Accountable provider organizations (APOs) are designed to control quality and cost. Provider groups are responsible for achieving clinical quality outcomes and avoiding unnecessary and duplicative medical tests and treatments for a defined patient population.
Like Medicare’s Accountable Care Organizations, Florida Blue’s APOs focus on primary care providers (PCPs), specialists and hospitals who care for our commercial members. APOs are a group of health care providers, such as family practice, specialists and hospitals that form a clinically integrated network, physician-hospital organization or integrated delivery system in order to deliver quality and cost-efficient care. APO providers agree to be accountable for the total cost and quality of a patient population.
- APOs may include various combinations of providers but are primarily hospitals and physicians.
- They may focus on a specific disease component or be multi-specialty focused.
- Primary care is the foundation of APOs because of the strong focus on preventive and wellness care to keep patients healthy.
Our Patient-Centered Medical Home (PCMH) and Comprehensive Primary Care (CP2) programs support the transformation of a primary care practice into a physician-directed, data-driven practice where integrated care teams and care coordination ensure our members receive appropriate care when and where indicated. Our PCMH and CP2 programs are voluntary, invitation-only programs offered to primary care physicians (family medicine, internal medicine, pediatrics and general medicine), advanced registered nurse practitioners and physician assistants who meet a defined set of clinical quality metrics, along with attribution and cost parameters. Practices who participate are eligible to earn a portion of shared savings at the end of the measurement period.
PCMH is an integrated health care delivery model that provides patients comprehensive, continuous and coordinated medical care, including wellness and preventive services, with a goal of improving health care outcomes. All groups enrolling in the PCMH program must be recognized as a PCMH through a national organization that provides accreditation and/or designation as a patient-centered medical home. Organizations include National Committee for Quality Assurance (NCQA), URAC, The Joint Commission, and Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). Fifty percent (50%) of participating physicians in the group must receive recognition. Application for recognition or documentation of completion is required as part of the enrollment process. Groups have 24 months to complete the recognition process.
CP2 is available for practices that are not able to take on the administrative activities associated with obtaining PCMH recognition at this time. Clinical quality metrics and outcome performance metrics are the same as PCMH, but the CP2 award percentage is less than the PCMH program award and does not require designation from a national accrediting agency.
To participate in the PCMH or CP2 program, a physician or group must meet the following requirements:
- Practice medicine in the field of internal medicine, family practice or pediatrics
- Participate in NetworkBlue.
- Meet membership requirements of 300 unique, attributed commercial Florida Blue members, excluding BlueCard® and Alliance members.
- Attest to having patient access for a minimum of six hours weekly after 6 p.m. weekdays and/or weekends.
- Use e-prescribing and its decision-support tool.
- Perform at an equal quality level with their peers in a core set of Healthcare Effectiveness Data and Information Set (HEDIS®1) clinical quality metrics.
- For PCMH participants: Complete a PCMH-recognition program within 24 months of enrollment. This includes those offered by the National Committee for Quality Assurance (NCQA) or URAC®.
PCMH/CP2 Core Principles
Once enrolled in the program, each participating practice agrees to follow nationally endorsed core principles of patient-centered care:
- Personal physician: Each patient has an ongoing relationship with a personal physician trained to provide first-contact and continuous comprehensive care.
- Physician-directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
- Whole person orientation: The personal physician is responsible for providing all of 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.
- Care is coordinated and/or integrated: 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 to ensure patients receive care when and where they need it in a culturally and linguistically appropriate manner.
Measurement and Design
The health care industry is rapidly moving from paying for volume of services to paying for outcomes of services by aligning appropriate payment for the right performance. Our PCMH and CP2 programs support this by measuring where health care dollars are spent.
We offer two tracks for physicians/physician groups in which to participate:
Track One is for groups with more than 5,000 attributed Florida Blue commercial members. We measure the risk-adjusted and weighted total cost of care per-member-per-month costs to compare the group’s cost trends with those of their peers. At the end of a 12-month measurement period, groups will share any earned savings if they performed better than their peers in managing the total cost of care growth rate. Track One PCMH groups receive 50 percent of any shared savings. Track One CP2 groups receive 40 percent of any shared savings. The shared savings are distributed through a one-time lump sum payment at the end of the program year.
Track Two is for groups with attribution of 300 to 4,999 Florida Blue commercial members. We measure PCMH efficiency through cost reduction as it relates to avoidable hospital admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs).
ACSCs are health conditions for which adequate primary care reduces the need for emergency room visits and/or hospital admission. Savings are calculated by evaluating the shift in location where members seek treatment for these conditions. Physician groups receive a portion of the savings by redirecting visits from hospital inpatient and emergency room settings to lower cost PCP and specialty office settings. Track Two PCMH participants will receive 50 percent of any shared savings. Track Two CP2 participants will receive 40 percent of any shared savings.
Practice Transformation Specialists
We provide PCMH practices with a designated Practice Transformation Specialist to assist them in understanding their performance scorecards, identifying opportunities for improvement and assessing practice infrastructure and alignment to activities that are critical to PCMH success.
PCMH Recognition Timeline
PCMH practices must achieve PCMH recognition from a third-party vendor like NCQA or the Accreditation Association for Ambulatory Health Care (AAAHC) within 24 months of their program implementation for continuous participation in PCMH. We offer some financial reimbursement for first-time recognition. Our Practice Transformation Specialists can provide details.
For more detailed program descriptions, click here.
1HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
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.