Unit 7: Value-Based Reimbursement Programs
Highmark’s network management methodology utilizes value-based reimbursement models, performance, and high-value networks and products. This strategy emphasizes efficiency and appropriateness over volume and waste, encourages provider/payer collaboration, and increases quality and cost improvement potential.
Highmark’s value-based reimbursement strategy evaluates providers' ability to deliver the right care at the right time and in the most appropriate setting. Our value-based reimbursement programs place intense focus on care coordination and population health management principles.
Along with our focus on member incentives and social determinants of health, these initiatives will mature the care continuum to shared quality and cost accountability, with fully capitated reimbursement methodologies launching for high performers in 2019.
Primary Care Solution
Highmark launched the True Performance value-based reimbursement program in January 2017. True Performance is a contracted program that replaced all previous pay-for-value and quality incentive PCP programs across all of our service areas and member populations. In True Performance, physicians are rewarded for their performance on quality and cost/utilization metrics and may be eligible to earn monthly care coordination reimbursement and quarterly or annual lump sum reimbursement.
This program is designed to continue to improve the quality of health care delivered to our members while working to reduce the overall cost of health for our members. For our provider partners, True Performance reduces the complexity of multiple programs, offers a higher performance-based reimbursement opportunity, and provides timely and actionable reporting.
For additional information, please see the True Performance Program section of this unit.
Specialist Solutions
Highmark began transitioning specialist reimbursement toward risk through the Bundled Payment and Specialist Efficiency programs in 2018.
Highmark piloted bundled payment solutions using retrospective gain shares in 2018 and will progress from retrospective gain shares to prospective payments beginning in 2019. Bundled payments are based on high-volume, high-cost episodes of care (e.g., major joint replacement) using a solid foundation of nationally recognized grouper logic, such as Symmetry® Episode Treatment Groups® (ETG®) and Procedure Episode Groups® (PEG®) and the Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI).
To assist in impactful referrals, PCPs receive information on the highest-value specialists through Specialist Efficiency, which monitors cost and detects variability in care delivery within select specialties. These specialties are associated with the highest reimbursements and, therefore, present the best opportunity to also enhance the value of the care our members receive. These cost profiles show PCPs which specialists provide the greatest value and help PCPs make more informed referral decisions. In addition, specialists will receive scorecards to help them observe care cost, detect variability in care delivery, and monitor adherence to care protocols.
Facility Value-Based Solution
Highmark’s facility-based value-based reimbursement program, Quality Blue Hospital Pay for Value, is operational in all service areas. The Quality Blue Hospital Program is designed to help providers align care with industry standards and best practices to better manage the care our members receive and improve outcomes. Under the Quality Blue Hospital Program, facilities contract with Highmark to place a portion of their reimbursement "at risk," dependent on their performance on rigorous clinical quality and cost measures that align with those advanced through national organizations, including the National Quality Forum (NQF) and National Committee for Quality Assurance (NCQA).
Incentives are paid on a retrospective performance basis. In addition to the clinical quality measures, the program includes measures for cost and utilization evaluation on select, high-volume episodes of care based on CMS BPCI logic and reduces wasteful spending while improving care.
Please see the Quality Blue Hospital Pay for Value Program section in this unit for additional program information.
Post-Acute Solutions
Helion, formerly known as HM Home & Community Services, is an independent company that provides post-acute network management services on behalf of Highmark Inc. and certain of its affiliated health plans. Helion operates in two key areas in the post-acute space — Skilled Nursing Facilities (SNF) and Home Health (HH). The value-based reimbursement (VBR) programs have been developed for the SNF and HH care settings.
In our SNF program, our first priority is to minimize readmission rates, ensuring that members receive effective care during their initial stay. In addition, there is a focus to actively manage emergency department (ED) utilization, aiming to reduce unnecessary ED visits and enhance member outcomes. Lastly, SNF providers are able to closely monitor and manage the measured cost of care, promoting best practices in market. Our SNF models are currently operational in Delaware (DE), Pennsylvania (PA), and West Virginia (WV).
In the Home Health (HH) sector, the VBR programs prioritize quality metrics as well as cost metrics. This focus on quality metrics includes timely follow-up with primary care physicians (PCPs) or specialists, as well as timely initiation of care. In addition, there is an emphasis on reducing readmissions and ED utilization while ensuring costs are aligned. The HH VBR models are currently operational in Delaware, Pennsylvania, and West Virginia.
Episodic Payment Model
In 2021, Helion introduced an episodic payment model (EPM) for both SNF and HH providers. Our EPM empowers providers to earn additional incentives by caring for and managing members efficiently and effectively. The EPM is based on 30-day episodes for SNF providers and 60-day episodes for HH providers.These initiatives represent significant steps toward improving post-acute care quality and managing costs effectively. Helion will continue working to scale these successful programs across Highmark’s entire footprint.
