Value-Based Reimbursement Programs

Medicare Advantage Stars

The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage plans and prescription drug plans separately on a scale of one to five stars, with five representing the highest quality. The Star Rating for Medicare Advantage plans is an overall measure of the plan's quality, and is a cumulative indicator of: Quality of care, Access to care, Beneficiary satisfaction, Customer Service, and Responsiveness to member needs. The intent of the program is to tie quality of care to financial reimbursements, whereby rewarding high performing plans and forcing low performing plans to exit the market.


Quality Blue Hospital Program

Highmark's mission is to provide access to affordable, quality healthcare and enable individuals to live longer, healthier lives. Participants in the Quality Blue Hospital Pay-for-Performance Program partner with Highmark to advance this mission at the point of patient care, throughout the facility and in the community at large. 


Specialist Performance Initiative

Highmark continues to expand its portfolio of value-based care programs and initiatives to include addressing specialist cost transparency and performance with the Specialist Performance Initiative (SPI). Starting December 2020, Highmark will offer select specialists a cost profile tool that provides physician-level data to inform practice performance, influence clinician behavior and optimize referral patterns.

SPI will include ranking information on over 11,000 specialists in 14 clinical specialty groupings and 52 clinical condition categories giving Highmark’s network brand new insights into performance to help them provide and guide our members to the highest value care possible. SPI includes the following specialties: cardiologists, dermatologists, endocrinologists, gastroenterologists, general surgeons, gynecologists, nephrologists, neurologists, ophthalmologists, orthopedic specialists, psychologists, pulmonologists, rheumatologists, and urologists. This initiative applies to all Highmark service areas in Pennsylvania, Delaware and West Virginia.

If you have questions regarding SPI, submit your inquiry to SpecialistPerformance@highmark.com.


True Performance Programs

True Performance is designed to continue to improve the quality of healthcare delivered to our members while working to reduce the overall cost of healthcare for our members.

  • True Performance Home Health Pay-for-Value Program
  • True Performance Lite Program
  • True Performance Skilled Nursing Facility Pay-for-Value Program
Last updated on 6/14/2023 3:00:56 PM

 

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