Summer Breeze Makes me feel fine


“See the curtains hangin’ in the window, in the evenin’ on a Friday night.

A little light a shinin’ through the window, lets me know everything is alright.

               Summer breeze, makes me feel fine, blowing through the jasmine in my mind.”

                                                            Seals & Crofts

                                                            Lyrics by Regine Schmidt

Centered Care Initiative

The GIC’s Centered Care program — an initiative that seeks to change the health care delivery system and implement payment reform pursuant to chapter 224 — entered its third year with successes and disappointments.  Customary payment methods tend to lead to overutilization of medical procedures and increased charges regardless of health outcomes.  Our contracts with the plans use incentives and penalties to encourage plans to contract with doctors, hospitals and other providers using global budgets – or Integrated Risk-Bearing Organizations (IRBOs) - for the management of care instead of the usual fee for service arrangement. 

The GIC set aggressive goals for member enrollment in IRBOs, with plans required to reach specific enrollment, cost benchmarks, and milestones. This program aligns with similar payer initiatives, including those of Medicare and MassHealth and is the wave of the future of health care payment and delivery.

However…it will take time as encouraging providers to take on risk and be paid on value rather than volume requires fundamental changes in the marketplace: management commitments; cultural changes; business redesign; patient-centric approaches; and new infrastructure.  As Bill Gates said, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.  Don’t let yourself be lulled into inaction.”

Enrollment Benchmarks Achieved

As of FY16, all six plans met a revised fiscal year benchmark of having at least 50% of their GIC members enrolled in these payment arrangements.  Additional enrollment opportunities are limited by provider groups that are too small to take risk, or that have insufficient numbers of GIC patients, in part due to the fact that the GIC’s membership is split between six carriers.

Rate Targets Harder to Achieve

Skyrocketing prescription drug costs, Affordable Care Act-related charges, an aging population, increased utilization and market clout by the most expensive providers has made the rate targets hard to achieve.  For the first two years of the program, overall rate increase caps of 2% were met, but the plans have struggled with the 0% and negative trend goals for the last three years of the contract, with some plans doing more poorly than others.

The initial proposed weighted rate increase for FY17 from the plans was substantial at 7.1%. After our annual rate renewal negotiation process, the final weighted average rate increase was 3.6%, in keeping with the state’s benchmark and lower than the national average. Some plans did better than this and some did worse.  However, due to the Harvard Pilgrim Independence Plan’s significant premium increases and spending beyond its premium rates, the Commission took a firm stand and closed the plan to new members.

Clinical Performance Improvement (CPI) Initiative

The GIC’s groundbreaking Clinical Performance Improvement initiative – also known as Select & Save – continued to advance transparency, quality of care, and efficient use of resources.  This program was developed in 2003, long before health plans were tiering physicians.  A combined de-identified claims data set of almost two million covered lives from the GIC’s six health plans was analyzed for differences in how physicians perform on nationally-recognized measures of quality and/or cost efficiency.  Members paid the lowest copay for the highest-performing doctors:

«««Tier 1 (excellent)

  ««Tier 2 (good)

    «Tier 3 (standard)

A 2014 study of the GIC’s CPI Initiative conducted by Anna Sinaiko Ph.D., M.P.P. and Meredith B Rosenthal, Ph.D. found that members looking for a specialist did take tiering into consideration when choosing a physician, but did not change specialists if had seen that doctor previously.  In FY16, the specialty copay differential for members was increased from $25/$35/$45 to $30/$60/$90.  We anticipate that the copay changes will have an effect on existing specialist selection.

With a commitment to transparency and collaboration, the GIC and our consultant, Mercer, met with many large provider group practices to discuss collaboration opportunities and ways the practices might use the CPI data and to get feedback that has led to major revisions in the reports.  In FY16, these meetings included:

  • Beth Israel Deaconess Physician Organization
  • Steward Health Care
  • Atrius Health
  • Reliant Medical Group
  • Baycare Health Partners
  • Lahey Health
  • Partners HealthCare
  • Boston Medical Center
  • Hallmark Health
  • Mount Auburn Cambridge Independent Practice Association
  • New England Quality Care Alliance

These meetings led to a total redesign of the provider reports to make them easier to understand and more engaging.  They now include bar graphs and pie charts to display the data visually, and have a new episode summary/mid-level report that breaks down individual episodes by service category.

The new consolidated report, with tier designation and information on how each tier was developed, was mailed in January to over 6,300 specialists.  This was followed up with a summary report mailing to 21 practice leaders of each practice’s low-scoring providers so they could initiate discussions with these practitioners about possible performance improvements.  A third mailing to almost 5,700 primary care providers (who are not tiered), provided quality and efficiency scores and insight into their performance. 

This information provided by the Group Insurance Commission .