Program offers preventive health, chronic care

Quality indicators, patient satisfaction are tracked

As part of its efforts to promote preventive care and appropriate management of chronic diseases, Blue Cross and Blue Shield of Florida has begun the Recognizing Physician Excellence (RPE) program, which will reward physicians based on several criteria, including patient satisfaction, clinical quality and efficiency, and administrative efficiency.

The program is designed to complement Blue Cross and Blue Shield of Florida’s disease management and case management programs, says Robert S. Mirsky, MD, regional medical director for the Jacksonville-based insurer.

"The case managers and disease managers have been providing the majority of support for members through our Personal Care Management and Chronic Disease Management programs. The RPE program encourages physicians to join in our effort to ensure that patients who need it get control of their chronic diseases and to ensure that patients get the preventative care they need. These are two very important areas that work together to create a system that results in optimum outcomes for patients," he says.

The company is collecting data on clinical quality indicators, patient satisfaction scores, clinical efficiency, and administrative efficiency indicators and will use that to compare physicians to their peers. The program takes the physician scores in all categories and compares them to each other, calculating the bonus payments based on how the physician meets the benchmarks. The bonuses will be paid on an annual basis, beginning in July.

The company contracts with Health Benchmarks Inc. of Woodland Hills, CA, to monitor physician performance.

"We developed a balanced score approach and included various areas where recognizing and rewarding physicians would make a difference in the way they serve their patients," he says.

Physicians eligible for the program are primary care physicians, including those practicing internal medicine, pediatrics, family practices, general practices, obstetrics, and gynecology.

They must participate in the company’s Network Blue high-performing network and have a high volume of patients. Enrollment is voluntary.

The physician scorecards are developed using administrative data, claims data, and the results of patient satisfaction surveys.

"We take a member-centric approach. If any physician orders the testing or the care that we are tracking, all the physicians who treat that patient get credit for it because if the patient gets the care they need, it means the system is working," Mirsky says.

For instance, if a patient is seeing an internist and a gynecologist, both get credit if she gets a Pap smear or mammogram.

"It may be because of the way the group is orchestrated, or the way they refer patients in their community. We just want to make sure that the physicians have a system that results in the patients getting what they need," Mirsky explains.

The quality indicators the health plan is tracking include preventive measures such as mammograms and Pap smears and cholesterol management in the prevention of heart disease, and chronic disease management indicators for patients with diabetes and asthma.

For instance, the program tracks whether diabetics had a hemoglobin A1C test and a retinal eye exam; asthma patients are on daily long-term medication; and patients are refilling their lipid-lowering medications.

"As the program evolves, we will increase the indicators and study the results of the laboratory tests to determine if the members received the care they needed to reach their goals," Mirsky adds.

When patients leave the offices of participating physicians, they receive a bilingual postcard directing them to complete a 19-question survey about their health care experience either on the Internet or over the telephone. Members who participate are eligible for a drawing for rewards.

"We ask them about their perception of access to care, the quality of the care they received, and the overall care experience," he says.

The program also measures clinical efficiency, or whether patients received care in a manner that is cost-effective for them.

For instance, it tracks emergency department visits by patients with asthma and diabetes.

"This metric should resonate with the other metrics. Patients who are well cared for should experience fewer emergency room visits than patients who aren’t getting the care they need," Mirsky says.

The program tracks the rate at which physicians prescribe generic and preferred brand name drugs, resulting in lower out-of-pocket costs for patients. "We compare them to each other on a peer-to-peer basis to determine who is saving their patients more money," he says.

Rewards also will be based on the physicians’ use of a secure web-based tool that allow patients to communicate with their physician offices for administrative services such as scheduling appointment, requesting prescription refills, and getting normal lab results.

Blue Cross and Blue Shield of Florida partnered with Relay Health of Emeryville, CA, to develop the tool, which also includes paid e-visits for established patients with nonemergency conditions.

Patients who log onto the HIPAA-compliant web site go through an algorithm that asks specific questions about their condition and past medical and medication history. The physician replies to the patient using the same web site with specific instruction that may or may not include a prescription.

"Our clinical efficiency measures focus on what is most efficient for the members. This category rewards physicians for reducing the amount of time the patient has to spend on the telephone and when members can stay home or on the job while getting advice about nonemergent care," says Mirsky.

The system also measures the physician’s participating in administrative tools, such as electronic claims submission and updating or validating their information in the company’s directory to make sure the members have the most up-to-date information.

The Institute of Medicine’s groundbreaking report Crossing the Quality Chasm: A New Health System for the 21st Century was part of the impetus for the insurer to create the program, Mirsky says.

"The report identified pay for performance as one of the cornerstones of improving quality of care and closing the gap," he says.

Blue Cross and Blue Shield of Florida studied pay-for-performance practices of other health plans before designing its own plan. It is the first program that includes the company’s commercial HMOs, PPOs, and other commercial lines of business.

"We believe that we have taken pay for performance to another level because our program is inclusive for all of our commercial lines of business. Our program not only increases the breadth of membership in other pay-for-performance programs but also the breadth of the types of indicators we monitor," he says.