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    Healthcare Plan Information

    Pacificare Patient Safety Initiatives

    PacifiCare serves more than three million health plan members and approximately nine million specialty plan members nationwide and has annual revenues of nearly $11 billion. As a leader in the health care arena, PacifiCare has always been committed to:

    • providing access to quality health care
    • promoting healthy behaviors
    • helping individuals gain the knowledge, motivation and opportunities to make informed decisions about their health.

    PacifiCare endorses the consumer advocacy group, Leapfrog, in its continuing efforts to improve patient safety and reduce preventable medical errors. Our strategy includes direct mail communication to all of our network hospitals about the importance of the Leapfrog Group's three hospital safety leaps:

    • Evidence-based Hospital Referral
    • Computerized Physician Order Entry
    • Intensivist staffing.

    Additionally, we regularly send Leapfrog-related communications to members through our enrollee newsletters.

    PacifiCare continues to support and promote the Leapfrog Group initiative through a variety of innovative programs. Our commitment to patient safety is illustrated by:

    • intense communication with, and education of, hospital providers
    • publication of the QUALITY INDEX profile of Hospitals, a report card disclosed to consumers that summarizes Leapfrog Group patient safety performance
    • Quality Incentive Program designed, in part, to reward physician organizations that primarily use Leapfrog-compliant hospitals.

    We believe that supporting health care innovation, encouraging the enhancement of programs and initiatives already underway, and integrating patient safety measures into quality improvement activities will provide the greatest benefit to the American public. At PacifiCare, patient safety is not just a goal, it's a commitment.

    Explain the goal or expected outcome you anticipate from this activity.

    PacifiCare expects our quality initiatives (including newsletter and report card mailings) will result in our enrollees continually moving to higher-performing providers. We expect our provider quality incentive program to result in improved quality of care through the provision of financial and non-financial incentives to providers.

    Describe the specific tools you will use to evaluate the results of this activity.

    PacifiCare uses the following reporting tools to evaluate results of our patient safety and quality initiatives:

    • Provider Profile
    • QUALITY INDEX® profile
    • QUALITY INDEX® profile of Hospitals
    • QUALITY INDEX® profile of Physician Organizations
    • Quality Incentive Program.

    Provider Profile
    PacifiCare's Provider Profile allows provider groups to compare their score to the average, lowest and highest scores on a plan-wide level. Often, providers are not aware of how their practice patterns compare to those of the health care community. Provider group practice patterns can be positively affected by offering them comparative data. Since 1993, PacifiCare has published the Provider Profile for physician organizations, which offers providers an in-depth management tool focused on clinical quality, service quality, member satisfaction, utilization management and administrative efficiencies. In this quarterly tool, we measure each provider group on 80 indicators and compare the scores to state and national norms.

    QUALITY INDEX® profile of Physician Organizations
    Building on provider profiling, in 1998 PacifiCare released its QUALITY INDEX® profile of Physician Organizations. This unique report provides consumer information on provider group performance in selected areas of clinical and service quality and affordability. The QUALITY INDEX® profile provides consumers with an effective tool to make informed health care decisions, including the quality, affordability and value of the services they receive from our contracted network of providers. Ongoing measures range from preventive health screenings and clinical treatment of chronic diseases to frequency of member complaints and overall satisfaction with the level of service. Physician groups ranking in the 90th percentile or above in any of the measures receive a "best practice" designation, which is also included in PacifiCare's provider directory. This semi-annual, award-winning report has been expanded and enhanced since its first release, and now features the relative performance achieved by provider groups on 58 credible and relevant measures.

    Providers have responded by competing and improving average mean performance in 65 percent of clinical and service measures. Also, enrollees have moved to better performing providers, which in turn represents $18 million in additional annual capitation payments to those providers. This represents a significant impact on the quality of health care delivered to our enrollees and rewards given to our providers and these results have been sustained annually since 1998 and are unprecedented in the health care industry.

    QUALITY INDEX® Profile of Hospitals
    The QUALITY INDEX® profile of Hospitals was released by PacifiCare in March 2003. It is the first-ever, comprehensive report on hospital performance publicly released by a health plan. It represents another PacifiCare initiative to measure and improve the health care quality for our members. PacifiCare's profile of hospitals measures the performance of more than 300 hospitals throughout California. The profile rates PacifiCare and Secure Horizons contracted hospitals in 56 measures related to clinical quality, patient safety, service quality, and affordability. Using hospital all-payer data and applying risk-adjustment methodology, hospitals are graded on performance in complication rates and mortality rates for common medical, surgical, obstetrical, orthopedic and pediatric conditions or procedures. Leapfrog Group patient safety performance is also summarized. Also, best practice stars are presented. Our second release slated for Fall 2004 will include the performance of PacifiCare contracted hospitals throughout all PacifiCare's states.

    Quality Incentive Program
    PacifiCare has developed a provider Quality Incentive Program, which rewards better performing providers, including physicians and physician organizations that utilize higher-performing hospitals, which are determined, in part, by Leapfrog criteria. In 2003, PacifiCare began our rewards program based on 16 measures included in the Quality Incentive Program. Recently, 124 higher-performing physician organizations were rewarded from an incentive pool of $14 million, and, most remarkably, 12 of the 16 measures have shown an average increase of 29 percent in performance. This program demonstrates PacifiCare's commitment to improving patient safety and quality through the following:

    • implementation of Leapfrog standards
    • organizing consumer and physician activities to support achievement of Leapfrog standards
    • publishing report cards
    • providing physicians with financial and non-financial rewards and incentives
    • developing innovative health plan designs to promote and reward quality.

    This response is based on the statement by Samuel Ho, M.D., Senior Vice President and Chief Medical Officer of PacifiCare Health Systems on the Testimony Before the Subcommittee on Health of the House Committee on Ways and Means, which took place March 18, 2004.

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