The Right Time for Right Care

calloutBeginning in September, Highmark will launch Right Care, a physician-led program that ensures members receive the right care, at the right time, and in the right setting.

The program features industry standard appropriateness metrics as well as claims data from Highmark, Medicare, and other sources. The purpose? To decrease the overuse of services that expose members to unnecessary risk or cost while promoting proactive, preventive, and conservative therapies that have been underutilized.

“We are taking a clinical approach to achieve the quadruple aim of health care, which is to improve outcomes, affordability, the patient experience, and the clinician experience,” said Sricharan Chalikonda, MD, MHA, FACS, who serves as medical director of the Right Care program.

Using technology and data to transform the delivery of health care and members’ health is a core tenet of Highmark’s Living Health model, and the Right Care program exemplifies the organization’s commitment to creating dynamic, positive change for providers and their patients.

In a just released series of videos , Dr. Chalikonda presents an overview of the new program, while sharing his perspective on why appropriateness measures are so critical in evaluating quality of care.


For years, payors, providers, and other leaders in health care have closely measured and managed clinician performance against cost and quality outcomes. While these areas are important, they only tell part of the story. Appropriateness measures supplement cost and quality outcome metrics to create a more holistic, clinical performance management system—one where clinicians are recognized for developing the plan of care that is best suited for the patient’s overall health.

It can be helpful in thinking of appropriateness as a leading indicator in a sequence with other criteria:

  • Appropriateness: Are we choosing the right care given the patient’s condition?
  • Total Cost of Care: Are we providing that care in a way that efficiently utilizes constrained health care resources?
  • Quality Outcomes: Are we effectively resolving issues and/or maintaining a healthy patient population?

How are Appropriateness Measures Developed?

The Right Care program identifies and measures unwarranted variation in care by partnering with Highmark’s own network clinicians as well as other clinically led organizations. Once an opportunity is identified, extensive work is then performed to define the relevant clinical criteria and patient populations, ensuring alignment with evidence-based clinical guidelines and an “apples-to-apples” comparison among clinicians. A distribution of clinician performance is then created using a national data set of both commercial and Medicare claims. Right Care provides our network physicians with visibility into the level of variation nationally and their own individual performance relative to peers.

There are three types of appropriateness measures detailed in the table below, as well as an example of the information shown for each measure:

 Types of Measures  Example  Impact of Improvement
    Overuse of low-value procedures
      Overuse of endovenous ablations for treatment of varicose veins
      • Improves affordability by eliminating unnecessary treatment

      • Reduces days lost to unnecessary appointments and risk of complications
        Rarely appropriate patterns in delivery of care
          Different day elective upper and lower endoscopy
          • Reduces risk of multiple rounds of anesthesia

          • Improves patient experience
          • Reduces cost

            Underuse of care that promotes better health
              Underuse of conservative management prior to lumbar surgery
              • Delays or reduces potential surgical procedures

              • Reduces risk to patient from infection or complications
              • Reduces cost

              Many of the initial Right Care metrics come from the Global Appropriateness Measures, a physician-led organization that uses clinical literature, direct input from practicing physicians, and data analyses to identify discernible patterns of variation in care.

              Where Can I See My Performance?

              The results for the initial set of metrics will be available on the Provider Facing Analytics platform, accessible from NaviNet® . Each metric will have the definition and parameters published as well as a distribution of individual physicians’ performance. You will be able to see where you specifically fall within the distribution and your performance relative to peers.

              Access to the Right Care program metrics will be available in September. Once available, a Special Bulletin will be published on the homepage of the Provider Resource Center with instructions for access.

              Physician-Led Program

              The Right Care program was born through the leadership of clinicians at Allegheny Health Network and is now expanding to include all of Highmark’s provider network.

              In the video series , Dr. Chalikonda talks about how physicians participating in the pilot program appreciate the amount and level of data available.

              “The overwhelming majority of clinicians we’ve worked with have given very positive feedback on these types of measures,” said Dr. Chalikonda. “This data is often not available at scale to the clinician community, and many have said how helpful they’ve found it simply to know how they compare to peers.”

              To gain a fuller understanding of the Right Care program, visit the Right Care section on the Provider Resource Center.