January 2011 STRATEGIC INNOVATIONS FOR AFFORDABLE, SUSTAINABLE HEALTH CARE: A Model for Health System Reform Environmental Scan Table of Contents 1 ACCOUNTABLE CARE ORGANIZATIONS 1 3 ELECTRONIC MEDICAL RECORDS 20 Accountable Care Organizations .................................................................. 1 Application Service Provider (ASP) Hosting Strategy ................................. 20 Physician Group Practice Demonstration ......................................................................... 2 EMR Facilitated Process Redesign – SIX SIGMA ...................................... 21 Brookings-Dartmouth ACO Collaborative ......................................................................... 3 Hospital Sponsored Incentives to Drive Physician EMR Adoption ............. 22 Carilion Clinic, Roanoke, VA ............................................................................................. 3 Adoption of Common Security Frameworks (CSF) to Manage New Security Aultman Health Foundation, Aultman Hospital, and AultCare Health Plans, Canton, Requirements ....................................................................................... 24 OH ................................................................................................................................. 5 Integrated Practice Management, EMR & Revenue Cycle Management Solutions ............................................................................................... 25 2 DISEASE MANAGEMENT 7 Disease/Risk Screening or Assessment ....................................................... 7 4 MEDICAL TOURISM 28 Blue Cross Blue Shield (BCBS) ........................................................................................ 9 Medical Tourism Insurance/Benefit Plans ................................................... 28 Kaiser Permanente (KP) ................................................................................................... 9 BlueCross BlueShield of South Carolina & Companion Global Healthcare,, .................. 29 Electronic (EDSS) or Computerized Clinical Decision Support Systems Medical Tourism Facilitators ....................................................................... 30 (CDSS), Physician Reminders ............................................................. 10 Healthbase Online Inc.: Healthcare Beyond Boundaries ............................................... 31 Patient Education/Self-Management Programs/Patient Action Plans/Goal Setting ................................................................................................... 10 5 PATIENT-CENTERED MEDICAL HOME 33 Remote Monitoring and Patient Support ..................................................... 11 Patient-Centered Medical Home ................................................................. 33 Peer, Social, or Community Support Programs .......................................... 12 PCMH for Medicaid Populations ................................................................. 35 Behavior and Lifestyle Modification Programs ............................................ 13 Community Care of North Carolina ................................................................................ 36 (Chronic) Disease Management Registries ................................................ 13 PCMH Within Large, Integrated Health Plans and Delivery Systems ......... 36 Holyoke Health Center Chronic Disease Registry .......................................................... 15 UnitedHealthcare ............................................................................................................ 36 Clinical Guideline Creation and/or Execution Engines ............................... 16 Purchaser-Sponsored Programs and the Patient-Centered Primary Care Provider Incentives/Pay-for-Performance ................................................... 16 Collaborative (PCPCC) ......................................................................... 37 STRATEGIC INNOVATIONS FOR AFFORDABLE, SUSTAINABLE HEALTH CARE: A Model for Health System Reform: Environmental Scan ALTARUM INSTITUTE January 2011 PAGE i 6 PAYMENT MODELS 39 Evidence-Based Medicine (EBM) ............................................................... 59 Employers Support For Primary Care ......................................................... 59 Market-level reimbursement and payment approaches or incentives ........ 39 Payment Systems Impact on Quality .......................................................... 60 Purchasing Pools ................................................................................................................ 39 Preferred Provider ............................................................................................................... 40 Pay for Performance (P4P) ......................................................................... 61 Value-based purchasing ............................................................................. 40 California P4P Program, Integrated Healthcare Association (IHA) ................................ 63 Report Cards ....................................................................................................................... 40 8 PHARMACEUTICAL INNOVATIONS 67 The eValue8 Common RFI ................................................................................................. 41 Incentive-based formularies (multi tier formularies) .................................... 67 Payment approaches and incentives .......................................................... 41 Pitney Bowes, Inc. .......................................................................................................... 70 Risk-adjusted Payment ....................................................................................................... 41 Generic Substitution .................................................................................... 70 Pay for Performance (P4P) ................................................................................................. 42 Coinsurance and Copayments .................................................................... 71 Bundled Payment ................................................................................................................ 43 Episode-based Payments ................................................................................................... 44 Pharmacy Benefit Management .................................................................. 72 The Prometheus Payment Model........................................................................................ 44 Disease Management ..................................................................................................... 72 Global Payment or Capitation ............................................................................................. 45 Utilization Management .................................................................................................. 73 Condition-specific ―capitation‖ ............................................................................................. 46 Quantity Limitations ..................................................................................................... 73 Gain-sharing ................................................................................................ 47 Prior Authorization ....................................................................................................... 73 Gain-sharing Hospital-Physician Agreements ..................................................................... 47 Drug Utilization Review (DUR) .................................................................................... 73 Gain-sharing Payer-Provider Agreements .......................................................................... 48 Delivery Systems ............................................................................................................ 74 Gain-sharing Patient-payer Agreements ............................................................................. 48 Benefit Design and Consumer Cost Sharing ............................................................... 74 Generic Incentives ....................................................................................................... 74 7 PERFORMANCE MEASUREMENT AND HEALTH CARE QUALITY 51 Multi-tiered Copayments .............................................................................................. 74 Performance Measurement ......................................................................... 51 Coinsurance................................................................................................................. 75 National Performance Measurement Systems .............................................................. 53 New England Tri-State Prescription Drug Purchasing Coalition .................................... 75 CMS Hospital Compare .................................................................................................. 53 Federal Employees Health Benefits Program ................................................................ 76 Joint Commission ............................................................................................................ 54 Computerized real time alerts ..................................................................... 77 Consumer Assessment of Healthcare Providers and Systems (CAHPS), Agency for Carespeak Communications and Mount Sinai Hospital ................................................