Record Detail

PROGRAM SPONSORSHIP Formal name of the incentive and/or reward program initiative (if applicable) Program name QualityBlue Hospital Pay for Performance Program and QualityBlue Physician Pay for Performance Program Program sponsor(s) and parent organization of sponsor(s), if applicable Program sponsor(s) Highmark Inc. Parent organization Highmark Inc. Primary program contact information Name Deborah Donovan Title Director, Provider Quality Performance Management Organization Highmark Inc. Email deborah.donovan@highmark.com Phone 412-544-8722 Sponsoring organization type Health Plan(s) Single PPO/other Source of funding associated with program set-up costs Funding source Funded by program sponsor(s) Percent contributed by sponsor and grant organization % Sponsor 100% Program set-up costs 0 Source of funding associated with program operations costs Funding source Funded by program sponsor(s) Percent contributed by sponsor and by grant organization % Sponsor 100% Program operations cost 0 Start date & end date of the program Start Date 07/01/2001 End ongoing   PROGRAM SCOPE Geographic scope of program Pennsylvania Individuals affected by program as a percentage of total population, if known Employer/commercial health plan- active workers Employer/commercial health plan- dependents Employer/commercial health plan- retirees Coverage of affected individuals (for purchaser sponsors only) HMO PPO Indemnity Consumer-Driven Health Plan (CDHP) Plan product(s) the program applies to (for plan sponsors only) HMO PPO Indemnity Consumer-Driven Health Plan (CDHP) Direct target(s) of your program's incentives/rewards Hospital type Specialty- Women's Academic hospital(s)- American Association of Medical Colleges (AAMC) member(s) Hospital unit Individual, System Physician type PCPs Physician unit Medical group Consumers- health plan enrollees (for health plan respondents only) HMO PPO Indemnity Consumer-Driven Heath Plan (CDHP) Other Specify Medicare Advantage Recruitment of program targets Mandatory- all members of the target group must participate (e.g. part of contracting) Mandatory- all members of target group that meet certain criteria Specify Based on clinical program indicators PROGRAM PERFORMANCE MEASURES Clinical/Safety Performance Inpatient clinical and safety measures included in your program Measure sources CMS/Premier Hospital Quality Incentive Demonstration Hospital Quality Alliance JCAHO Core Measures Other NQF Measures Specify HAI Infections, Information Technology IHI 5 Million Lives Campaign Other Specify AHA GWTG, SCIP Measure areas Cardiac Acute myocardial infarction (AMI) Congestive heart failure (CHF) Coronary artery bypass graft (CABG) surgery Percutaneous coronary interventions (PCI) Other Specify cardiac surgery Neurosurgery/Neurology Stroke Obstetrics-Gynecology Hysterectomy Orthopedics Hip replacement Knee replacement Pulmonary Community-acquired pneumonia (CAP) Safety Surgical infection rate Other Specify post-operative normothermia Other measurement areas MRSA, C-Diff, CLAB, Catheter Associated UTI's. Technological improvements to improve safety i.e. Computeried tracking systems for CPOE, mediactions and infections; automated medication delivery systems, and others specific to hospital needs. Outpatient clinical and safety measures included in the program Measure sources HEDIS (clinical components) NCQA - Physician Recognition Programs Other Specify ABFM, ABIM Measurement areas Cardiac Coronary artery disease (CAD) Other Specify CHF, AMI Cancer screening Breast Cervical Pulmonary Adult Asthma Pediatric Asthma Safety Appropriate antibiotic prescribing for infections Other measurement areas Diabetes Hypertension Adult Preventive Care Pediatric Preventive Care Health information technology adoption measures Adoption of inpatient HIT Barcoding CPOE Adoption of outpatient HIT Patient tracking (e.g., managing patient data) Registry functions tracking (e.g., clinical data repository) E-prescribing Other Specify technology aimed at improving clinical quality care and / or pt safety. Resource Utilization and Cost Resource utilization Diagnostic imaging- radiology Pharmaceutical usage- formulary compliance Pharmaceutical usage- generic usage rate Re-admission rates Cost Total cost in Episode Treatment Groups (ETGs) Health plan performance measures Performance measure weighting Clinical performance % or N/A 60% HIT adoption % or N/A 10% Other Specify Member/Patient access 5%, generic/brand Rx 30%, HIT 5% Consumer measures Provider choice Chooses high-performing physicians Additional details about your incentive/reward performance measurement mix By transparency by diabetes, women's care and well child Data Reliability Sources of data Existing or new data Existing data sources, New data collected explicitly for program reporting Data type Administrative in origin (derived from claims data) Medical record data Self-reported Data extracting entity Other Specify internl for physician QB program only Data aggregator/analyzer Other Specify internl for physician