One way to improve profitability without cutting benefits or increasing premiums is to steer your members to the high-value primary care practices in your networks.
A study done by The Peterson Center on Healthcare and the Clinical Excellence Research Center at Stanford Medicine, found that a high-quality primary care practice, using a team approach to patient-centered care, can help prevent the complications and hospitalizations that drive up the cost of chronic disease care, lowering the total spending per patient. If you can identify and increase the number of high-value primary care teams in your network, you can control costs without compromising benefits.
What is a high-value primary care team?
You may have noted that I use the phrase “primary care teams” and not “primary care physicians.” That’s because these high-value practices are based on teams of caregivers, all practicing at the top of their licenses.
With a team-based approach, the PA or APRN can manage the routine needs of patients, leaving the physician free to focus on the complex needs of chronically ill patients, who are often co-morbid. That careful management is at the heart of the team’s ability to reduce costs. Not only is there a reduced need for specialist referrals and hospitalizations, there is also a watchful eye to make sure that each transition happens smoothly and no patient falls through the cracks. (If you’d like to read more about high-value primary care, download the white paper, Accelerate value-based care success by concentrating on primary care.)
Use your data and analytics to identify the right players
To identify the primary care teams that are providing high-value, you will need two types of data: quality and cost. As most health plans are capturing and storing data from multiple sources, you likely have the majority of the data you need.
Claims can provide most of the data needed to identify high-value teams in your network, though there will be gaps. For example, claims data often lacks information to identify the patient’s underlying diagnoses or whether the care adhered to evidence-based standards or best practices. This data, which can improve the accuracy of your quality analysis, can be found in the EHR systems of your provider network(s) and hospital systems.
Identifying high-value primary care providers is a four-step process.
- Attribute plan members (patients) to the providers. While there are multiple attribution methodologies, a useful method is that which CMS uses to attribute members for the creation of the Quality and Resource Use Reports (QRUR’s). This is a two-step process, details of which can be found on the CMS website. Your results will include specialists who care for people with chronic diseases such as kidney failure, congestive heart failure, diabetes, chronic obstructive pulmonary disease or asthma. Sort the specialists from the primary care physicians, but don’t discard that list. You’ll want to compare these specialists with their peers to look for high value in that group, too.
- Calculate the performance rates for clinical outcomes measures. You can choose your own measures for use in comparisons, or you can use pre-defined measure sets such as HEDIS (Healthcare Effectiveness Data and Information Set) or Medicare Advantage Stars ratings. While these measure sets are reported at the health plan level to NCQA and CMS, the logic to produce these results can be implemented at the provider level. More than 90% of all U.S. health plans use HEDIS to report data to maintain their accreditation by NCQA, so this is a pretty solid measure set with which to start.
- Calculate the annual cost per patient figure for each provider. Cost can be defined in a variety of ways. For this reason, it is useful to refer to existing methodologies (such as that found in QRUR reports) or to evaluate using relative value units (RVU’s) when calculating annual cost per patient. The key point is to include adjustments for the risk level of each patient. You want to compare apples to apples when you look at the cost data, because a physician who treats older diabetic patients with co-morbidities is going to have a much higher annual cost per person than a physician who has a population of younger, healthier patients.
- Rank your providers based on the quality of care and the cost per patient. Those who are can demonstrate high quality scores at a lower cost are the high-value providers. Don’t expect to see large numbers of high-value teams. The study referenced previously looked at approximately 15,000 practices and was able to identify only 11 that met the high-value criteria. You are likely to have more than 11 high-value primary care teams on your list, but this will depend on a) the methodologies used and b) whether you are conducting your comparison between only the providers in your plan or against national benchmarks. Either way, expect the numbers to be small.
If this appears complicated, it is, but it is doable. To complete the steps outlined, you’ll need a solid analytics platform, well defined data management practices and resources with healthcare analytics expertise. The investment needed by each health plan will vary but, but with costs rising, you are likely see a very good return on your investment. To minimize the investment, you might want to use a vendor that provides analytics software on a cloud-based platform as a subscription service to avoid the cost of the technology purchase. If you don’t have in-house analytics expertise, invest in a consultant.
So we’ve identified the high-value primary care teams, now what?
There are several actions you can take to use this data to the benefit of your organization and your health plan membership. First, tell your members about these high-performing practices. With increasing deductibles and co-payments, patients want to know that their physician is helping them hold down their out-of-pocket expenses, in addition to providing high-quality care.
Since not all your members can be patients of this high-value group of practices, you’ll also want to help spread that culture to other providers. By using education and outreach, and working collaboratively with the providers in your network, you can achieve real transformation. One example of such outreach and education is the High Value Healthcare Collaborative.
You can also use a combination of financial incentives, investments in support services and identification of performance standards designed to encourage physicians to improve. Several health plans were early adopters of incentive programs for providers: Humana, United Healthcare, BCBS of Minnesota and WellPoint are just a few such programs. Pennsylvania-based Highmark is the most recent insurer to offer such a program.
Deciding which avenues to pursue may require additional data analysis, but the better you understand your data, the more effective your health plan will be at creating a network of high-value primary care teams. And that will benefit everyone – providers, patients and health plans – as we continue the journey from fee-for-service to value-based healthcare.
Post Date: 2/14/2017