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Home > Disease Management
Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration
Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration
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Like the convenience of an instant PDF download but still want a hard copy of this book? Order both versions and save 35 percent!

In tandem with adoption of post-reform care delivery models like the patient-centered medical home (PCMH) and accountable care organization (ACO), healthcare organizations are constructing payment and compensation models that reward physicians for improving population health, the patient experience and per capita cost — approaches that may encourage more medical residents back to primary care.

The Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration explores newly minted reimbursement formulas at two health plans and two independent practice associations (IPAs), providing payor and provider perspectives on the formula development process; clinical, quality and efficiency measures in use; physician incentive payments and program outcomes.

This 68-page special report also examines the collection and sharing of physician performance data by these four organizations and the impact of data sharing on physician engagement, health outcomes, utilization and cost. Additionally, the Q&A section answers more than 40 questions on the programs presented in this resource.

Download the executive summary of the Guide to Physician Performance-Based Reimbursement.

The Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration documents the following physician performance-based payment programs:

  • After 14 years of administering pay for performance (PFP) programs for its 700 providers and specialists, HealthPartners has figured out what motivates physicians. Babette Apland, senior vice president of health and care management for HealthPartners, describes the payor's strategy for supporting transformation of care delivery, including its strategic framework, payment and compensation models, and population health data models. Apland describes the health plan's alignment of physician incentives and shared savings with pay-for-performance programs and a total cost of care initiative.

  • Mark Shields, MD, MBA, senior medical director for Advocate Physician Partners (APP) and vice president of medical management for Advocate Health Care, details the clinical integration (CI) program APP developed for its 3,000 physicians — from the structure of the CI group to funding, incentives, mechanisms and technology that support CI. Dr. Shields shares the key strategies of this IPA to improve physician performance and why a successful CI program can provide the framework for an accountable care organization.

  • Capital District Physicians' Health Plan Inc., (CDPHP), a network model health plan, launched a two-phase medical home pilot in 2008 to reform both the practice of primary care in its network and the payment to these physicians. Participating practices receive an incentive for practice transformation and are eligible for additional reimbursement for meeting quality and efficiency targets. Bruce Nash, MD, MBA, senior VP of medical affairs and CMO for CDPHP, describes how CDPHP met the challenge of developing a novel risk adjustment methodology that would drive a global payment combined with a significant bonus structure to attract physician participation and encourage future growth by medical students to enter primary care.

  • Taconic IPA, through a community transformation program, is leveraging performance reporting data to engage 237 physicians in its medical home pilot in quality improvement while increasing reimbursement rates for its physicians. Paul Kaye, MD, medical director at Taconic IPA and Susan Stuard, executive director, THINC, provide details from this multi-payor collaborative, describing how the sharing of data across its organization is improving physician performance and value-based reimbursement levels and other details from this multi-stakeholder initiative.

Download the executive summary of the Guide to Physician Performance-Based Reimbursement.

Table of Contents

  • Aligning Physician Incentives for Shared Risk and Reward
    • Drivers of Low-Value Care
    • Calculating Shared Savings
    • Defining Total Cost of Care
    • Reports and Analytics
  • Framing the ACO Through Clinical Integration of Independent Physicians
    • Advocates Vision of CI
    • Components of CI
    • Pay for Performance Incentives
    • Performance Improvement Tools
    • Lessons Learned
    • Key Success Factors
    • CI as ACO Chassis
  • Rewarding Primary Care Practice Reform with Physician Payment Reform: A Medical Homes Experience
    • Motivations for Medical Home Project
    • Readying for Practice Reform
    • Moving on to Payment Reform
    • Risk-Adjusted FFS Model
    • Analyzing the Bonus Model
    • Future Plans
  • Improving Physician Performance and Value-Based Reimbursement Levels Through Meaningful Data Sharing
    • Medical Home Transformation
    • NCQAs Nine Standards of a PCMH
    • Team-Based Care
    • Challenges and Goals
  • Q&A: Ask the Experts
    • Adjusting for Risk
    • Physician Response to Total Cost of Care
    • Handling Withholds
    • Determining the Trend Goal
    • ASOs and Shared Savings
    • Results from Total Cost of Care
    • Calculating RUI
    • Performance Reporting
    • ETG Distribution
    • Employer Refunds
    • EHRs and Evidence-Based Protocols
    • More HealthPartners Analytics
    • Medical Groups Compensation Model
    • Why Payors Should Partner in an ACO
    • Quality and Performance Measures
    • Focusing on Efficiency Measures
    • Exclusive Versus Non-Exclusive Programs
    • Responsibility for Tracking Care
    • Overcoming Physician Resistance
    • Post-Acute Network
    • Convincing Payors to Collaborate
    • Future Contracting Plans
    • Evaluating Current Models of Direct Care
    • Behind Physician Motivation
    • Moving Specialists into the Medical Home
    • NCQA Accreditation Standards
    • Contribution of the Medicare Coordinator
    • On Membership Models of Direct Primary Care
    • Using Surrogate Measures
    • Positioning for ACOs
    • Building C-Suite Support for the PCMH
    • PCMH Revenue from Improved Efficiencies
    • Primary Care-Specialist Collaborations
    • When Leadership Doesnt Support the PCMH
    • Improving Efficiency of Practices
    • Employers and Incentives
    • Next Steps with the Primary Care-Specialist Collaboration
    • Utilization Measures for the Quality Profile
    • Importance of Aggregating Payor Data
    • Using EMRs
    • Changing Responsibilities in the Practice
    • Bringing Together Community and Private Practice
    • Attribution Methodology
    • Paying TransforMed Fees
    • Paper Charts and Eligibility
  • Glossary
  • For More Information
  • About the Speakers

Product Review

I would recommend Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration “as it is helpful in how to add quality performance expectations with your medical staff.”

Rebecca T. Smith, MBA, BSN, RN
Chief Operating Officer, Vice President
Caldwell Memorial Hospital
Publication Date: May 2011
Number of Pages: 68
ISBN 10: 1-936186-78-0 (Print version); 1-936186-79-9 (PDF version)
ISBN 13: 978-1-936186-78-5 (Print version); 978-1-936186-79-2 (PDF version)
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