1. Pay for Performance in BCBS Plans Nationally June 22, 2005 National Press Club Bruce E. Landon, M.D., M.B.A.

2. Project Goals Describe P4P programs in BCBS plans nationally Describe P4P programs in BCBS plans nationally Identify health plan capabilities with respect to implementing P4P Identify health plan capabilities with respect to implementing P4P Exploring the extent to which consumer participation is incorporated into P4P programs Exploring the extent to which consumer participation is incorporated into P4P programs

3. Survey Administration Internet based survey Internet based survey Administered May 2005 Administered May 2005 Target: Medical Director, VP Quality, VP Provider Contracting Target: Medical Director, VP Quality, VP Provider Contracting 51 health plans identified 51 health plans identified –2 did not identify a contact –2 did not respond –47 responses received (92% RR)

4. Survey Content Developed by BCBSA with assistance from HMS, UCSF and AHRQ Developed by BCBSA with assistance from HMS, UCSF and AHRQ Domains: Domains: –Affiliated physicians –Plan capabilities –P4P programs (up to 2) Targeted physicians Targeted physicians Types of measures Types of measures Payment structure Payment structure –Consumer reporting –Consumer incentives

5. Where Does the Consumer Fit In? Quality measurement/targets Quality measurement/targets –(e.g., CAHPS, A-CAHPS, etc.) Public Reporting Public Reporting –Medical groups –Individual physicians –Hospitals Financial incentives Financial incentives

6. P4P Programs Nationally PCP Program PCP Program Specialist Program Specialist Program Both PCP and Spec. Both PCP and Spec. Total Total 18 (22 programs) 1 (2 programs) 10 (10 programs) 29 (37 programs)

7. Those without programs….. 14 are actively discussing 14 are actively discussing –1 plans to implement within 6 months –4 plan to implement within 1 year –7 plan to implement within 2 years 4 with no current plans 4 with no current plans –Competing priorities –Expense –Inability to link –Lack of outcome measures

8. Program Age (n=38 programs) < 1 year8 < 1 year8 1-5 years15 1-5 years15 >5 years 15 >5 years 15

9. Specialists Targeted (Health Plans) OB/Gyn (8) OB/Gyn (8) Cardiology (7) Cardiology (7) Orthopedics (5) Orthopedics (5) GI (2) GI (2)

10. Participating Physicians PCPs 59% eligible for the program 59% eligible for the program 68% of those eligible participated 68% of those eligible participatedSpecialists 34% eligible for the program 34% eligible for the program 48% of those eligible participated 48% of those eligible participated

11. Performance Measures HEDIS37 HEDIS37 –Individuals10 –Groups19 –Both6 Satisfaction22 Satisfaction22 –Individuals5 –Groups12 –Both4 Access Indicators17 Access Indicators17 –Individual3 –Group8 –Both5

12. Performance Measures (cont) Electronic Connectivity Electronic Connectivity –Claims12 –Clinical/e-prescribing6 –Both6 Digital Infrastructure Digital Infrastructure –EMR3 –Disease registries0 –Both8

13. Other measures Generic drug utilization Generic drug utilization Appropriate prescribing Appropriate prescribing Pharmacy, overall utilization Pharmacy, overall utilization Efficiency index Efficiency index Overall PMPM Overall PMPM

14. Incentive Types PCPSpec Lump sum 185 Lump sum 185 Graduated bonus12 Graduated bonus12 Fee schedule increase83 Fee schedule increase83 Higher pay tier31 Higher pay tier31 Penalties10 Penalties10 MD recognition74 MD recognition74

15. Who Gets Paid? Absolute, 1 threshold10 Absolute, 1 threshold10 Absolute, >1 threshold11 Absolute, >1 threshold11 Improvement, 1 threshold 3 Improvement, 1 threshold 3 Improvement, >1 threshold5 Improvement, >1 threshold5 Tournament7 Tournament7

16. $$ at Risk Up to $4.5 PMPM Up to $4.5 PMPM Up to $30,000 aggregate Up to $30,000 aggregate Wide variability Wide variability

17. Public Reporting and Consumer Incentives 5 plans report group performance 5 plans report group performance 1 plan reports individual performance 1 plan reports individual performance 8 planning in 2006 or 2007 8 planning in 2006 or 2007 What is reported What is reported –5/6 report HEDIS measures –5/6 report member satisfaction –1 reports measures of access 5 post on web sites; 1 sent to members 5 post on web sites; 1 sent to members 1 plan reported incentives for consumers related to health promotion behaviors 1 plan reported incentives for consumers related to health promotion behaviors

18. Conclusions: the Role of the Consumer The majority of programs used patient reports of experiences with care as a metric The majority of programs used patient reports of experiences with care as a metric Fewer current programs incorporate public reporting at the individual or group level…but many are contemplating Fewer current programs incorporate public reporting at the individual or group level…but many are contemplating A lot of thought and activity is being directed at multi-pronged programs that incorporate all of these dimensions: A lot of thought and activity is being directed at multi-pronged programs that incorporate all of these dimensions: –P4P –Public reporting –Incentives to motivate choice