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Strategic Alignment in Health Care
Presented to
CAJPA Fall Conference9/15/16
Transforming Care Delivery
Value-Based Pay for Performance
Oncology Practice of the Future
Maternity Care Focus - C-Sections
Choosing Wisely
Narcotic Safety Initiative
Transformation to value-based care
Principles of Value-Based CarePay for VALUE, not volume
Rewards and incentives for quality, health outcomes, and patient satisfaction
Providing doctors and hospitals with tools and real-time patient data to transform their practices
Integration of patient care across the care continuum
Helping consumers to become active in their healthcare through transparency and technology
3
Health Care todayProviders are fragmented and unable to coordinate care well
Fee for service payment systems drive
fragmentation, rewards unnecessary care
Inconsistent quality with no line of sight for member care across the continuum
4
Studies estimate
30 cents of every
healthcare dollar goes
to care that is ineffective
or redundant.
Evidence clearly shows that more does
not equal better care.
The Challenge
5
Today
He
alth
ca
re C
ost
s Drivers of Cost:• Fragmentation• Lack of accountability & coordination• Narrow focus of providers• Waste/redundancy• Difficult system for consumers to
navigate
Shifting paradigms
Fragmented health care based on fee for
service model
Coordinated
experiences
founded on pay
for performance
Passive involvement
Member is
empowered
and actively
engaged
Brief History of Value-Based Pay for Performance
(VBP4P)
A shared savings incentive program to stem the commercial HMO
cost trend in CA while continuing to improve quality.
Statewide collaboration:
The Integrated Healthcare Association (IHA)
Health plans
Physician organizations (POs).
Pay for Performance (P4P) launched in 2001 and expanded to
include Valued-Based Incentives in 2013 to address utilization and
cost management.
10 health plans and more than 200 California Provider
Organizations caring for 9 million Californians in commercial HMOs
or POS.
What Does VB P4P Look Like at BSC?
BSC began participating in 2003.
VB P4P closely tracks with Our mission as a not-for-profit health plan, to ensure all Californians have access to high-quality health care at an affordable priceOur Values: creative solutioning and agility, while acting with integrity to get results.
Our Strategic Truths: To Change the Game and to Be Bold and Think Big
Reinforces that providers can impact the highest dollar care services
while actively maintaining quality standards.
To date, BSC has awarded over $137M to participating Provider Organizations.
VB P4P Goals
VB P4P incentivizes Provider Organizations throughout the course of
the program while Blue Shield assesses the ability of each
participating Provider Organization to:
Improve population health outcomes in key clinical areas;
Ensure patient satisfaction;
Align with CMS’ meaningful use of health information
technology;
Manage the overall cost of care; and
Encourage patients to access appropriate care resources.
How Is Performance Measured?
Three domains in the VB P4P program design:
1. Quality:
Prevention and chronic care management measures
Patient experience measures from the Patient Assessment Survey
Meaningful use of HIT to improve patient care
2. Total Cost of Care (TCC):
The actual costs associated with care for members attributed to a PO
3. Appropriate Resource Units (ARU):
A set of efficiency measures to improve the delivery of appropriate and
quality care
Tomorrow’s healthcare starting today
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Specialty Care Management: Oncology
oncology practice ofthe future
cancer care today
• Rapid paradigm shift in diagnosis & treatment
approach, from cancer site to tumor genomic profile
• Scientifically advanced molecular
diagnostics & personalized therapy
• Care not evidence-based in up to 30% of
adult cancer patients
• Real-time clinical decision support to
promote evidence based medicine
• Patients not well informed of diagnosis,
treatment options, likely outcomes & cost
• Embedded shared decision making &
delivery of preference-concordant care
• Quality of cancer care not
well measured
• Robust quality metrics, including
patient-reported outcomes
• Provider and drug reimbursement
not aligned with rational care
• Reimbursement that rewards
quality and value
• Patient wishes for care at end of life not
documented/followed
• Respect for patient autonomy
throughout care & end of life
Oncology practice of the future
Ongoing processesto assess andaddress patient needs, with support that extends beyond the clinical setting
Compensation models reflecting quality and value
Delivery of evidence-based
medicine, and faster adoption
of it into practice
Shared decision making to align
treatment selection with patient’s preferencesand values
Whole-person, patient-centered care
Maternity Care Focus: C-sections
Blue Shield has joined Covered California, California Maternal Quality
Care Collaborative (CMQCC) and Leapfrog Group, among others, to
address the troubling trend of increasing C-section rates.
