News and Information

CaroMont Health and BCBS of North Carolina Launch Pilot Program

07-14-2011

Many health systems today are taking steps to become accountable care organizations (ACOs). In doing so, they are seeking to enhance each patient’s experience of care, to improve the health of the population, and to cut costs. This “triple aim” of health care redesign is being used widely across the nation and is one of the reasons CaroMont Health has developed a collaborative arrangement with Blue Cross and Blue Shield of North Carolina (BCBSNC), the state’s largest health insurer, to offer a new way to deliver and pay for care for those patients needing knee replacement surgery.

Under this value-based initiative, BCBSNC is using the PROMETHEUS Payment model from the Health Care Incentives Improvement Institute (HCI3). Introduced in April, this initiative is designed to cover the entire knee replacement, including the pre-surgical period of 30 days before hospitalization, the surgery itself, and most follow-up care within 180-days after discharge.

Implementing the PROMETHEUS model is important for three reasons. First, BCBSNC and CaroMont believe care redesign must accompany payment structure redesign and that health systems and health plans should have programs to meet the triple aim objectives.

The second reason PROMETHEUS is significant is that administrators of BCBSNC and CaroMont worked closely with the clinical staff to implement this payment model. Although our clinicians are independent community physicians, they have been leading the development of this program. As a result of their leadership, we have aligned ourselves around what’s best for the patient.

“Collaboration with providers that eliminates fragmentation in the way care is provided and paid for—and promotes better outcomes in the process—is our priority at Blue Cross,” said BCBSNC President and CEO Brad Wilson. “We believe initiatives like this one at CaroMont are key to promoting health care quality, while also holding down costs.”

The third reason the PROMETHEUS model is important is that it is a step toward becoming an ACO and demonstrates how CaroMont Health and BCBSNC are responding to economic challenges and health reform legislation.

Over the full episode of care required for knee replacement, the PROMETHEUS model involves implementing cost-effective initiatives that cover both hospital and physician services. By paying for care over 210 days, this model is longer than other bundled payment models for knee replacement, one of which covers only the cost of the surgery itself and a three-day hospital stay.

But here at CaroMont, we think bundled payments should cover a broader definition of care. Health systems can embark on innovative pilot programs for coordinated care to reduce the cost of care and improve the patient experience and patient outcomes. We must be willing to take responsibility for the full episode of care, meaning even after patients leave the hospital.

This bundled knee replacement program is an extension of CaroMont’s vision and mission. As a community health system, we take seriously our mission of creating vibrant communities where we live and work. BCBSNC has recognized our commitment to quality care by designating CaroMont as one of six providers in North Carolina that is a Blue Distinction Center for Hip and Knee Replacement, Spine Surgery, and Cardiac Care.

In addition, even though CaroMont and BCBSNC worked with HCI3 to implement this program, it extends to all independent licensed Blue Cross plans nationwide. That means a member of any Blue Cross national plan can come to CaroMont Health for the excellent care we provide.

By next spring, we will evaluate our results and consider adopting this model for other clinical conditions and perhaps extending this pilot beyond the first 12 months. In the meantime, as we improve the way care is delivered and paid for, providers and payers must act as true partners to be accountable and to deliver coordinated care for our communities. That is a hallmark of the relationship between BCBSNC and CaroMont Health: We are acting as true partners.

Betty Herbert leads managed care strategy and performance for CaroMont Health in North Carolina. She can be reached at HerbertB@caromonthealth.org.