BCBSMA 2012 Annual Report

Better Care, Lower Cost

2012 marked three years since we introduced the Alternative Quality Contract (AQC), a groundbreaking payment model that rewards providers for quality, efficiency and effectiveness rather than quantity of care.

By the end of the year, more than three-quarters of the contracted primary care providers and specialists in our HMO network were participating in the AQC. The results of the AQC to date, including those from a formal evaluation by Harvard Medical School researchers, show that its use is improving patient care while slowing the growth in health care spending.

A September 30, 2012 editorial in The New York Times, entitled, "How Insurers Can Help," said this of the AQC: "The experience with Massachusetts Blue Cross suggests that global payments can help change the culture of medical practice. If this model shaves just a few percentage points off the spending growth rate, total health care expenditures in the nation could drop by tens of billions of dollars a year, saving trillions over the next two decades."

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Improving Coordination of Care

BIDPO photo
BIDPO's Richard Parker and Marilyn Wright.

It is often said that, to improve the quality of health care while reducing costs, patients need to receive the right care, in the right place, at the right time. The concept is simple, but the reality is not. As Richard Parker, MD, medical director of the Beth Israel Deaconess Physician Organization (BIDPO), points out, "Unlike most services, health care is rendered in millions of little pieces, around the clock, in multiple locations. Physicians constantly have to decide which is the path to quality."

The potential adverse consequences of fragmented care are many, especially for the sickest patients–avoidable hospital admissions, unnecessary or duplicative tests and procedures, and serious gaps in care, to name a few. In other words, it increases the likelihood of receiving a lower quality of care and higher costs. Physician groups operating under our
Alternative Quality Contract (AQC) have a strong incentive to invest in the people, processes, and programs needed to make sustainable improvements in health care delivery.

At BIDPO, nurse case managers assigned to each of the group's primary care practices use an electronic health record system to identify patients at high risk for hospitalization and reach out to offer them help in managing their conditions. Patients making a transition from the hospital to home are contacted to check on their condition, make sure they comply with recommended medications and follow-up appointments, and identify gaps in care. Marilyn Wright, RN, director of Quality and Community Case Management, believes the transition program has played an important role in reducing avoidable hospital

Improving Coordination of Care

readmissions while also improving the quality of patient care. During the first year of the program, BIDPO's readmission rate fell by 14 percent.

"The AQC has played a huge role in improving communication and coordination of care."


Accountable Care Associates (ACA), which was one of the first physician groups to adopt the AQC, has gained a strong reputation among other practices in the state, and elsewhere, for their comprehensive approach to care coordination. Notably, they have developed their own version of an electronic care-coordination tool that connects ACA primary care providers with each other, with specialists treating their patients, with care managers, and with hospitals.
"We're always working to find the right setting for our patients' care," says ACA's Chief Medical Officer, Gopal Sarker, MD. "Our programs and tools provide all relevant information about the patient, so that we can reach out to help our sickest patients manage their conditions. Our inpatient providers frequently meet patients in the emergency room to make sure they avoid any unneeded tests or admissions, then providers facilitate their patients' care transitions from hospital to rehab and home, and coordinate their follow-up care."

As Lowell General Physician Hospital Organization (PHO) began exploring opportunities for improvement under the AQC, it discovered that its primary care providers were seldom notified when their patients went to the emergency room.
In response, the PHO created a system for sending each of its 80 primary care practices lists of their patients who had gone to the emergency room the previous day. This gives the practice an opportunity to educate patients about alternatives to emergency room use and to arrange appropriate follow-up care. "Getting the primary care provider involved quickly is the key to coordinating care," says Emily Young, director of Health Care Operations for the PHO. "The AQC has played a huge role in improving communication and coordination of care. Without it, we'd be getting there slowly, but our physicians and the hospital would never have been so aligned in terms of their incentives and common goals."

Managing Complex Conditions

MACIPA photo
Barbara Spivak, MD, consults with Betsy Pollock, LICSW, (center) MACIPA's Director of Social Work.

With its incentives for physician groups to improve quality and outcomes while slowing the rate of spending, our Alternative Quality Contract (AQC) has fostered innovative
approaches to helping patients who are most at risk for medical crises and hospitalization. Last year, for example, the Mount Auburn Cambridge IPA (MACIPA) and the Northeast Health Systems Physician Hospital Organization (Northeast PHO) bolstered their primary care teams with behavioral health and social worker expertise.

"The AQC sets the stage for physicians to look at their practices differently," says MACIPA's President, Barbara Spivak, M.D. "Once they realize they are getting paid for quality performance, they begin to explore ways to improve the health of challenging and costly patients by investing in the redesign of care delivery."

MACIPA formed a team of social workers in 2012 to support the group's physician practices
in caring for their most vulnerable patients. "We have a terrific care management and coordination team," says Dr. Spivak, "but some of our sickest patients may also have issues with safety, complicated family problems, or difficulty connecting to programs and services in the community that can help them cope with their medical situation. They may also need help with copays and medications, particularly in this shaky economy. Now our physicians and nurse case managers can connect patients with a social worker who can help overcome these barriers."

"Simply put, it's a model that improves the care experience for both the patient and the physician."


At Northeast Physician Hospital Organization, a new Integrated Care Management (ICM) team

Managing Complex Conditions

was created to address the combined medical, psychological, and social needs of their sickest patients. Executive Director, Nicole DeVita, explains the process, "Our physicians, nurse practitioners, and care managers talk to at-risk patients and their families about the opportunity for additional services. If they agree, the ICM team conducts an assessment, evaluates various services, and develops an action plan to meet patients' comprehensive health-related needs. Patients and families can accept as much or as little of the plan as they desire, and the team will then coordinate, monitor, and reassess the plan on a regular basis."

With their multi-disciplinary teams in place, MACIPA and Northeast PHO physician groups can offer their high-risk patients an array of added services–behavioral health support; crisis
intervention; caregiver support; home visits; guidance with obtaining supportive community and health plan services; and help with preventing avoidable hospital readmissions by making sure patients can get to their follow-up appointments and obtain medications.

Dr. Spivak points out that the concepts of teamwork and care coordination are at the core of a rapidly advancing health care model known as the patient-centered medical home. Several MACIPA practices are adopting the medical home model, thanks in large part to their success with the AQC, she adds. "Simply put, it's a model that improves the care experience for both the patient and the physician."