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BCBS Rolls Out Rates for Optimum Physician Alliance

Updated: 5/9/2013

Teams meeting today with insurance brokers to explain how ‘align’ will work

BlueCross BlueShield of Western New York today launched a new health insurance product providing a physician-led, patient-centered model that is new for the region and among few such models nationwide.

align is supported by the Optimum Physician Alliance (OPA), 500 primary and specialty care physicians associated with Kaleida Health dedicated to improving quality of care with metrics-driven medical analytics.

Officials told the region's insurance brokers at a meeting today that the product has the potential to cost six percent to 10 percent less than other health insurance offerings.

Announced about a year ago, OPA is a physician-led, evidence-based network of doctors committed to providing high-quality, efficient health care. BlueCross BlueShield and Kaleida Health partnered to support OPA, which has approximately 250 primary care doctors and 250 specialty care doctors.

“The key to savings is clinical integration and creating a more efficient model,” said Michael Conroy, BlueCross BlueShield vice president of commercial accounts. “This is unique, ground-breaking work in Western New York that a lot of people have had input into. Our partnership with Kaleida Health will give us a lot of different angles to come at cost savings, services and benefits.”

Mary Miller, the insurer’s director of business planning and product development, said the focus in align is on physician-directed changes.

“It’s about innovation and listening to physician-led recommendations,” she said. “We want to make sure they have all the tools they need to deliver coordinated care, especially employing technology to reduce administrative duties and costs.”

Thomas C. Rosenthal, MD, is chief medical executive and serves as the leader in creating and coordinating physician support activities and clinical integration management for OPA’s network of doctors. 

“Our partnership's goal is to deliver high quality services at a lower cost, resulting in a greater value for each dollar spent on health care,” said James R. Kaskie, Kaleida Health’s president and CEO. “I am confident that together, Kaleida Health, BlueCross and OPA can accomplish this goal for the betterment of our community.”

Federal agencies define clinical integration as an active and ongoing program to evaluate and modify the practice patterns of a physician network's participants to create a high degree of interdependence and cooperation among the physician members. The goal is to continuously improve the quality of care provided to patients while simultaneously controlling the cost of the healthcare services provided.

The model creates a process and an environment that is supported by the overriding organizational structure outlined in an “accountable care organization” concept. Clinically integrated physician networks create an opportunity for physician-driven quality initiatives to demonstrate value to health plans and employers. Clinical integration creates a high degree of interdependence and collaboration among physicians to control costs and ensure quality.

“Each practitioner will work in real-time with individual patient and total practice information to address gaps and provide the appropriate care, at the appropriate time, in the most appropriate setting,” Dr. Rosenthal said.

align is aimed at businesses with fewer than 50 employees, but all sized companies are welcome, and over-50 employee organizations are expected to be active in it.

Various groups benefit from clinical integration, including the following:

  • Patients receive greater consistency of high-quality care delivery from a trusted source – their physician. This is possible through multidisciplinary clinical teams, patient-centered tools and co-management care, facilitated by the use of advanced information technology to support information sharing between primary care physicians, specialists, and patients.
  • Physicians are able demonstrate their quality and efficiency at the highest levels to current and future patients, health plans, and employers. They will also enter in to physician-directed incentive programs and other contractual arrangements with the health plan. These are realized in a way that financially recognizes their efforts to improve healthcare quality, service and efficiency.
  • Hospitals gain the ability to develop more collaborative relationships with their medical staff, enlist physician support from quality initiatives, and position themselves at an advantage in the market on the basis of quality and service.
  • Employers gain the ability to more effectively manage the healthcare costs of their employees and their dependents through the purchase of more efficient healthcare services.
  • The health plan is able to partner with healthcare providers, hospital systems and the community to provide better health care, improve health and reduce costs.
  • All involved benefit from an emphasis on an infrastructure of cross-functional clinical teams; the use of practice support tools, data connectivity, improved care coordination; dissemination of best practices; patient engagement; performance measurement and enhanced accountability.

Central to the program is the adoption and maximization of clinical technology such as electronic health records (EHR), electronic medical records (EMR), and patient registry by participating physicians.

The Optimum Physician Alliance is a physician led, evidence based network of physicians committed to providing high-quality, efficient health care. OPA is a collaborative partnership between the physicians, hospital system and the health plan. The overarching goal of clinical integration is to continuously improve the quality of care provided to patients, while simultaneously controlling the costs of healthcare services provided. Improving clinical outcomes and operational efficiencies provides opportunities to share cost savings driven by a more efficient delivery system.

HealthNow New York Inc. is one of New York’s leading healthcare companies that provide access to quality health care and innovative solutions for individuals and employers.  HealthNow offers a full range of insured, self-insured, and government programs and services, as well as life and disability coverage, dental and vision plans and stop-loss coverage. Headquartered in Buffalo, NY, the company operates BlueCross BlueShield of Western New York (Buffalo), BlueShield of Northeastern New York (Albany), Health Now Brokerage Concepts (Blue Bell, PA) and Health Now Administrative Services (across the Northeast US and California).  In 2012 the company had revenues of $2.5B and reserves of $550 million.

For more than 155 years, the hospitals and healthcare facilities of Kaleida Health have been providing quality care to the communities comprising the eight counties of Western New York. We are the largest healthcare provider and the largest private employer in the area, and a major teaching affiliate of the University at Buffalo. Kaleida Health is also affiliated with Great Lakes Health System of WNY, the entity integrating Kaleida Health, ECMC and the University at Buffalo. Kaleida Health hospitals include Buffalo General Medical Center/Gates Vascular Institute, 548 beds; DeGraff Memorial Hospital, 70 beds; Millard Fillmore Suburban Hospital, 261 beds; Women & Children's Hospital of Buffalo, 200 beds; Kaleida Health also operates HighPointe on Michigan and the DeGraff Memorial Hospital skilled nursing facilities, the nation's oldest - and original - Visiting Nursing Association, a major laboratory division as well as the Millard Fillmore Ambulatory Surgery Center.