Why Highmark Health Chooses Collaborative Care


CEO Commentary: Holmberg on the benefits of being value-based and patient-centric.

David Holmberg

Highmark Health has earned attention as the largest integrated healthcare system created by an insurer rather than a provider network. Our affiliated companies serve nearly 50 million people nationwide. We have also created a fully integrated delivery and financing model in western Pennsylvania that connects coverage from Highmark Blue Cross Blue Shield and care from the Allegheny Health Network (AHN), which includes eight hospitals, 2,800 physicians, and numerous Health + Wellness pavilions, urgent care facilities, outpatient surgery centers, and other home- and community-based health services.

But the value of our integrated approach to healthcare is not limited to what we own in our western Pennsylvania service area. Whether it involves our affiliated companies or external partners like Johns Hopkins Medicine, we believe the healthcare enterprise of the future should be fundamentally collaborative and built around certain shared strategic priorities.

First, the primary focus must be the consumer. That can’t just be patient-centered care in hospitals. We must work together to get a 360-degree view of the entire healthcare journey and then, collaboratively, design coverage, care and related services that are more responsive to the real-life needs of today’s consumers.

Prioritizing Customer Value

Second, a value-based framework must replace old, volume-driven, fee-for-service models. That includes value-based reimbursement – but also prioritizing value creation for the customer. The first step in overcoming fragmentation in healthcare is an industrywide commitment to defining and measuring value in terms of access, quality, safety, affordability, and the customer experience. That common starting point makes it easier to see how different stakeholders in the system can better work together to deliver such value.

Third, we must address the cost crisis. Rising healthcare costs are a national problem that constrains employers from hiring; drives up out-of-pocket costs and taxes for individuals; exacerbates disparities in access to quality care; and presents a risk of destabilizing our economy. Any effort to improve the healthcare system must prioritize cost control.

Last, we have to develop better ways to connect different stakeholders within the healthcare system in order to align goals, coordinate efforts, and share data and insights. Highmark Health makes those connections internally through our integrated delivery and financing system in western Pennsylvania, and through affiliated businesses in health information technology, and dental and vision products and services. The same mindset drives our collaborations with external provider network partners, such as Geisinger Health Systems in central Pennsylvania, and industry innovators like Quartet Health and Axial Healthcare.

Cancer Collaborative

A good example of these strategic principles in action is the Highmark Cancer Collaborative, which brought together the best and brightest from Highmark Blue Cross Blue Shield, Allegheny Health Network, and the Johns Hopkins Kimmel Cancer Center. The goals of this collaboration include:

  • Improving patient safety, patient experience, and clinical outcomes
  • Enhancing quality by increasing the use of evidence-based treatment and reducing unwarranted variations
  • Lowering total costs of care
  • Expanding patient access to high-value care

The Cancer Collaborative team is responsible for an evolving portfolio of long-term programs, but I’ll share just two of its recent success stories.

To promote use of evidence-based treatment pathways, Allegheny Health Network clinicians and Highmark insurance professionals reviewed and unanimously chose a web-based, decision-support tool powered by the National Comprehensive Cancer Network. We then designed a Medical Oncology Pathways Program that gives clinicians free access to that tool and, among other things, rewards 80 percent or higher use of recommended pathways by removing prior authorization hurdles. The platform puts the latest, evidence-based treatment pathways at the doctor’s fingertips and can be integrated with electronic medical records and other data. It also includes cost information, allowing the medical oncologist and patient to have real-time conversations about treatment costs, where appropriate.

In Year One of this program:

  • 28 physician practices across Highmark’s three-state insurance service area joined Allegheny Health Network in using the decision-support tool to aid more than 2,000 decisions
  • Based on initial success, the program has been expanded to cover more than 96 percent of cancers faced by our health plan members
  • Participating medical oncologists used the platform’s treatment guidelines 83 percent of the time on average during the first seven quarters, exceeding our target goal of 80 percent (See Exhibit 1.)

Streamlining Care

Another collaborative success is our Episode of Care Reimbursement Program, designed to remove systemic factors that can contribute to overtreatment, streamline the care experience for everyone involved, and provide physicians with a more predictable revenue stream. Through this program, we are reducing the use of six-week radiation treatments for breast cancer in cases where evidence shows that a three-week regimen will be just as effective and less toxic.

We have a pre-agreed fee – with half paid when treatment begins, half at conclusion – based on appropriate care, not volume of care. We again remove preauthorization based on compliance with standards. During Year One, this resulted in a 46 percent decrease in average cycle time between treatment and payment. (See Exhibit 2.)

In terms of quality and access, the collaboration with Johns Hopkins Kimmel

Cancer Center has given people covered by our health insurance plans second-opinion consults for rare and complex cancers, increased the use of appropriate molecular testing to optimize treatment, and tripled the number of clinical trials available to patients in western Pennsylvania.

That’s a small taste of what can be achieved when different parts of the healthcare system put the consumer at the center and take a highly collaborative, valued-based approach to improving outcomes and controlling costs. Beyond just uniting payers and providers on the same platform, I’ll add that the Highmark Cancer Collaborative includes regular meetings and check-ins between providers and Highmark’s dedicated support team.

We have replicated this model of integration with other providers and are looking at how to make it work in additional areas of care as well. But what’s driving us, and those with whom we partner, isn’t a question of who can buy or build the biggest integrated healthcare system – it’s a commitment to doing whatever it takes to make healthcare work better for our customers, and our nation.

  • David Holmberg