RP: We have a Physician Recognition Program and the Hospital Recognition Program to acknowledge their efforts in the areas of patient safety, clinical outcomes, patient satisfaction and administrative work – because these areas ultimately produce a better result for individuals who subscribe to our various products.

RP: We had a similar program in place since the late 1990s, primarily focused on primary care physicians in our managed care line of business. It utilized readily available preventive NCQA and HEDIS measures, and member satisfaction. Our current program began in June and was developed over the last year and half. As we were able to generate better data about performance, from more varied sources, we began to think about using that data in ways that would better recognize physicians in the program. It is focused on nine specialties: internal medicine, pediatrics, family practice, ob/gyn, pulmonary medicine, cardiology, gastroenterology, urology and orthopedics. Those are the specialties in which there is the most robust amount of evidence-based data to support our quality programs.

Most health plan data that comes out of the claims system is transaction-based data and needs to have referential integrity – we need to be able to know that a particular patient is being cared for by a particular physician, and getting a set of services. We need to be able to capture those links, knowing that there are limitations in using a transaction-based data set. We do enhance those claims data with lab and pharmacy data. We didn’t have all those elements five years ago. It’s more robust today, and we’ve spent a fair amount of time working with these claims data around certain specialties to make sure that the data are credible. We plan to expand the program to three more specialties over the next year: otolaryngology, general surgery and endocrinology. In order to have statistical validation, there is a volume requirement of 40 episodes of care annually for participation, so there may be physicians who have a very low volume of Horizon members that won’t qualify.

RP: We use quality metrics relevant to a given specialty. For example, the percent of patients who have congestive heart failure who fill the prescription for a beta-blocker. For coronary artery disease, use of statins for patients with high cholesterol. We measure each specialty independently and the top 15 percent of performers in each of the nine specialties get a 15 percent increase in their fee schedule for the subsequent year – for most E&Ms and CPTs. The program will go through the evaluation cycle on an annual basis: if you continue to be in the top 15 percent, you continue to get a 15 percent increase over the regular fee schedule.

The measures that go into the calculation are clinical (weighted 45 percent), efficiency (45 percent), and Rx dispensing (10 percent). For example, for Rx dispensing, we look at the generics dispensing rate. The clinical process and outcome measures come from a variety of well-recognized organizations that generate universally acceptable standards. Our risk-adjusted efficiency methodology uses episode treatment groups: you’re efficient against the average performance of your peer group, so if you consume more resources than the average, you’re less efficient. We calculate actual cost over case mix-adjusted expected cost based on a peer group, while we also take unique circumstances into consideration.

We also offer three types of non-financial recognition. We’ll publish in press releases the names of all physicians in each of the specialties who are in the top 15 percent, we’ll put those physician names on our website, and we send plaques that physicians can hang in their office – and we’ve gotten some anecdotal feedback that physicians appreciate that third type of recognition, and that there is value and desire for the non-financial recognition.

RP: Not yet. We haven’t made a decision whether we will make that publicly available or not. We have been looking at that particular issue for quite a while.

RP: The data are mixed, but there are certainly some studies that demonstrate that recognition – financial and non-financial – produce higher levels of quality. In general, financial incentives between 10 and 20 percent are enough to generate attention and action regarding practice pattern modification.

RP: We want to acknowledge hospitals’ efforts in patient safety, clinical outcomes, patient satisfaction and certain administrative measures – both with financial and public recognition. The program launched this year enables us to distinguish hospitals in our network for sustained excellence and improvement that we think will lead to better clinical performance. We have created two programs, generally focused on the same outcomes: the Leapfrog Hospital Rewards Program and the Horizon Hospital Rewards Program. Not all hospitals wanted to embrace the Leapfrog Group program, and we didn’t want to force that program on hospitals that didn’t want it. Leapfrog is a nationally standardized hospital program, inspired by CMS’s Premier Hospital Quality Incentive Demonstration, and it uses a national dataset of hospital quality and efficiency information. Its clinical measures include coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, community-acquired pneumonia, and deliveries/newborn care – all of which account for a significant share of inpatient hospital admissions and cost. Efficiency measures include severity adjusted average length of stay for routine care days and special care days; readmission rate to same facility within 14 days. Administrative measures added by Horizon to the Leapfrog program include patient satisfaction outcomes and timeliness of electronic claims submission.

The Horizon program focuses on clinical measures from CMS’s core quality reporting measures related to heart attack, heart failure, community-acquired pneumonia and prevention of surgical site infections. In Leapfrog, the individual measures within each clinical area are weighted based on evidence that a hospital’s performance in that specific clinical area will have an impact on mortality and morbidity. For Horizon, all the measures are weighted equally, including administrative and patient satisfaction data. Hospitals will have the opportunity to review the data and present any changes to reconcile the final data to be used.

RP: Recognition will be on an annual basis. Non-financial recognition will be in the form of publicity surrounding the achievement of either being in the top 25 percent of quality or resource use for each or all of the disease states for which this status is accomplished. Hospitals will also be acknowledged for improving by 10 percent or more in each disease state in which they achieve this improvement. Financial recognition levels for the Leapfrog programs are: $175,000 for hospitals with 400 or more beds, $150,000 for hospitals with more than 200 beds but less than 400 beds, and $125,000 for hospitals with less than 200 beds. For the Horizon program, the recognition levels for those three hospital sizes are $150,000; $125,000; and $100,000, respectively. There are no penalties for poor performance. Our focus is rewarding high-performing hospitals, feeding back information to those hospitals that are not as high-performing and working with them to raise their performance levels. The same is true of our physician recognition program: we have physicians and support staff who go out to practices and provide feedback to help them – to the extent that we can – to focus on areas where there are great opportunities for improvement.