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AIS's Health Business Daily
Featured Story March 18, 2008 Health Insurers Collaborate With Providers to Develop Pay-for-Performance Standards for SpecialistsReprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans. By Chris Meehan, Editor, (cmeehan@aispub.com) As insurers expand pay-for-performance (P4P) programs to cover specialists, they sometimes must collaborate with providers to establish standards if nationally recognized quality measures aren't available. During an AIS audioconference, Babette Apland, senior vice president of health and care management and provider relations at HealthPartners, Inc., stressed the need for collaboration with providers when developing a specialty P4P program. The health plan has implemented several specialty P4P programs. "A really important aspect of our program is collaboration," Apland told listeners. She added that when possible, the plan adopts nationally recognized, evidence-based performance measures, but when those measures don't exist, the plan "works closely with the specialty groups in our networks" to develop P4P programs with the providers. She added that HealthPartners decides which specialties to include in its P4P programs based on claims volume. When developing measures with providers, the insurer develops "stretch goals…but we [must] have some evidence that the goal is not too high, but is attainable," she explained. HealthPartners has seen improvement in targeted areas of the specialist programs, Apland said. For instance, she stated that the plan has seen significant improvements in coronary artery disease (CAD) process and outcome measures, which included more screenings of members since 2004. For the heart failure measure, four out of seven groups participated, resulting in service agreements with 10 primary care groups, she said. "We think that's really impactful to improving coordination of care for those patients" with CAD, she said. William Hauser, M.D., regional head of medical and quality management operations for Aetna, Inc.'s Southeast and Southwest regions, agreed that collaboration must be a key part of such programs. The insurer does not call its rewards program P4P because it encompasses steering additional members to providers, special network designations, administrative relief as well as direct financial rewards or any combination, he explained. Aetna also is expanding such programs into new markets or specialties where national performance benchmarks are sometimes not available. "In those markets where we do not have the ability to implement Bridges to Excellence or Leapfrog Group [standards], those local markets would be responsible for taking measures from a library of — accepted by us — nationally validated measures," said Hauser. He offered CMS quality measures as an example of an accepted measure. Hauser asserted that the plan will, in such instances, develop measures based on those it recognizes elsewhere, in an attempt to make the measures as similar as possible across its provider networks on a nationwide scale. This poses additional problems since the insurer faces different regulations and constituencies from state to state, Hauser explained. To buy a CD of AIS's
audioconference Health Plan P4P Programs for Specialists: Recent Financial
and Clinical Outcomes, call (800) 521-4323 or click
here.
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