Highmark Announces Accountable Care Alliance

The health insurer's goal is to shift its physician network from fee-for-service payments to a value-based compensation model that rewards physicians for the quality of that care and may reduce healthcare costs.

Pittsburgh-based Highmark Health Services, has formed the Accountable Care Alliance with the physicians employed by the Allegheny Health Network. Highmark officials expect to expand the model throughout its markets.

The incentive-based program holds the promise of enabling physicians to increase their reimbursements by as much as 30% by meeting certain quality measures. The goal is for Highmark to shift its physician network from fee-for-service, which encourages physicians to focus on the number of patients they treat, to a value-based payment system that rewards physicians for the quality of that care and may reduce healthcare costs.

At the press conference announcing the ACA, Mike Fiaschetti, president of health markets for Highmark, described the program as "our foundation for transforming the way healthcare is delivered through how we provide incentives to physicians and how we reimburse them."

Fiaschetti said the program will include enhancing the way the insurer shares data and information with physicians, care management, and the coordination of patient care across the care continuum.  

"For the first time we'll be looking at the overall per capita cost of patient care," said Fiaschetti, who made a point of stating that the program was developed with input from "physicians, not physician administrators."

Fiaschetti noted that the program will reward certain physician behaviors such as spending more time with patients and meeting quality goals.

The physician incentives will be awarded based on enhanced quality and population health management costs. The 28 quality parameters include familiar Healthcare Effectiveness Data and Information Set (HEDIS) and National Quality Forum measures such as tracking that patients receive mammograms at the appropriate stages of their lives and that heart attack patients receive appropriate medications.  

Incentives will also be based on follow-up services to make sure patients understand physician orders, fill prescriptions, and take their medications.  

For now, the ACA is entirely incentive-based, but plans call for it to grow to a "broader, full gainsharing, risk-sharing model in about three years," said Fiaschetti. "We call it a glide path. You can't just go to full risk and expect physicians, hospitals and specialists to all succeed until we start working together."

Highmark has already signed up 500 physicians employed by the Allegheny Health Network, an integrated delivery system that includes six hospitals. It plans to expand the program to physicians at Saint Vincent Health System in Erie, which Highmark acquired last week, by the end of the year. Officials said they expect the ACA to grow to include independent physicians throughout its central and western Pennsylvania markets, as well as its Delaware and West Virginia markets.  

For now the focus is on primary care physicians but specialists will be added at a later date. Paul Kaplan, MD, Highmark's senior vice president for provider strategy and integration, said Highmark is looking for physician groups where "someone is willing to be a champion for the new delivery system [who] understands the investment in time required to understand what their patients want, as well as the investment in IT and infomatics infrastructure needed."

Highmark officials declined to reveal how much the giant Blue Cross Blue Shield affiliate intends to invest in the alliance. Some funding for care coordination mangers will be included for selected physician groups to enable physicians to spend more time with costly chronically ill patients such as diabetics.  

"We're hoping to create a 'wow' factor for our patients," said Kaplan. "When they leave their doctor's office we what them to feel like they got what they needed, when they needed it, and at the right price."