A decade ago, we wanted an alternative to the old system of paying physicians a fee for each service, test and procedure. So instead, we began paying participating clinicians for improvements to the quality and efficiency of care. For example, we reward doctors whose patients improve their control of chronic conditions like hypertension and diabetes – control that helps patients avoid devastating complications such as heart attacks, strokes, kidney failure or blindness. Our approach became a national standard, and research studies have found that it results in better care and lower spending. Now, we are expanding our value-based payment model to hospitals.
Traditionally, hospitals earn more if they have a high volume of patients and receive no financial rewards for helping to keep people who do not need hospital care out of the hospital. We are changing that. Under our new program, which is being piloted with South Shore Health System, Blue Cross will provide data, support and financial incentives to help the hospital ensure that patients are treated in the setting that is most appropriate for their needs, whether in the hospital or at their doctor’s office, an urgent care center or their own home. The model asks hospitals to be champions of care in their communities – collaborating with physicians in their geographic area to improve quality, outcomes and cost for the patients they share, and rewarding them for doing so.
“What’s so encouraging about this partnership is that the hospital and the health plan are finally coming together at the same table with the same goal: drive down costs while improving quality of care.”
Dr. Gene E. Green,
President and CEO, South Shore Health System (on left)
Spreading patient-centered quality measures
“How are you feeling?” may sound more like a courtesy question than a medical assessment, but we are finding that carefully designed patient questionnaires can help measure the outcomes of surgery and other procedures – and guide future treatment. We have been collaborating with physician groups across Massachusetts to use patient reported outcome measures, or PROMs, to survey people undergoing treatment for conditions ranging from depression to prostate cancer, angina to joint pain. Together, we are compiling solid data on what patients tell their doctors about their symptoms, pain, ability to function and well-being before and after surgery, therapy or other procedures. This “before and after” information allows clinicians to learn about which treatments achieve the best results for patients with a given clinical profile. And that in turn allows them to refine their treatment plans for individual patients.
“PROMs are increasingly understood to be among the most relevant measures of quality – they promote truly patient-centered care with measures that tell us how patients are feeling and how they are functioning,” said Blue Cross Senior Vice President of Enterprise Analytics Dana Gelb Safran. “For example, these measures are helping to improve diagnosis of depression, and once diagnosed, helping to monitor in a quantitative way whether patients are getting better. Similarly, for patients with hip, knee or back pain, patient-reported measures enable clinicians to quantify the extent of impairment that patients are experiencing, and to measure the improvement that occurs with surgery, physical therapy or other treatments.”
The Mount Auburn Cambridge IPA, an organization of 500 primary-care physicians and specialists at physician groups in almost a dozen greater Boston communities, has made depression screening a routine part of their patients’ annual visits. Using a standardized questionnaire, patients check off how many times over the past two weeks they have struggled with issues such as lack of sleep, energy, appetite and concentration; feelings of depression, hopelessness and failure; or thoughts of self-harm. Their scores, which become part of the medical record, are used to diagnose depression, and depending on the severity, determine the best course of treatment – including whether to prescribe medication and whether to refer to a psychiatrist.
“Patients may not want to talk to their physicians about their depression because of the stigma, or they may not even be aware of it until they fill out the questionnaire. Using it has opened our eyes to thinking more deeply about how patients are feeling and how to address and follow up on their treatment when they screen positive for depression.”
Dr. David Shein,
MACIPA’s Medical Director (on right)
MACIPA also uses PROMs as a tool for improving their patients’ adherence to medication therapies. “We survey patients again after treatment,” Shein said. “Once we have follow-up data, we can look at whether certain antidepressants resulted in better or worse adherence, and whether adherence was better if the prescription came from the patient’s primary-care physician versus a psychiatrist. With PROMs, you can look at how different approaches improve patient care and outcomes, which is the bottom line for our practice.”