Our goal is to lower the nulliparous term singleton vertex (NTSV) cesarean
section rate to the Healthy People 2020 target of 23.9%, the emerging
standard.
How will we do this? Five pronged approach involving the member,
physician and hospital in a collaborative environment.
Maternity Care Focus: C-sections
• Member Engagement: Our Prenatal Program features collateral and telephonic coaching that educates women that C-section is major surgery. Our program also promotes text4baby, a free text messaging service for pregnant women and new moms.
• Physician Engagement: Our Provider Education Program – a collaboration of Quality Improvement and MCS Enhanced Clinical Programs – is under development and will provide to providers with key messages and evidence-based practice guidelines from expert sources.
• Hospital Engagement: Our plan to address low-performing hospitals in targeted rating regions (managed by the Regional Delivery Network team) will use Maternal Data Center tools as well other elements that are under review.
• Contracting: We’re working to align incentives for POs and hospitals. We have piloted blended case rates in two hospitals and are reviewing the data for possible expansion.
• Data: Key to measurement and improvement using the “Plan-Do-Check-Act” model is key. Blue Shield has encouraged its hospital partners to participate in the Maternal Data Center and 90% of ACO hospitals are now participating
To access the free Consumer Reports materials:
ConsumerHealthChoices.org/Choosing
• 100+ campaign topics
• Specialty society endorsed
• All in Plain English and Spanish
• Support conversations
• PDFs, for easy printing
• Suited for email, linking, hosting
• Suited for clinic display/handouts
• Great for social media posting
What is Choosing Wisely
Source: Consumer Reports
Examples of Choosing Wisely Materials: Pregnancy Care
Source: Consumer Reports
Examples of Choosing Wisely Materials: Cancer Care
Source: Consumer Reports
How Is BSC Supporting The Choosing Wisely Campaign?
National Grantee
In 2015 BSC helped form a collaborative including the Institute for
Healthcare Improvement, Sharp Rees-Stealy Medical Group, Sutter
Health and California chapter of the American College of Physicians.
The goal of the collaborative is to leverage the Choosing Wisely materials
to reduce overuse by 20% in 5 key areas within 3 years:
• Avoidance of antibiotics for adults with acute bronchitis
• Imaging for uncomplicated headache
• Don’t perform repetitive CBC and chemistry testing
• Imaging for nonspecific low back pain
• Preoperative stress testing
Our collaborative is one of only 14 collaboratives nationally to receive
grant funding from ABIM Foundation and the Robert Woods Johnson
Foundation.
BSC also takes part in the California State Workgroup on Reducing
Overuse co-chaired by CalPERS, the California Department of Health
Care Services and Covered California, to address overuse of selected
medical care across public and private payers.
How Is BSC Supporting The Choosing Wisely Campaign?
Statewide Policy Development
BSC takes part in the California State Workgroup on Reducing Overuse
co-chaired by CalPERS, the California Department of Health Care
Services and Covered California, to address overuse of selected medical
care across public and private payers.
Collectively the workgroup covers 15 million California consumers.
The charter of the workgroup is to develop, initiate, monitor and evaluate
approaches to reducing the overuse of selected unnecessary and
wasteful medical services in CA.
The statewide workgroup is primarily focusing on reducing:
• Cesarean section for low-risk, first-time birth
• Diagnostic imaging for low back pain
• Opioid overuse