Breakthrough Strategy - Promoting Consumer Choice and Reengineering of Health Care Delivery

Problem: Health care costs have doubled in the last five years. While trends have moderated slightly, there is continuing pressure from factors such as an aging population, new drug therapies, biomedical advances and ongoing administrative inefficiencies. Meanwhile, improvement in health care quality when measured by satisfaction ratings, clinical outcomes and the rate of avoidable medical errors has not kept pace with rising costs. The chances of getting the "right" care are about 50/50.

• Engage consumers with information and incentives to become more active in the self-management of health care and in making value based choices.
• Integrate affordability and quality information for physicians and hospitals that demonstrate value and positive outcomes.
• Use best-in-class partners to deliver effective care to the chronically ill and to foster administrative efficiencies.

PBGH supports purchasers in advancing breakthroughs in several ways:

• Identify best-in-class vendors that meet the goals of the Breakthrough Strategy.
• Implement breakthrough elements in their health purchasing, such as adding consumer Web tools and promoting value-based benefit design.
• Encourage health plans to adopt breakthrough elements.

Impact: The goal of the Breakthrough Strategy is to improve health care quality by introducing competition and aligned incentives among hospitals, physicians and other providers to be best value producers. It also seeks to provide tools and incentives to members to be "smart shoppers" in meeting their health care needs. A critical feature of the Breakthrough Strategy is to make the cost and quality differences among providers transparent to consumers.

Current Activities: PBGH continues to assess and encourage health plans’ efforts to measure, identify and promote providers that deliver better quality and more efficient care. To this end, PBGH conducted an evaluation of health plans' adoption of best-in-class features (read more below).  PBGH's efforts have informed NCQA's incorporation of the competencies into accreditation standards and promoted their use in health plan performance guarantees.  ROI estimation methodologies for Breakthrough element adoption and effective implementation are being refined.

PBGH supports efforts of national carriers and California plans to develop new product offerings that promote consumer engagement and incentives and provider value differentiation.  To that end, PBGH seeks to foster health plan adoption of common hospital performance metrics and disclosure of performance results through Leapfrog and other means.

To promote the use of performance information by consumers, PBGH undertook a detailed assessment of California health plan consumer websites, health plan sponsored hospital chooser tools, and commercially available health plan chooser tools.  The results of that work assist purchaser acquisition efforts and provide valuable product development information to health plans.

Recognizing purchaser opportunities to affect Breakthrough, PBGH provides benchmark and analytical feedback to purchasers and carriers about benefit design strategies and incentives.

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Breakthrough Competencies Evaluation

As part of its Breakthrough Strategy to promote health care value, PBGH defined a set of Breakthrough Plan Competencies that have high impact on quality and trend moderation.  Defined in consultation with national clinical experts and health plans' medical leadership, these competencies can impact 6% to 28% of premium by fostering consumer engagement and provider performance differentiation.   In 2003, PBGH conducted an evaluation of Breakthrough Plan Competencies among leading California and national plans. The report benchmarks ten health plans - PPOs, HMOs, and consumer-driven options - in the areas of health promotion, risk reduction/lifestyle behavior change, consumer health decision support, disease management, provider performance measurement, and consumer and provider engagement.

As expected, no single plan met all of the best-practice features. Most met some of the criteria in health decision support and disease management, but more effective consumer engagement in health promotion and risk reduction is a key opportunity. Consistently across all competency areas, plans fell short in quantifying net cost savings and premium impact and in offering incentives for participants.

A number of plans are developing products that differentiate providers.   PBGH supports the use of standard metrics (e.g., National Quality Forum or AHRQ indicators) and is also trying to advance the science of physician-level measurement - both efficiency and patient experience.   Reducing variation in care and promoting use of high-value providers are key opportunities for improving quality and moderating long-term cost.

Purchasers are using the report to inform benefit design and collaborate with plans to optimize consumer support and engagement. In addition, purchasers are incorporating competency expectations into RFPs, contract discussions and performance guarantees with plans. PBGH also is promoting the inclusion of these competencies in national standards for measuring plan value (e.g., NCQA's accreditation standards and guidelines). Read the Executive Summary.

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