Highmark program increasing focus on the total cost of care

PITTSBURGH, Pa. (May 2, 2018) — In early 2017 Highmark launched a new value-based reimbursement program for Primary Care Physicians (PCPs) called True Performance, which focuses on quality and affordability, as well as improving outcomes and the overall patient experience for its members.

In the True Performance program, PCPs that meet certain quality and cost measures earn value-based payments via monthly care coordination fees and performance-based reimbursement. True Performance also helps ensure that PCPs are focused on preventive care and treatment services, such as childhood immunizations, appropriate drug therapy for chronic diseases, cancer screenings and annual wellness exams. This helps members avoid more costly care later. In turn, PCPs can earn up to 30 percent more than the standard fee-for-service payments based on their quality and cost management performance.

"We have determined through our claims data that PCPs receive about 5 percent of our total provider reimbursements," said Tom Fitzpatrick, senior vice president of provider contracting and relations. "But PCPs actually influence nearly 80 percent of the health care spend through services such as prescriptions and referrals to specialists."

For example, a member who had not been to her PCP for over a year visited the emergency room eight times, using the ER as her "primary care" provider. Working with Highmark's experienced staff of Provider relations resources and utilizing our True Performance Advanced Analytics, Highmark was able to help her PCP identify the situation. The patient was seen in the office and diagnosed with diabetes. Now her PCP helps to ensure she is on the right medications, getting appropriate tests and screenings and is in touch regularly with a Highmark health coach. The member is then able to stabilize her blood sugar levels, maintain vision and circulatory health and take fewer medications. In the absence of this intervention, the PCP might have had to refer the member to various specialists and prescribe additional medications.

Now, Highmark's True Performance Plus program is offering PCPs an opportunity to earn even more for reducing health care costs in addition to improving outcomes.

Looking to better manage those costs, True Performance Plus gives PCPs the opportunity to earn additional shared savings reimbursement when their patient's health care costs are reduced.

Highmark has participation agreements for True Performance Plus with many health systems and independent physician practices, including, but not limited to:

Western Pennsylvania

• Premier Medical Associates
• Physician Partners of Western PA, LLC
• Butler Medical Providers
• Advantage Point Health Alliance Laurel Highlands, LLC
• Excela Health System
• Heritage Valley Healthcare Network
• Vale U Health Physician Organization
• St. Clair Medical Service
• Washington Hospital Physicians Organization

Central Pennsylvania

• Medical Group of Pennsylvania
• Penn State Health

Delaware

• United Medical Accountable Care Organization, LLC

West Virginia

• MHC Accountable Care Organization, LLC

By helping members better manage their care or by providing guidance for appropriate treatments, PCPs can significantly influence the overall cost of care and be rewarded with a portion of the savings generated under the True Performance Plus program.

"The idea of value-based provider reimbursement is much more than the True Performance program," said Fitzpatrick. "It's the way we want to do business with all of our providers going forward."