Clinically Integrated Networks (CINS)
Highmark is supportive of Clinically Integrated Networks (CINs) and strives to partner with as many providers as possible to ensure delivery of high-quality, affordable care. We will usually encourage their formation if strategic value is created for the provider(s) involved, and will design custom arrangements for them depending on their needs and aspirations.
Highmark is currently developing advanced reimbursement models that incorporate pay-for-value, shared savings, shared risk, and capitation for entities across our multi-state service area, and expects to see more partnerships with CINs in 2019 and beyond.
True Performance, Highmark’s flagship primary care pay-for-value program, offers primary care practices additional funds for managing their attributed population of Highmark members. Our True Performance value-based program is one of the largest PCP-based, private, value-based reimbursement programs in the country.
Physicians are rewarded for their performance on quality and cost/utilization metrics and may be eligible to earn monthly care coordination reimbursement, as well as quarterly or annual lump sum reimbursement. Timely and actionable reports are provided to give physicians regular insight into determining which care and referral decisions contribute to optimum results for quality, outcomes, and value.
In addition, True Performance meets the nationally consistent criteria for patient-centered, value-based care to be designated as a program of Blue Distinction® Total Care, an initiative of the Blue Cross Blue Shield Association. For more information, please see the Blue Distinction Programs section in the manual’s Chapter 5.1: Care Management Overview.
Participants
True Performance is a contracted program offered to entities in Highmark service areas that have at least 250 uniquely attributed members, whose providers practice primary care, and who accept placement of approximately 30% of their revenue risk based on performance cost and quality metrics.
Reimbursement Opportunities
True Performance provides PCP practices with two reimbursement opportunities – Monthly Care Coordination and Performance Lump Sum.
Care Coordination is based on achieving quality thresholds for the practice’s pediatric, adult, and senior patients. It accounts for 25% of potential total program reimbursement.
Lump Sum encompasses those same quality measure, plus three cost and utilization metrics – total cost per member per month (PMPM), emergency department utilization, and all-cause readmissions. Lump Sum accounts for 75% of total program reimbursement.
Participating practices that meet or exceed a minimum level of quality performance on their attributed membership receive risk-adjusted Care Coordination Reimbursement on a PMPM basis. Performance Lump Sum Reimbursement is paid on a quarterly or annual basis and is based on performance across both program components of Quality and Cost/Utilization. Calendar year performance determines the amount of Lump Sum Reimbursement earned as a percentage of maximum potential Lump Sum Reimbursement, which is based on a practice’s attributed membership.
Quality Metrics
Risk-adjusted care coordination fees are advanced monthly for each attributed member as long as a minimum quality performance on 30 quality metrics, as scored by age group (e.g., pediatric, adult, senior), is maintained.
Industry-supported quality metrics are nationally sourced from National Committee for Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS) Stars and align with:
- Avoiding Inappropriate Ambulatory Antibiotic Use
- Adolescent Well-Care Visits
- Well-Child Visits in the First 15 Months of Life
- Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life
- Childhood Immunization Status: Combination 10
- Development Screening in the First Three Years of Life
- Lead Screening in Children
- Medication Management for People With Asthma
- Cervical Cancer Screening
- Comprehensive Diabetes Care: Medical Attention for Nephropathy
- Comprehensive Diabetes Care: Eye Exam (Retinal) Performed
- Breast Cancer Screening
- Colorectal Cancer Screening
- Comprehensive Diabetes Care: HbA1c Control ( ≤ 9%)
- Medication Adherence for Diabetes Medication
- Medication Adherence for Hypertension: Renin Angiotensin System Antagonists (RASA)
- Medication Adherence for Cholesterol (Statins)
- Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
- Statin Therapy for Patients With Cardiovascular Disease
- Controlling High Blood Pressure
- Annual EKGs or Cardiac Screening
- Statin Use in Persons With Diabetes
- Use of Opioids at High Dosage
- Use of Opioids from Multiple Providers
- Screening for Future Fall Risk
- All-Cause Readmissions 2
- Adult BMI Assessment
- MTM Program Completion Rate for CMR
- Osteoporosis Management in Women Who Had a Fracture
- Annual Wellness and Initial Preventative Physical Exam Rate
- Medication Reconciliation Post Discharge
Opportunities for Advanced Arrangements
In 2018, opportunities for both upside and downside shared risk arrangements were offered to select providers who excelled at cost and care management. True Performance will continue to serve as the foundational value-based program and select well-performing providers will be offered more advanced arrangements to increase their reimbursement opportunities through shared savings and/or shared risk in 2019 and beyond.
The Quality Blue Hospital Pay for Value Program is a contract-based initiative in which a hospital agrees to put a portion of its Highmark reimbursement at risk, contingent upon attainment of specified objectives in the areas of quality improvement and patient safety.
