In­sur­ers ex­pected to fol­low Wel­lPoint’s lead

Modern Healthcare - - Front Page - Mau­reen McKinney

Other in­sur­ers ex­pected to fol­low Wel­lPoint on ty­ing pay to qual­ity

Less than a month af­ter the CMS com­pleted its value-based pur­chas­ing pro­gram, Wel­lPoint is lead­ing pri­vate pay­ers down that path. The in­surer re­cently an­nounced plans to make its vol­un­tary qual­ity re­port­ing pro­gram manda­tory, thus ty­ing all pay­ment in­creases to per­for­mance on set mea­sures at ev­ery hos­pi­tal that con­tracts with its plans. Wel­lPoint es­ti­mates the pro­gram will re­duce the $25 bil­lion it spends an­nu­ally on in­pa­tient care by 3 to 5 per­cent­age points over time.

And now that Wel­lPoint has jumped in first and made its qual­ity pro­gram an across-the­board re­quire­ment for new and re­newed con­tracts, ex­pect other in­sur­ers to en­act sim­i­lar re­quire­ments, said Dr. Wil­liam Born­stein, chief med­i­cal of­fi­cer and chief qual­ity of­fi­cer at three-hos­pi­tal Emory Health­care in Atlanta.

“Most of us rec­og­nize that this is the direc­tion we’re mov­ing to­ward,” said Born­stein, who also co-chairs Wel­lPoint’s Hos­pi­tal Na­tional Ad­vi­sory Panel, a 17-mem­ber group of hos­pi­tal lead­ers and other stake­hold­ers. “Qual­ity mea­sures will be tied to re­im­burse­ment.”

The move was hailed by the Leapfrog Group, a health­care qual­ity im­prove­ment or­ga­ni­za­tion formed by large em­ploy­ers. “This is ex­actly what we’ve been hop­ing health plans will do, which is pay for ex­cel­lence,” said Leah Binder, Leapfrog’s CEO. “It’s a very bold move.”

But the devil is in the de­tails, Binder warned, and in this case, that means the mea­sures. “We want the stan­dards that Wel­lPoint sets to be tough be­cause hos­pi­tals are not per­form­ing where they should be,” she said. “They need to pick mea­sures that set a very high bar.”

Wel­lPoint’s qual­ity re­port­ing pro­gram, Qual­ity-in-Sights: Hos­pi­tal In­cen­tive Pro­gram, has 504 par­tic­i­pat­ing hos­pi­tals, ac­cord­ing to a spokes­woman. All of the mea­sures, which num­ber 51, are en­dorsed by or­ga­ni­za­tions such as the Na­tional Qual­ity Fo­rum and the Joint Com­mis­sion, or by pro­fes­sional so­ci­eties such as the Amer­i­can Col­lege of Car­di­ol­ogy.

The com­pany’s new pol­icy would ex­tend Q-HIP to all of the roughly 1,500 hos­pi­tals in the 14 mar­kets where Wel­lPoint op­er­ates Blue Cross and Blue Shield health plans.

Me­mo­rial Health, a 610-bed hos­pi­tal in Sa­van­nah, Ga., has been a par­tic­i­pant in Q-HIP since Jan­uary 2006, and ac­cord­ing to Dr. Ra­mon Meguiar, the hos­pi­tal’s se­nior vice pres­i­dent and CMO, the pro­gram’s re­quire­ments have not been par­tic­u­larly bur­den­some. “We didn’t re­ally have to do any­thing ex­tra to par­tic­i­pate in Q-HIP be­cause we were al­ready look­ing at most of the things it mea­sures,” he said.

The hos­pi­tal, which has taken part in a num­ber of other qual­ity im­prove­ment ini­tia­tives, in­clud­ing the In­sti­tute for Health­care Im­prove­ment’s “100,000 Lives Cam­paign,” $58.8 bil­lion In­di­anapo­lis Cal­i­for­nia, Colorado, Connecticut, Ge­or­gia, In­di­ana, Ken­tucky, Maine, Mis­souri, Ne­vada, New Hamp­shire, New York, Ohio, Vir­ginia, Wis­con­sin 34 mil­lion 1,500 504 has been suc­cess­ful at se­cur­ing bonus pay­ment in­creases through the pro­gram, he added. This year, Me­mo­rial Health scored enough points to qual­ify for the max­i­mum in­cen­tive rate in­crease of 2.5%.

“It worked well with what we were do­ing and it gave us a way to get credit for it,” said Chris Pavlo, Me­mo­rial Health’s man­ager of qual­ity im­prove­ment.

Q-HIP’s list of mea­sures is di­vided into three sec­tions: pa­tient safety; process and out­comes mea­sures; and mea­sures of pa­tient sat­is­fac­tion. Pa­tient safety mea­sures in­clude many of NQF’s Safe Prac­tices, such as pres­sure ul­cer preven­tion and timely com­mu­ni­ca­tion about ad­verse events. Ex­am­ples of process and out­comes mea­sures in­clude an­tibi­otics be­fore surgery and rates of cer­tain in­fec­tions.

Hos­pi­tals are scored based on their weighted per­for­mance on each sec­tion. Pa­tient-safety mea­sures are given a weight of 55%, process and out­comes mea­sures de­ter­mine 35%, and pa­tient sat­is­fac­tion mea­sures get 10%.

It’s no sur­prise that pri­vate in­sur­ers are mov­ing in this direc­tion, said Linda Fish­man, se­nior vice pres­i­dent for pub­lic pol­icy anal­y­sis and de­vel­op­ment at the Amer­i­can Hos­pi­tal As­so­ci­a­tion. But there are a few con­cerns, too, she said.

First, Wel­lPoint’s mea­sures must be ad­e­quately risk-ad­justed to ac­count for fac­tors such as age, sever­ity of ill­ness and pa­tients’ so­cioe­co­nomic sta­tus, Fish­man said. Those fac­tors will be­come es­pe­cially im­por­tant as the com­pany de­vel­ops mea­sures for pre­ventable read­mis­sions, she added. Fish­man also said hos­pi­tals can be­come over­loaded with the pro­lif­er­a­tion of qual­ity-re­port­ing pro­grams.

Mea­sure­ment fa­tigue has been a com­mon topic of dis­cus­sion at meet­ings of Wel­lPoint’s Hos­pi­tal Na­tional Ad­vi­sory Panel, said Dr. Kelvin Baggett, se­nior vice pres­i­dent and CMO of Tenet Health­care Corp., Dal­las.

“There are so many ways that qual­ity, safety and ser­vice are be­ing de­fined, and you can’t over­whelm those who you’re try­ing to in­flu­ence,” said Baggett, who also serves on Wel­lPoint’s panel. “We need some de­gree of har­mo­niza­tion so we don’t ex­haust those who are do­ing the work.” That’s why the mea­sures be­ing used are com­mon ones, he added.

But the panel and other or­ga­ni­za­tions are grap­pling with plenty of other is­sues, said Born­stein, Emory Health­care’s CMO who co-chairs the panel. Qual­ity mea­sures are still fairly im­ma­ture and more re­search is needed to de­ter­mine which ones work best. And most providers will need a ro­bust elec­tronic health record in place to ef­fec­tively re­port on qual­ity, he added.

“It’s a dif­fi­cult chal­lenge to put up mean­ing­ful qual­ity mea­sures that are not ex­ces­sively bur­den­some and that ad­just for things that are out­side of a hos­pi­tal’s con­trol,” Born­stein said. “There’s still a lot of work to be done, but I think we’re all in­volved be­cause we have a shared goal of im­prov­ing qual­ity and re­duc­ing costs.”

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