Rewards Set Up For Care Quality


    Seeing the potential to generate cost savings, Blue Cross Blue Shield of Michigan is offering financial incentives to physicians who meet certain standards for improving the quality of their care.

    The Blues has set aside a pool of $11 million that 10 physician groups participating in the pilot program can tap. The state’s largest health insurer is specifically targeting quality improvements in treatment of congestive heart failure, coronary heart disease, persistent asthma and diabetes.

    By improving the quality of care and emphasizing improvements in disease management, the Blues ultimately wants to better contain the escalating cost of heath care by keeping patients healthier, resulting in lower prescription medication costs and reductions in hospital admissions, length of stays and complications for hospitalized patients.

    Among the steps required of participating physicians is the development of a disease registry to identify patients at high risk of complications from their illness and working proactively to reach out to those patients.

    By providing case management, disease management and quality improvement resources for our providers, we will be able to improve many clinical quality measures,” said TomPeterson, M.D., medical director for Michigan Medical PC, a Grand Rapids-based medical group participating in the Blues Physician Group Incentive Program

    “We will be able to identify all patients with a certain disease state, help our providers follow national guidelines and provide feedback on how to manage these patients and manage them better,” Peterson said.

    The Physician Group Incentive Program pilot involves 2,900 physicians in 33 counties who collectively treat 400,000 Blues subscribers enrolled in traditional and preferred-provider organization (PPO) health plans.

    The pilot stems from similar quality initiatives that offer financial incentives for hospitals and for physicians participating in the Blue Care Network HMO.

    Funding for the program comes from money the Blues allocates annually for increases in reimbursements paid to physicians.

    “The concept of using incentives is growing and shows that containing costs and improving quality of care are not incompatible,” said Thomas Simmer, M.D., senior vice president and chief medical officer for Blue Cross Blue Shield of Michigan.

    “They show that financial incentives can stimulate ongoing health-care improvement,” Simmer said. “We can help physicians provide care consistent with evidence-based guidelines while holding down costs and reward them for doing both.”

    The pilot program is part of a growing push by health plans to drive quality improvements through financial incentives to care providers.

    Priority Health last year paid out $3.7 million to more than 700 primary-care physicians who meet certain quality measures, spokesperson Amy Miller said. Priority Health will expand the program in 2005 to include specialty care physicians.

    The drive to improve the quality of care accelerated with a 1999 Institute of Medicine report that found medical errors in U.S. hospitals are responsible for 98,000 avoidable deaths annually.

    A report put out late last month by the National Committee for Quality Assurance stated that the U.S. health-care system remains “plagued” by what it termed “quality gaps” that lead to 42,000 to 79,000 avoidable deaths annually.

    In Michigan, Blue Cross Blue Shield will reward physicians who develop ways to measure and improve the quality of care for patients with chronic illnesses by sharing best practices and directing patients to the insurer’s BlueHealthConnection care management program that’s designed to get people more engaged in their care.

    Improving care for diabetes patients, for instance, can lead to fewer heart attacks, strokes and other complications, said David Blair, M.D., chairman of the Medical Management Committee for the Regional Delivery Network of West Michigan.

    The network includes physician groups affiliated with Saint Mary’s Health Care and Metropolitan Hospital in Grand Rapids and Mercy General Health Partners in Muskegon.

    Soundly managing chronic diseases also helps to contain health-care costs by reducing emergency room visits and hospital admissions, as does the use of generic medicines, Blair said.

    “This provides yet another opportunity to reduce costs,” he added.

    Blue Cross Blue Shield will also measure how cost-effectively physicians prescribe medications. That includes their adherence to national guidelines and their generic dispensing rates.

    Beyond heart disease, asthma and diabetes, Blue Cross Blue Shield wants physicians to identify and refer to care management those patients with lower back pain, hysterectomy for benign uterine conditions, post-surgery chemotherapy for breast cancer, and men age 50 and older who are eligible for prostate-specific antigen tests that detect possible prostate cancer.

    Through the physician incentive program, Blue Cross Blue Shield wants to see improvements in the care of people with chronic diseases and better outcomes, improve physicians’ ability to support clinical improvements, and increase the effectiveness of its own patient education efforts.

    “In the long run, we hope to motivate ongoing positive, productive changes in care delivery, and encourage best clinical and safe practices,” Simmer said.    

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