The AmeriHealth program is another step designed to reward doctors for keeping patients out of the ER — a particularly stubborn problem for patients with heart conditions.”We’ve seen a higher probability of our members with chronic conditions being in the ER, taking a lot of medications and being readmitted to the hospital — and then going home with no discharge plan from their physicians to help them stay out of the hospital,” said Michael Ruiz de Somocurcio, vice president of contracting and reimbursement for AmeriHealth New Jersey.
The new program, he said, may prevent that: “It’s a big change for the physicians, so by joining this program, really they’re saying, ‘We know this is the direction everything’s going.’ “
Josh A. Ginsberg, executive director of the Cardiovascular Associates of Delaware Valley Heart House, said the cardiology community “hasn’t been pressured by insurers to measure quality before,” but he noted AmeriHealth’s program is based on “measures that we believe we were performing on a routine basis with patients already.”
Heart patients are often readmitted, he said, “because they did not get their prescriptions refilled after discharge and they did not see a physician on the outpatient side within 72 business hours after discharge.”
“Before the partnership with AmeriHealth, we were able to create a discharge clinic focused on insuring the things that are supposed to be done to prevent readmission are being done. So really, for us, not a lot is changing,” Ginsberg said.
Ruiz de Somocurcio said a unique aspect of AmeriHealth’s risk-based quality initiative with the Heart House is it offers “full transparency to give physicians the information they need to work more effectively with our members.”
“The health plan is a driver for this model, because even if a physician uses an electronic medical records system tied into the hospitals, they’ll only see the data for their own practice, so they’re not going to know when their patients refill medications and the care their patients receive at other practices,” he said.
According to Ruiz de Somocurcio, those metrics include medication compliance, frequency of cardiac imaging and hospitalization rates — including admissions, readmissions and ER visits. But Ruiz de Somocurcio said the criteria is not “one size fits all” for all of the cardiology and specialty care groups in New Jersey that AmeriHealth hopes to enroll in the program.
“We’re not a national plan that has a standard template for all cardiologists. As a local plan, we have the benefit of being able to work individually with the practices to see what metrics have the best outcomes for patients,” Ruiz de Somocurcio said. “The physician is really the gatekeeper.”
Ruiz de Somocurcio said AmeriHealth established a similar risk-based quality program with Moorestown-based Radiology Consultants of New Jersey Inc. in July, and the insurer is working on partnering with three other freestanding specialty physician groups for the program.