.
Employees resisted when the program began in 2008. Anecdotal reports now reflect high employee satisfaction overall.
Comments From George Heuser, MD, VP/Senior Medical Director
Author affiliations: Hawaii Medical Service Association, Honolulu, HI (JTB); Community Care of North Carolina, Raleigh, NC, Engelberg Center for Health Care Reform, Brookings Institution, Washington, DC, and University of North Carolina at Chapel Hill School of Medicine, NC (LAD); Optima Health, Virginia Beach, VA (GKH); Cardiothoracic Intensive Care Unit and Surgical Intensive Care Unit, Columbia University College of Physicians and Surgeons, New York, NY (PS); Kaiser Permanente, Oakland, CA (JW).
Funding source: This information contained in this publication was sponsored by GlaxoSmithKline (GSK). GSK reviewed the content of this publication for compliance with its own policies; GSK played no role in the selection or content of the material that appears here.
Author disclosures: Dr Heuser reports employment with Sentara Healthcare. Dr Weissberg reports employment with Kaiser Permanente and board membership with Archimedes and Avivia Health. Dr Weissberg has also disclosed ownership of various stocks; information on file at the office of The American Journal of Managed Care, Plainsboro, NJ. Dr Berthiaume, Dr Dobson, and Dr Salgo report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this supplement.
National Committee for Quality Assurance. The State of Health Care Quality 2007. http://www.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf. Accessed September 19, 2012.