Value Based Payment

Value-Based Care: Not Just for Primary Care Practices

February 16, 2017 5:39 pm

What’s hot and trending in health care? Value-based care (VBC) that makes specialty practices a priority.

VBC is the payment structure that rewards physicians and hospitals for achieving the best possible outcomes for their patients at the lowest possible cost. It moves health care away from fee for service (FFS), which has been the dominant relationship between payers and providers for decades and which rewards the volume of care rather than quality.

VBC isn’t a new approach for us at Blue Cross and Blue Shield of Illinois (BCBSIL). We knew long ago that we had to branch out from the FFS model to manage costs and improve results.

In the late 1970s, BCBSIL introduced VBC with the launch of HMO Illinois. The program is still going strong. Our HMO products have grown to include more than 5,000 primary care physicians, more than 9,000 specialists, and 86 hospitals.

But there is no one-size-fits-all solution. Over the years we have built a suite of VBC models, including HMOs, accountable care organizations (ACOs), and intensive medical homes (IMHs). 

We continue to evolve and customize these programs to meet the needs of patients, payers (both BCBSIL and our employer groups), and providers. While our VBC programs initially focused on the primary care physician, we have branched out to specialty care groups and are seeing exciting results in terms of both care quality and cost savings.

Why Specialty Practices Matter

For many people with chronic illnesses, their specialist serves as their primary care physician. So the very patients who could benefit most from the enhanced access, care coordination, and illness management that VBC provides could be missed if we focused our VBC models only on standard primary care services.

That is why we sought to develop solutions to help patients manage complex diseases. In 2014, we pioneered our first specialty IMH contract, with the Illinois Gastroenterology Group (IGG).

By providing financial support and opportunities for shared savings, IMHs allow smaller specialty practices to remain independent while innovating their practice model. These are practices that normally would not be able to make an investment in such programs. BCBSIL provides the practices with quality and cost data that they can use to determine how to best care for their patients.

Through this IMH arrangement, IGG uses a team-based approach to care management combined with a patient engagement tool to closely monitor patients with chronic conditions. Its first population for this model of care was patients with Crohn’s Disease.

The tool uses smartphone technology to “ping” a patient once a month, asking him or her to answer a few questions about symptoms. The technology uses an algorithm to identify whether the patient’s status is good or, based on specific scores or trends over time, may be deteriorating unbeknownst to the patient. These patient-reported outcome measures (PROMs) are communicated to the gastroenterology care team via a web-based platform. Members of the care team monitor the PROMs and, if necessary, ask the patient to visit his or her gastroenterologist for preemptive care.

In the first year of this program, we saw significant declines in emergency department utilization and inpatient admissions. To date, we see medical savings trending at $6,000 for each “pinger”—patients using the technology—compared with other patients. This rate has resulted in almost $500,000 in savings for the 81 pingers in the initial program.

Based on the success of this initiative, we have contracted with the technology company to expand the IMH program to other gastroenterology groups this year.

Along with specialty IMHs, we also are pioneering specialty ACOs. In January, we launched the first pediatric ACO in Illinois, through which the Ann & Robert H. Lurie Children’s Hospital of Chicago will treat 76,000 patients.

Value-Based Care 2.0

Our vision for a sustainable healthcare system involves working with specialty practices and the chronic patients they treat.

Today, more than 30 percent of our 8 million members benefit from our VBC arrangements. Our goal is to bump that number to 75 percent by 2020 by creating programs and networks that ensure our members can get the right care at the right time at the right place.

Let’s see if we can get that trending.

Donna Levigne is divisional senior vice president, Illinois Health Care Delivery, Blue Cross and Blue Shield of Illinois, Chicago. Read more entries on the Leadership Blog.


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