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Value-Based Alternative Payment Programs

We’re committed to developing value-based programs that ensure our members receive high-quality, efficient health care. We continue to implement value-based programs, focusing on “pay for value,” not volume. We do this by working collaboratively with our physicians and hospitals to improve the quality of our members’ patient experiences and overall outcomes.

  • Accountable Provider Organizations and Patient Centered Medical Homes

    Accountable Provider Organizations (APOS) and Patient Centered Medical Homes (PCMHs) are designed to align compensation to quality of care, patient satisfaction, affordability, health equity, and health outcomes. The program fosters collaboration and relies on the use of health care analytics to create shared accountability for clinical and financial outcomes. APOs / PCMHs are responsible for achieving clinical quality and cost-efficient care, by avoiding unnecessary and duplicative medical tests and treatments for a defined patient population. Like Medicare’s Accountable Care Organizations, Florida Blue’s APOs / PCMHs focus on primary care providers (PCPs), specialists and hospitals who care for our commercial members. They form a clinically integrated network, physician-hospital organization or integrated delivery system to deliver quality and cost-efficient care. 
    Additionally, our APOs / PCMHs:

    • May include various combinations of providers and may have third-party Patient Centered Medical Home (PCMH) recognition
    • May focus on a specific disease component or be multi-specialty
    • Rely on primary care as its foundation because of the strong focus on preventive and wellness care to keep patients healthy
    • Manage patients through an attributed PCP. Patients are encouraged to maintain an ongoing relationship with a personal physician trained to provide first contact and continuous comprehensive care.

    Deliver coordinated and/or integrated care based on whole person orientation:

    • The attributed PCP is responsible for providing all the patient’s health care needs and takes responsibility for arranging appropriate care with other qualified professionals when applicable. This includes care for all stages of life: acute care, chronic care, preventive services and end-of-life care.
    • All elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies and nursing homes) and the patient’s community (e.g., family, public and private community-based services) are coordinated. Care is facilitated by registries, information technology, health information exchange and other means. This ensures patients receive culturally suitable care, when and where they need it. 
    • Include a designated Value-Based Performance Consultant. The consultant assists in understanding performance scorecards and identifying opportunities for improvement. They can also help assess practice infrastructure and alignment for activities critical to program success.
  • Episode Bundle Program

    Focused primarily on specialists, Episode Bundle Program providers are physicians who organize around improving the cost and quality of episodic care. They agree to be accountable for the entire cost and quality of certain acute episodes of care. This bundling collaboration is aimed at providing the utmost in quality care for Florida Blue patients along with a cohesive/collaborative patient experience. The bundled services are measured against a target episode cost and where cost efficiencies are gained for the entire episode cycle, including through avoidance of post-acute complications, the savings will be experienced in decreased medical spend. The savings are shared with the physician practice.

    Some of the primary procedures that are in the bundled package include:

    • All related surgical procedures, including anesthesia services, injections or drugs administered during the surgical procedure and antibiotics
    • Radiology/imaging services
    • Cost of the implant and surgical supplies
    • Discharge planning and nursing care
    • Pre- and post-office visits

    We are working with several physician practices to understand the entire episode of care; identify improved quality paths/patterns for treatments; and identify cost efficiencies that achieve improved or equivalent quality.