Provider Quality Tools Blue Precision HPNs

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Provider Quality ToolsBlue Precision HPNs
George Lenko Program Director National Network
Management
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Clearing the Way to Better Health Blues
Leadership

• A consensus has emerged on transparency and
  quality. All key stakeholders are aligned
• Anthem many BCBS Plans are committed to the
  principles of Value-Driven Health Care as
  expressed by HHS Secretary Leavitt

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Dimensions of Efficiency Quality

• Conceptual grid widely used by Mercer other
  consultants
• Efficiency Quality viewed as independent
  variables
• Providers can be displayed to enrollees as
  efficient or quality or both

Quality Efficient
Quality Only
TOP PERFORMING
QUADRANT 1
QUADRANT 3
Quality
Not recognized for Quality or Efficiency
Efficient Only
LOW PERFORMING
QUADRANT 2
QUADRANT 4
Basic Information
Efficiency
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Blue Precision

• What is Blue Precision?
• High performance networks composed of providers
  that are selected through a variety of
  contracting strategies to steer members to
  efficient and effective care.

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Network Design Specialist Model

• Tiered Network
• Specialist Focused, since specialists control the
  episode of care 12 targeted specialties
• Cardiovascular/Cardiology, Orthopedics, General
  Surgery, Gastroenterology, Urology,
  Neurology/Neurosurgery, Otolaryngology,
  Pulmonary, OBGYN, Oncology, Ophthalmology,
  Dermatology
• Efficiency Episode Treatment Grouper (ETG)
  measures full case costs professional,
  institutional, ancillary, pharmacy
• Quality Primarily based on external
  recognition.
• Cardiac specialties recognized for (1) ABIM PIM
  completion, (2) NCQA/BTE certification, (3)
  participation in ACC/STS registries, or (4) high
  performance on AQA measures

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Provider Display
Anthems designation of cost effectiveness and
quality for Blue Precision
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Blue Precision Specialist Model
Provider Designations in 22 states by 2008
VT
WA
ME
MT
ND
MT
NH
MN
NY
OR
MA
WI
ID
SD
MI
RI
PA
WY
NJ
CT
IA
OH
NE
DE
NV
MD
IL
IN
AK
WV
UT
DC
VA
CO
CA
KS
MO
KY
NC
TN
OK
SC
NM
AR
AZ
AL
GA
MS
HI
LA
TX
FL
PR
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Benefit Designs

• Informational Model
• Provides members with consumer tools to help them
  choose high performing providers.
• Tiered Benefit Incentive Model
• Steers members to high performing providers by
  means of a plus benefit
• Tiered Benefit Sanction Model
• Steers members to high performing providers
  increasing member liability for services rendered
  by lower-performing providers

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Benefit Design Tiered Benefits Sanction Model

• Original benefit design
• Maximal savings
• High disruption high sensitivity

TOP PERFORMING
Quality
Basic Information
Efficiency
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Benefit Design Informational Model

• Highest customer interest
• Interim model
• Low initial savings

TOP PERFORMING
Quality
Basic Information
Efficiency
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Benefit Design Tiered Benefits Incentive Model

• Early market interest
• Friendlier steerage model
• Respectable savings potential

TOP PERFORMING
Quality
Basic Information
Efficiency
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Next Steps

• Work with external organizations to expand
  quality measures to other specialties
• Enhance and align efficiency measures
• Expand to additional BCBS Plans
• Align HPN efforts with other provider measurement
  initiatives transparency, pay-for-performance