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Although pay-for-performance programs for primary care physicians are fairly well established, there is less agreement about the methodology, guidelines and data sources to be used for a P4P program for specialists. There also is a smaller number of accepted evidence-based medical standards for specialist care, and there are more professional disciplines and organizations with a stake. What’s more, cardiologists, endocrinologists, surgeons and other specialists oversee care for many high-cost conditions, and no pay-for-performance initiative can achieve all its objectives without taking into account the role of specialists.

Health insurance executives from Aetna, Inc. and HealthPartners, Inc. describe their specialist P4P programs. HealthPartners’ Babette Apland describes the clinical, utilization and financial results stemming from its initiative. And Aetna’s William Hauser, M.D., discusses how Aetna developed its soon-to-be-launched specialist P4P program, incorporating lessons learned from the Aexcel specialist tiered-network program.You’ll gain valuable insight into their program development and refinement, and get all the details of:

• How the two insurers structured their specialist P4P programs, including which specialties to target, which standards to use, and how to link patients to a specific physician.
• How the health plans gathered enough data to calculate statistically significant performance measures despite the smaller numbers of physicians and patients in any given specialty.
• How the insurers are getting specialists’ attention, despite competing programs from CMS and other health plans.
• What medical and financial outcomes HealthPartners achieved from its pay-for-performance programs for specialists, and what outcomes Aetna expects.
• How P4P programs for specialists are used most effectively in provider network and product development.
• What return on investment HealthPartners’ program generated, and how these important results were calculated.
• Which clinical areas saw the greatest improvements in terms of process and actual outcomes.
• What lessons the two plans learned in developing their programs.

Speakers

BILL HAUSER, M.D., is regional head of medical and quality management operations for Aetna, Inc.’s Southeast and Southwest regions. He has had more than 20 years of progressive experience in the health care industry, and joined Aetna in April 2002. Immediately prior to joining Aetna, Dr. Hauser was a director in the national health care consulting practice of PricewaterhouseCoopers and had his own independent consulting practice. He also served as vice president of medical management at Prudential Healthcare and associate medical director at Blue Cross Blue Shield of Massachusetts. He obtained his M.D. degree from the University of Texas Southwestern Medical School at Dallas, and did his internship and residency in internal medicine at Wayne State University School of Medicine in Detroit and his fellowship in infectious diseases at Stanford University School of Medicine. Following his clinical training, Dr. Hauser was an assistant professor of medicine for nearly 10 years, first at Wayne State University and then at Boston University School of Medicine.

BABETTE APLAND is senior vice president of health and care management and provider relations at HealthPartners, Inc. In this role, she provides leadership for health improvement, disease and case management, quality improvement and medical policy. She also oversees HealthPartners’ provider network, which involves managing contracted relationships with primary care physicians, specialty physicians and hospitals. Prior to joining HealthPartners, Ms. Apland was a health care consultant for hospital and clinic care systems. Before that, she served as vice president of Mount Sinai Hospital, and was executive director of Phillips Eye Institute. Ms. Apland holds an M.B.A. degree in finance and a master's degree in speech pathology.

Moderator: Jill Brown, managing editor of AIS's Health Plan Week

Designed Especially For

• Health plan CEOs, medical directors, network and provider relations executives, strategic planners, financial managers, and product development and marketing executives

• Medical group executives and directors of managed care contracting

• Benefits executives at self-insured employers

• Attorneys, actuaries, and consultants

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