QB program only Ensures data accuracy Yes Means of ensuring accuracy Auditing Specify who audits and how often Hospital: third party at Plan's discretion & Plan audits internally yearly. Physician: Program self audits monthly. Internal auditing annually Self-attestation as to accuracy Specify who does the self-attestation, e.g. CEO CEO and lead Quality staff assure accuracy Risk-adjustment mechanisms used None of the above INCENTIVE/REWARD CHARACTERISTICS Start date & end date of the incentive/reward Start Date 07/07/2006 End Date 06/30/2007 Structure of the incentive or reward Direct financial reward- increased payment Lump-sum bonus Differential reimbursement for providers; (e.g., increase in rate of reimbursement) Specify A certain percentage of each hospital's contracted reimbursement is placed at risk and is obtained only if program requirements are met. Indirect financial reward Publicize good performance Support for HIT infrastructure improvement Support for performance improvement (e.g., education, care planning) Target audience for publication of performance To consumers To provider peers To purchasers Direct financial penalty Withhold/performance guarantee tied to performance goals Other Specify reimbursement is tiered, based on performance in hospital program. Non-financial reward Provision of administrative and clinical support Other Specify Plan collaborates w/ Providers through hosting regional learning at Best Practices Forums and greenhouse programs. Scoring used to determine payment Incremental goals - improvement over previous reporting period Pay for improvement of one measure/group of measures Relative goals Relative ranking to peer group on each measure Frequency of reward or penalty Annually Reimbursement rate increase on all claims; i.e., "continuous" Time lag between measurement and receiving reward/penalty Other Specify hospital is less than 1 month. Physician program is quarterly. Total dollar amounts awarded during the most recent calendar year Hospital: ~$28 Million. Physician: ~$ 3.5 Million Source of financial payments for meeting performance goals Other Specify contracted reimbursement Shared savings breakdown (percentage should add to 100) if applicable Additional details about the incentive/reward characteristics and scoring methodology no rewards paid to consumers. Could not tell if "Scoring used to determine payment' was for consumers or the providers. In our case it is to providers. COLLABORATION CHARACTERISTICS Phases of program where sought target collaboration Program design and creation Other Specify Hospital Program: Through the performance year, Plan gathers input from Providers. Characteristics of pre-implementation target feedback Provider participation in program design Cost of compliance per target group considered by sponsor Other Specify Program operations/administrative operations (Hospital only) Physician: Medical Management Consultant field work. Receives compensation for administrative burden of data collection Yes Characteristics of post-implementation target feedback Incentive target given opportunity for full explanation of results before use Incentive target groups/individuals given comparative information Information provided on how results will be used Blinding of performance feedback with targets Results disclosed with comparison to benchmarks Results to peers with names disclosed Other Specify Partial public reporting of select measures for physician transparency Frequency of performance feedback to the targets Quarterly Annually Other Specify In the physician program, the Highmark Medical Management Consultants support with data, information and Best Practices. PROGRAM EVALUATION How the program evaluates its success Improvements in clinical performance Improvements in health status of population Other types of evaluation Specify Compare QB hospital with benchmarks at mid year and year end. Independent program audits Evaluator Program sponsor Additional results of program evaluation An achievement summary is written that summarizes the year end results. Hospitals are compared to state and/or national benchmarks as well as compared across the qualitybluehospital spectrum. Potential cost savings are calculated for indicators with published cost-factors. Lessons learned from designing and implementing the program Be certain that outcomes are measureable; Standardize and clearly document data definitions. Base these on national standards when possible. Align with national organizations. Create a internal team of experts, such as infection control practitioner, a seasoned hospital quality expert, epidemiologist or statistician, physicians, physician focus groups, proficient writers and administrative support staff. Set stretch goals. Modify the program annually, based on current/changing healthcare needs. Physician Program: Use physician focus groups to establish measures and network communication. Take group acct. customers opinions into consideration.

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