This health plan’s P4P program is generating better quality for members and a healthy competition among physicians.

Unison Health Plan likes to bill itself as a different type of health organization, and its new pay-for-performance program, Gold Star, certainly supports that assertion. In April, Unison paid a combined $1.1 million in bonuses to the 109 physician practices in its network that earned this high quality designation.

Dr. Joseph Sheridan

A group of top executives, including CEO Dr. John Blank, Pennsylvania-plan president Jennifer Kessler, and Sheridan, began to consider this question in depth and realized it was common sense to remove administrative barriers, especially for physicians they knew were doing a high quality job.

The idea grew from there into a full-blown P4P program that was rolled out in Pennsylvania in July of last year. Physician practices are measured on a variety of quality and patient satisfaction benchmarks; Gold Star practices garner bonus dollars and are exempted from administrative tasks such as referrals and most prior authorizations.

“We wanted our program to be the opposite of the typical P4Ps you hear about—they’re unobtainable, you can’t understand them, and no one wins,” said Kessler. “We went with a program that was quality driven yet reachable and easy to understand.”

Cost will follow
Unison, headquartered just outside Pittsburgh, has around 400,000 members and generates $1.2 billion in annual revenue. It provides managed care services to Medicaid and Medicare patients in New Jersey, Delaware, Tennessee, South Carolina, Ohio, and Pennsylvania. The company has grown steadily in the last few years and is poised for more growth, said Blank. It recently moved to a larger headquarters, which Blank said will allow Unison to grown to approximately 700,000 members.

One reason for the growth is that, on average, only 50% of the Medicaid population is in some form of managed care. Most are in fee-for-service programs, and states are looking to companies like Unison to help lower their Medicaid expenses.

Blank said the key to lowering costs is providing access to high quality care. “The Medicaid managed care market is interesting because you do well by doing good. It’s a cliché, I know, but we truly believe if we can improve the quality of and access to care for our members, cost will follow,” he said. “For most states, the cost of Medicaid is higher than the cost of education. They need significant help to manage that, and that’s where we think we’ll be successful in the long run.”

The Gold Star program helps Unison’s members with both quality and access, since one of the criteria for being a Gold Star practice is that it’s open to Unison members. “We don’t want to have a situation where a practice is identified as excellent, but when our member tries to access care he can’t get an appointment,” said Sheridan.

Another criteria for reaching Gold Star status is the ability to submit encounter and claims forms electronically, and Blank said some of Unison’s practices plan to use a portion of Gold Star bonus dollars to upgrade their electronic systems. “Some practices gave bonuses to physicians,” he said. “Some chose to invest in pieces that will improve the quality of their practices.”

Credible numbers
Several factors contributed to the success of the Gold Star program, which has now been rolled out in most of Unison’s coverage states. The first was having reliable data, said Blank. “We spent more than a year designing the data reports and making sure they were credible, reliable, and trended properly over time,” he said. “We used those reports with doctors long before we had P4P associated with them, so physicians could feel confident that these were credible and real numbers.”

Another factor was the lack of a punitive element in the program. Other payors have run into trouble with P4P programs that either don’t recognize enough physicians or penalize members for going to physicians who have not received a certain quality recognition.

“This type of program has to be built on respect for the physician,” said Sheridan. “We believe there are outstanding physicians that work very hard—our program is designed to, in a fair way, identify who they are and give them tools that are not typically available to them. The quality physicians will take those tools and run with them to improve quality.”

For example, last September, Unison carefully analyzed member data to identify those who had not received a flu immunization. The company reached out to both doctors and members, letting them know of the oversight. “To the extent the physicians acted on the information, it will improve their scores so they can earn the Gold Star designation,” explained Blank.

That type of data analysis is something that Blank and his team are starting to do in conjunction with the company’s disease management programs. For example, they look at where and how asthmatics are getting care and which diabetic patients are not getting to the eye doctor often enough.

“It’s interesting because we’re looking at using that type of analysis as a tool for us to do almost public health trials: determining which interventions ‘move the needle’ in terms of quality and cost of care for cohorts of populations,” said Blank.

One of those experiments involves a new type of Wal-Mart gift card given to pregnant women for each early pregnancy visit. Each visit earns patients a $10 gift card, for a total of about $80 for completing early pregnancy care, and the cards are SKU restricted so only healthcare items can be purchased. “We can track and see the impact of pre-natal care. Are they getting it done, and does that have an impact or not,” said Blank.

An important finding, to be sure, but Gold Star’s impact on the physician practices in its network may be even more vital. Physicians are responding positively to the data Unison shares with them, and the program is generating something sorely lacking in healthcare.

“The physician community is very competitive, and they all want to perform well against one another,” said Kessler. “Providers might hear the office across the street earned a Gold Star designation and call us saying, ‘We’d like you to look at our data even closer to see how we can improve our quality.’ Our ultimate goal was to improve the healthcare status of our membership, and when the health plan, the providers, and the members are looking at that, it’s nothing but a win.”