Georgia Blues launch new P4P program

Program follows in footsteps of Virginia initiative

Following in the footsteps of a successful program initiated by Anthem Blue Cross and Blue Shield in Virginia, Blue Cross Blue Shield of Georgia (BCBSGa) is piloting a new provider-directed quality improvement program — Quality-In-Sights: Hospital Incentive Program (Q-HIP). The program will recognize and reward hospitals throughout the state that meet and exceed quality measures in patient safety, patient outcomes, and patient satisfaction.

How much can the Georgia hospitals expect to earn? Anthem Blue Cross and Blue Shield in Virginia has said that it will award 41 hospitals around the state an estimated $12 million for improvements in patient safety and health outcomes.

The performance of the Virginia hospitals indicates that the Georgia facilities can hope to see significant performance improvement. For example, of the participating Virginia cardiac care hospitals with full data available, more than a 47% reduction was seen in serious complication rates for angioplasty, along with a 29% reduction of serious complications for cardiac catheterization.

During the same time period, hospitals nationally averaged reductions of 20% and 22%, respectively.

American College of Cardiology guidelines set the gold standard for door-to-balloon time at 90 minutes or less. The eight Virginia Q-HIP hospitals remain significantly better than the national average and have demonstrated an improvement of 17% against the 90-minute standard over the two-year time frame. The national average increased 12% over the same period.

Hospitals participating in Q-HIP voluntarily commit to improving programs and processes to reduce the rate of medical errors, improve patient health outcomes and better satisfy their patients. As they succeed, the participating hospitals earn financial incentives.

How the incentives work

"Blue Cross Blue Shield of Georgia's approach emphasizes accountability but takes a tailored approach to each hospital," says Randy Axelrod, MD, vice president, east region healthcare management, WellPoint Inc. (BCBSGa is an operating subsidiary of WellPoint Inc., as is Anthem.) "For instance, one hospital might focus more on reducing the incidence of hospital-acquired infections, while another might work toward developing an enhanced interventional cardiac program."

Performance objectives

The incentives the hospitals can earn reflect a percentage of their total revenues with the Blues, Axelrod explains.

While noting that exact percentages are confidential, he says they are "substantial enough that we get the attention of the hospitals. I don't think there will be much trouble encouraging hospitals to participate."

The Q-HIP performance objectives are based on safety and care processes as published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Leapfrog Group and other respected national authorities. BCBSGa, through its agreement with Anthem Blue Cross Blue Shield Virginia, also collaborates with the American College of Cardiology in identifying cardiac-related indicators.

Under Q-HIP, hospitals are evaluated annually on a series of performance objectives with a calculated Q-HIP score, on which the monetary incentives are based.

The score is calculated as follows: At the macro level, the scorecard is divided into three parts — patient outcomes or clinical outcomes; patient safety; and patient satisfaction. The latter, notes Axelrod, will be derived from CMS. "As they will have the tool, we will use their exact scores," he explains. "We try to use a lot of the things the hospitals already have in play."

A score grid is created for all the different metrics, he continues. "You might get no points, all the points, or half the points," Axelrod offers. "Your cumulative score will dictate the 'percentage of your percentage' you will receive."

Differences recognized

The scoring system recognizes differences in hospital services, Axelrod continues. "Take clinical outcomes, for example. We will take into account whether or not you are a cardiac hospital. Even further, we will look at whether or not you do open heart [surgeries]. So, we do not penalize you if you do not do these things; the points are re-allocated and redistributed."

For hospitals that perform bypass surgery, however, there are different measures. "We will soon be announcing a fairly comprehensive relationship with the Society for Thoracic Surgery," Axelrod shares, "And one of the things we will be embedding will be the collections of outcomes measures on their side, so those hospitals will be graded on something they should be submitting as well as on cardiac surgery; this is the best severity adjuster when you look at expected mortality and morbidity."

Smaller community hospitals, on the other hand, will be measured on JCAHO hospital quality measures for conditions like pneumonia, obstetrical care, congestive heart failure, and National Hospital Quality Measures.

Process orientation

The patient safety measures, says Axelrod, are "a little more process-oriented, as opposed to outcomes." They will use measures from organizations such as The Leapfrog Group, the NQF's recommended safe practices, and IHI's 100,000 Lives campaign.

Just as the evaluations are tailored to the hospitals, the hospitals themselves determine their major goals and objectives — as well as how they will use their rewards.

"One very large hospital in Virginia took their earnings, and from the get-go said they would be divided in three parts," he shares. "One third went to the bottom line of the system, another into improving the 'cath' lab under the direction of the physicians, and the third went to the support staff in the labs. So, the technicians would receive bonuses as employees for achieving improved rates for success."

This is a "great engagement tool" for hospitals, notes Axelrod. "Interestingly, that hospital scored the best of all the hospitals in Virginia – which was a pretty big eye-opener," he declares.

Axelrod says the program will continue to evolve. "We're in our third year, so someone is always getting the next, or best, version," he explains. "We started with "Version III" in Georgia, which has a little more emphasis on health outcomes and a little less on the other two categories, because we felt this really had to be about the 'proof of the pudding.'"

For more information on Anthem Blue Cross and Blue Shield in Virginia, please visit and choose "Virginia."