Managed Care - January 2008 - (Page 17) been expected to pay for post-operative complications, we’ll transfer the risk for that care from you as a payer to us as a health system,” says Casale. If, because of complications, a CABG patient requires additional care or hospitalization, GHP is not charged for that follow-up care. For instance, Geisinger Clinic will pick up the cost for additional hospital stays, typically $12,000 to $15,000. In this manner, ProvenCare is an add-on for the traditional diagnosis-related group system, says Jaan Sidorov, MD, a consultant, a member of MANAGED CARE’s Editorial Advisory Board, and a former medical director at Geisinger. “ProvenCare differs in that the global payment for the episode includes not only the patient DRG but certain additional services as well, such as an unplanned re-admission. It also covers for a period of time after discharge of the index hospitalization.” This is a timely development. Geisinger’s effort coincides with Medicare’s decision to end payment for eight preventable errors in hospitals, so the entire area of what plans or plan sponsors should pay for is very much in focus. “We feel we’re addressing many of the specifically identified issues that Medicare is addressing in a much more general comprehensive way through the development of quality initiatives specifically in the hospital with ProvenCare,” says Richard J. Gilfillan, MD, president and CEO of Geisinger Health Plan and Geisinger Indemnity Insurance. Bonuses All Geisinger physicians receive a base salary and incentive. It’s a ratio of about 80 percent salary to 20 percent incentive based on goals. Those goals include certain benchmarks, including patient satisfaction and quality measures. For ProvenCare doctors, hitting the ProvenCare benchmarks is one of those goals for potential bonuses. This internal experiment is attracting a lot of external interest. “Geisinger is addressing an issue that has bothered many insurers and employers — that when quality of care is less than ideal, the extra services often required by patients experiencing complications generate more revenue for the providers and higher spending for those who pay for care,” says Paul B. Ginsburg, PhD, president of the Center for Studying Health System Change. “Geisinger is telling insurers that it will take on this financial risk. It is doing this both to motivate its staff to achieve even higher levels of quality and to make it Clinical outcomes indicate that warranty shows promise eisinger is looking to sell its ProvenCare program to other health plans. Those plans must determine whether the “warranty” can work when the same company does not own the insurer and the physician groups. Meanwhile, some argue that the clinical benefits alone might make ProvenCare worthwhile. A study in the Annals of Surgery comparing ProvenCare patients to a conventional care group shows that “most adverse events occurred less often in the ProvenCare group than in the conventional care group, though only the likelihood of being discharged to home was statistically significantly different.” G Conventional care group (n = 137) Readmission within 30 days Discharged home Patients with any complications Patients receiving blood products Readmitted to ICU Pulmonary complications Operative mortality Atrial fibrillation Deep sternal wound infection 9 111 53 32 4 10 2 31 1 % 6.6 81 39 23 2.8 7 1.4 23 0.7 ProvenCare group (n = 117) 7 106 41 19 1 3 0 30 1 % 6 91 35 16 1 2.5 0 26 0.9 P 0.99 0.03 0.55 0.17 0.38 0.15 0.50 0.58 1.00 Statistical test Fisher exact Fisher exact Chi-square Chi-square Fisher exact Fisher exact Fisher exact Chi-square Fisher exact Source: Casale AS. “ProvenCare: A Provider-Driven Pay-for-Performance Program for Acute Episodic Cardiac Surgical Care,” Annals of Surgery, October 2007 JANUARY 2008 / MANAGED CARE 17
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