Purpose
Highmark seeks to improve the health of its members by bringing to the market an innovative approach that supports providers in continuously improving the care and services delivered to their patients and our members. Highmark understands that an efficient health care delivery system promotes and maintains a high standard of quality and rewards cost-efficient care.
Highmark also understands that hospitals provide a unique opportunity to promote health care through collaboration, coordination, and communication among all providers by aligning services and enhancing the patient experience. This can be achieved by providing resource support, data sharing, aligning objectives, and encouraging care coordination across all aspects of care delivery.
Definition
The Quality Blue Hospital Program focuses on improving quality, controlling costs, and enhancing the member/patient experience. The Program components have been carefully designed to demonstrate value for Highmark, our customers and members, and our Participants, and support Highmark’s Mission, Vision, and Values.
Program Participation
Eligibility in Highmark’s Quality Blue Hospital Program requires Participants to have a current contract with Highmark for the period of July 1, 2019 through June 30, 2020 (hereafter fiscal year; “FY 2020”).
In order to have a current contract for FY 2020, a hospital must meet the following criteria:
- The hospital has signed one or more Highmark network participating contracts that under the terms of such contracts will be in effect during FY 2020.
- The hospital is not in default under the terms and conditions of the aforesaid network contracts at any time during FY 2020.
- The hospital has not provided a notice of termination to Highmark or Highmark’s regulators with respect to any Highmark network participating contract and such notice provides for termination prior to June 30, 2020 (for avoidance of doubt, this criteria is satisfied by the notice providing for a termination date prior to June 30, 2020, whether the contract is actually terminated on June 30, 2020).
Once enrolled in the program, contracted hospitals become eligible facility partners (hereafter, “Participants”). Participants are required to complete the following component metrics:
- Quality Bundle
- Readmissions
- 3-Day Returns to the Emergency Department (ED)
- Palliative Care for Complex Patients
- Follow-up Visits for Select Episodes of Care
- Average Episode of Care Costs for select episodes metric
For calendar year 2019 (“CY 2019”), Palliative Care for Complex Patients and Average Episode of Care Costs will not be an applicable measure for Specialty Care Hospitals since they predominantly treat certain diagnoses or perform certain procedures. Hospitals with employed physician practices will be required to complete the Quality Bundle metric.
Program Components
The Quality Blue Hospital Pay for Value Program focuses on key public health topics that have been identified nationally as areas of opportunity for improvement. For CY 2019, two component categories each with specific standardized metrics have been established to address these topics and include the following:
- Quality:
- Quality Bundle
- Clinical Quality Measures
- Readmissions
- 3-Day Returns to the ED
- Palliative Care Consults for Complex Patients
- Follow-up Visits for Select Episodes of Care
- Cost and Utilization:
- Average Episode of Care Costs
- Major Joint Replacement of the Lower Extremity
- Chronic Obstructive Pulmonary Disease (COPD),Bronchitis, Asthma
- Esophagitis, Gastroenteritis, and Other Digestive Disorders
- Sepsis v. Cardiac Arrhythmia
- Percutaneous Coronary Intervention
- Simple Pneumonia and Respiratory Infections
- Major Bowel Procedure
- Spinal Fusion (non-cervical)
- Stroke
- Average Episode of Care Costs
Program Evaluation and Scoring
Participant performance will be monitored throughout the program year and dashboard reports will be shared quarterly in an effort to provide insight for further process improvements.
Performance measurement for the CY 2019 Program begins January 1, 2019, and concludes December 31, 2019. The claims-based reporting methodology requires that the measurement period begins in advance of the program start date to allow for sufficient time for data collection and claim run-out so that comprehensive and complete results can be provided. Individual metric measurement periods and, when applicable, baseline information can be found in the Program manual.
A final three month run-out period will be used on program components to identify all claims that should be included for performance measurement and scoring purposes. Participants are scored at the end of the program year.
Participants will be measured and scored on all program components for which they qualify. Participants with accountability for participating in all program component metrics have an opportunity to receive a maximum of 100 points (105 points with potential Quality Bundle bonus points). Participants that do not meet the criteria for inclusion in all program components (due to specific component requirements or other exclusions) will have their applicable component scores converted to a score out of 100 percent.
Ongoing Changes to the Program
The Quality Blue Hospital Program continually evolves to meet the needs of Highmark and participating network facilities. Accordingly, the Quality Blue Hospital Program will be reviewed and revised annually.
For More Information
For additional information regarding the Quality Blue Hospital Program, contact the Provider Service Center.
The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.
All revisions to this Highmark Provider Manual (the “manual” or “Highmark Provider Manual”) are controlled electronically. All paper copies and screen prints are considered uncontrolled and should not be relied upon for any purpose.
