Audio CD and written materials of AIS's audioconference on April 3, 2008

Innovative Provider Payment Strategy or Capitation All Over Again?

Health plans are experimenting with new provider payment strategies that could replace the traditional fee-for-service model, which is blamed for contributing to the rapid increase in health care expenditures. Blue Cross Blue Shield of Massachusetts (BCBSMA) recently launched a payment strategy that pairs risk-adjusted per-member, per-month reimbursements with bonuses based on success in 70 quality measures. But critics say the strategy could create new problems without achieving cost reductions from quality gains. And such a radical change could be a tough sell to doctors who might view it as just an updated version of capitation. Find out what these developments mean to your organization.

Sponsored by Atlantic Information Services, Inc., publisher of Health Plan Week, Inside Consumer-Directed Care and The AIS Report on Blue Cross and Blue Shield Plans

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BCBSMA says its new voluntary program greatly improves upon traditional capitation strategies. Under the risk-adjusted model, a physician group that serves a large population of young and healthy 20-somethings, for example, would receive a far lower global fee than a practice that has a large population of patients over the age of 50. The insurer says the model — along with rewards for quality — would improve enrollee health and reduce administrative costs for providers. And the risk-adjustment feature, it says, eliminates the potential for doctors to cherry-pick the healthiest patients.
 
Another organization, Prometheus Payment, Inc., says it has developed a superior model based on clearly parsing probability and technical risks, which it says improves patient quality, lowers medical costs and enhances price and quality transparency. Its model stresses payment for episodes of care rather than fee for service. The design team includes members of the Blue Cross and Blue Shield Association, RAND Health, Harvard School of Public Health, CMS and Towers Perrin. Under this model, care for various diseases or conditions is paid for according to standardized case rates.

Hear a provocative debate over innovative provider-payment strategies for health plans. First up, Robert Mandel, M.D., vice president of health care services for the Massachusetts Blues plan, offers an overview of his plan’s new payment strategy and explains how it improves upon earlier capitation models to achieve greater cost saving without sacrificing quality of care.

Next, François de Brantes, CEO of Bridges to Excellence and national coordinator of Prometheus Payment, Inc., explains why he believes the Massachusetts Blues plan’s model is a step in the wrong direction. He explains why he thinks his group’s episode-of-care model may be more effective in achieving the quality and cost-saving objectives.  

Get information and strategies on:

• How should risk be apportioned in any alternative payment methodologies?
• Which provider-payment models are the most promising?
• How can insurers avoid paying bonuses for standard care?
• What can be done to hold providers accountable for substandard care?
• How can episodes of medical care be used to pay providers fairly?
• How should payments be made to hospitals and specialists?
• What happens to global fees and bonuses when patients switch coverage?

 

Speakers

Robert Mandel, M.D. is vice president of health care services at Blue Cross Blue Shield of Massachusetts. Dr. Mandel is helping to lead the Blues plan’s multi-faceted, multi-year transformation initiative which is aimed at creating a health care system in Massachusetts that delivers safe, timely, effective, affordable, patient-centered care to all. Prior to this, Dr. Mandel was on loan from Blue Cross to the Massachusetts eHealth Collaborative, where he served as chief operating officer for one year. He previously was at Blue Cross Blue Shield of Massachusetts for five years most recently as vice president of eHealth. He practiced ophthalmology full time for eight years in Harrisburg, Pa. before beginning his administrative career.

François de Brantes is the CEO for Bridges To Excellence (BTE), a national program focused on rewarding physicians for better quality care. As the national coordinator for Prometheus Payment, he is responsible for coordinating the implementation of the program, from data modeling of the Evidence-informed Case Rates to the operation of pilot sites. Prior to that, Mr. de Brantes was the program leader for various health care initiatives at General Electric’s corporate health care programs. He serves on the board of directors of MassPRO (the Massachusetts Quality Improvement Organization) and is a member of NCQA’s Committee on Physician Performance.

Moderator: Steve Davis is managing editor of AIS's industry-leading newsletters, Health Plan Week and Inside Consumer-Directed Care.

 

Designed Especially For

• Health plan and insurance company
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• Provider group
  • Administrators
  • CFOs
  • Directors of managed care contracting
  • Business development directors
• Attorneys and consultants
• Actuaries

 

Written Materials