Highmark program encourages docs to focus on quality

Highmark Inc. is offering midstate physicians in its network a new reimbursement model designed to reward them for the quality of care rather than the volume.

The Pittsburgh-based insurer launched the new voluntary program in January, consolidating seven programs into a single package called the True Performance Program. 

The consolidation allows Highmark to improve data collection and compare health outcomes across its network, according to Dr. Mark Jacobson, medical director at Highmark.

“It’s very difficult, when you have seven other programs, to measure physician performance, because you’re not talking apples to apples,” Jacobson said.

Among the program’s features are inducements to spend more time with patients, which Highmark believes will lead to a decline in overall health care costs as patient health improves, Jacobson said. Highmark will pass the savings onto its commercial group health plan and Medicare Advantage members.

Employers struggle to find a balance between paying more themselves for health insurance premiums or passing higher premiums onto employees. True Performance aims to decrease the waste in health care costs by improving health outcomes and the patient experience, Jacobson said.

The concept of focusing on quality verses quantity isn’t new.

The shift grew with the Affordable Care Act, which contained language around improving care and compensating physicians based on quality instead of volume.

As a result, the Centers for Medicare and Medicaid Services, and even private insurers, jumped on board and partnered with providers to find more efficient ways to treat patients and monitor health care trends, an industry concept known as population health management.

Despite the potential repeal of the ACA under the Trump administration, providers in the midstate feel that the value-based focus on health care is now a permanent part of the health care system.

The U.S. has the highest per capita health care costs in the world, and it’s been that way for a long time, Jacobson explained.

The reason costs are so high, according to Jacobson, is because of the way Americans pay for health care services – based on volume, or per service.

“That’s why people are saying, health care really can’t sustain itself with the cost increases that are occurring,” Jacobson said.

Physicians can make up to 30 percent more

The goal of True Performance is to find a way to curb those high costs for Highmark’s commercial and Medicare Advantage members in Pennsylvania, Delaware and West Virginia.

Under True Performance works, physicians earn a monthly fee, called a risk adjusted care coordination fee. If they care for a sicker population, the fee might be higher. The monthly fee will help cover additional time spent on coordinating care for patients, or hiring more people to help with care coordination.

Then, on top of that, physicians can also earn a lump-um bonus based on quality, cost and utilization – such as how well they do in reducing patient emergency room visits – for each calendar year.

Highmark will be measuring quality of care for preventive services such as immunizations or diabetes management, Jacobson said, adding that physicians stand to make 10 percent to 30 percent more than they currently do, if they can consistently deliver high quality care.

Providers will be able to join the program if they want, but their eligibility will depend on the number of Highmark members that are in their group. The group must have at least 250 attributed members for the physician to enroll in True Performance.

Highmark selected that number because it’s where the insurer can start to collect the best data, Jacobson said.

“Now we can do apples-to-apples comparisons between providers, and use that data as a foundation for future, more advanced programs,” Jacobson said.

Lenay Ruhl

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