Value-Based Reimbursement Programs

Medicare Advantage Stars

The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans and prescription drug plans separately on a scale of one to five stars, with five representing the highest quality. The Star Rating for Medicare Advantage plans is an overall measure of the plan's quality, and is a cumulative indicator of: Quality of care, Access to care, Beneficiary satisfaction, Customer Service, and Responsiveness to member needs. The intent of the program is to tie quality of care to financial reimbursements, whereby rewarding high performing plans and forcing low performing plans to exit the market.


Quality Blue Hospital Program

Highmark's mission is to provide access to affordable, quality healthcare and enable individuals to live longer, healthier lives. Participants in the Quality Blue Hospital Pay-for-Value Program partner with Highmark to advance this mission at the point of patient care, throughout the facility and in the community at large.

The Highmark Quality Blue Hospital Pay-for-Value Program affords Highmark an opportunity to partner with network hospitals toward the common goal of improving patient care and safety. The program aligns with nationally recognized guidelines and incorporates industry standards and evidence-based care. The Quality Blue Hospital program focuses on key public health issues and quality indicators that have been identified nationally as areas for improvement.

Additional information regarding the Quality Blue Hospital Program can be obtained by reviewing Chapter 5 of the Highmark Provider Manual.


Specialist Performance Initiative

Highmark continues to expand its portfolio of value-based care programs and initiatives to include addressing specialist cost transparency and performance with the Specialist Performance Initiative (SPI). Starting December 2020, Highmark will offer select specialists a cost profile tool that provides physician-level data to inform practice performance, influence clinician behavior and optimize referral patterns.

SPI will include ranking information on over 11,000 specialists in 14 clinical specialty groupings and 52 clinical condition categories giving Highmark’s network brand new insights into performance to help them provide and guide our members to the highest value care possible. SPI includes the following specialties: cardiologists, dermatologists, endocrinologists, gastroenterologists, general surgeons, gynecologists, nephrologists, neurologists, ophthalmologists, orthopedic specialists, psychologists, pulmonologists, rheumatologists, and urologists. This initiative applies to all Highmark service areas in Pennsylvania, Delaware and West Virginia.

If you have questions regarding SPI, submit your inquiry to SpecialistPerformance@highmark.com.


True Performance

This is a contracted program that replaced all previous pay-for-value and quality incentive PCP programs across all markets and member populations. This program is designed to continue to improve the quality of healthcare delivered to our members while working to reduce the overall cost of healthcare for our members. For our provider partners, True Performance reduces the complexity of multiple programs, offers a higher performance based reimbursement opportunity, and provides timely and actionable reporting. PCP entities with 250 or more members will be eligible to participate in the new program.


True Performance Home Health Pay-For-Value Program

Highmark continues the evolution of our efforts to reinforce and improve quality, enrich our member experience, and reduce the overall cost of care by supporting home health providers with the flexibility to implement innovative care delivery models focused on health outcomes and quality, as well as reduce the operational burden of administrative requirements that do not add value. This True Performance Home Health Pay-for-Value Program will serve as a foundational value-based reimbursement program for Highmark’s home health provider networks. The program offers the potential for significant value-based reimbursement by rewarding participants for managing their Highmark member patient population toward high value, for both quality and efficiency.


True Performance Skilled Nursing Facility Pay-For-Value Program

Highmark continues the evolution of our efforts to reinforce and improve quality, enrich our member experience, and reduce the overall cost of care by supporting skilled nursing facility providers with the flexibility to implement innovative care delivery models focused on health outcomes and quality, as well as reduce the operational burden of administrative requirements that do not add value. This True Performance Skilled Nursing Facility Pay-for-Value Program will serve as a foundational value-based reimbursement program for Highmark’s skilled nursing facility provider networks. The program offers the potential for significant value-based reimbursement by rewarding participants for managing their Highmark member patient population toward high value, for both quality and efficiency.

 

Log in to NaviNet, then navigate to the Resource Center for all the information, including training and education, on these and other programs.

Last updated on 8/29/2022 9:48:55 AM

 

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