Highmark Health Services is striving to transition from fee-for-service to incentivized reimbursement of doctors to promote efficiency, affordability and better care.
Highmark's Accountable Care Alliance will begin in western Pennsylvania with employee doctors from Highmark's six Allegheny Health Network hospitals - Allegheny General, Allegheny Valley, Canonsburg, Forbes, Jefferson and West Penn - but will include other hospitals and doctors, including independent ones.
The program could eventually come to Blair County, according to Highmark officials.
The program attempts to "align" the incentives of the insurance company with those of the doctors, according to Dr. Tony Farah, chief medical officer of Allegheny Health Network.
Currently, the fee-for-service model dominates health care.
Doctor groups perform a service, bill the insurance company and get paid for it.
The setup rewards volume, and it can promote unnecessary care, because the more services - consultations, treatments, tests - performed, the more the doctor groups get paid.
It's not "sustainable," Farah said.
The new alliance will adjust payments to reward doctors for good outcomes and for abiding by national standards of care in obtaining them.
"We want to eliminate the concept of paying for volume," Farah said. "We do want to jump into paying for value."
The program will emphasize coordination between doctors, so when a patient with multiple problems sees one, he won't be getting the same test he had the week before at another doctor.
It will emphasize prevention, so diabetes patients stay out of crisis.
It will emphasize proper slotting, so doctors can focus more time on patients with more serious complaints and providers with lesser degrees can handle lesser complaints.
"Not every person who intersects with the health care system needs to see a doctor," said Dr. Paul Kaplan, Highmark's senior vice president for provider strategy and integration.
And the program will emphasize the use of technology and data analysis to ensure doctors are taking advantage of all the best tools.
The financial rewards can increase doctors' incomes up to 30 percent, according to Highmark officials, who spoke in a conference call last week.
Some of that payment will come in the form of capitation, which in general is a fixed payment upfront to provide an open-ended menu of services for a given number of patients.
Some of the payment will come in the form of unit compensation for services, according to Mike Fiaschetti, Highmark's president of health markets.
Capitation has been criticized for providing an incentive not to give care.
But it also rewards prevention of disease.
"Some combination of these things will evolve as the right model," Fiaschetti said. "The last thing we want is to give an incentive not to give care."
The savings from eliminating over-utilization of services and from prevention of illness and prevention of hospital readmissions for mistakes should more than offset the reward payments, generating savings of 3 to 5 percent, even as patients get better care, according to Highmark officials.
Highmark expects the program to "morph and grow" for the next three years, possibly into something close to a full-fledged accountable care organization, as laid out in the Accountable Care Act.
It was too dicey for doctors and patients to try to "get there overnight," Kaplan said.
It may develop into a "full risk share model," Kaplan said.
Highmark rival UPMC years ago went past where Highmark is headed eventually, according to spokeswoman Wendy Zellner.
"We were an ACO [accountable care organization] before that term was invented," Zellner wrote in an email Friday. "That's what a payer-provider is - and we are the second-largest in the nation after Kaiser and have been for years."
UPMC is working to take "that focus to a new level" under leadership of its doctors by using "sophisticated data analytics" and "rolling out evidence-based guidelines for specific conditions to help our physicians deliver the best possible care," she wrote.
UPMC has culled these guidelines from medical literature, scientific societies and clinical feedback and has begun to use them for hip and knee replacements and treatment for patients who have had heart attacks, she wrote.
Meanwhile, Highmark is looking to build up its new program with doctors "willing to be a champion" - "who get the bigger picture" and who are willing to convince other doctors to join, one official said.
"I think this will be transformational," Fiaschetti said.
Mirror Staff Writer William Kibler is at 949-7038.