Download PGIP Clinical Quality Initiative

Value-based reimbursement:
Partnering for high-quality care
April 2016
Value Partnerships Team
Background and goals
• Now in its 11th year, the Physician Group Incentive Program
continues to focus on transitioning Blue Cross Blue Shield of
Michigan from a fee-for-service to a value-based payment model.
PGIP has significantly transformed the state’s health care delivery
system into one where providers are earning more for achieving
improvements in quality, safety and outcomes.
Physician Group Incentive Program goals:
– Better align provider reimbursement with quality of care standards
– Improve health outcomes
– Control health care costs for Blue Cross customers
Value-based reimbursement fee schedule
• Practitioners who meet certain criteria are eligible for reimbursement
in accordance with the Value-Based Reimbursement Fee Schedule
• The VBR Fee Schedule sets fees at greater than 100 percent of the
Standard Fee Schedules
Value-based reimbursement for
primary care physicians
Value-based reimbursement for primary care
physicians
• We’re changing our value-based reimbursement structure for
primary care physicians who participate in the Physician Group
Incentive Program, effective July 1, 2016.
• Primary care physicians can receive value-based reimbursement of
105 percent to 140 percent of the Standard Fee Schedules for
certain procedure codes, depending on the program(s) in which they
participate and the criteria they meet.
VBR Fee Schedule
Clinical quality value-based reimbursement for
primary care physicians
Effective July 1, 2016, three tiers of clinical quality value-based
reimbursement will be available for all PGIP-participating primary
care physicians. Previously, only one tier was available.
The three tiers for clinical quality performance and their value-based
reimbursement are:
– Ranking in the 95th to 100th percentile - 115 percent of the Standard
Fee Schedules
– Ranking in the 85th to 94.99th percentile - 110 percent of the Standard
Fee Schedules
– Ranking in the 80th to 84.99th percentile - 105 percent of the Standard
Fee Schedules
Clinical quality measurement
• Performance is measured for the calendar year 2016. For calendar
year 2016 performance, value-based reimbursement on that
performance is effective July 1, 2017.
• For calendar year 2016 performance, measures are aligned with
Medicare star ratings, Quality Rating System and HEDIS® and
performance is measured across all populations.
• The revised quality incentive structure aligns with Blue Cross’
shared emphasis on collaboration, coordination and population
management.
• Practices will be measured on performance and improvement over
time, consistent with PGIP principles.
Clinical quality measures – primary care
(2016 calendar year performance)
• Twenty-seven measures
• Based on the measures from Medicare star ratings, Quality Rating
System and HEDIS®
• All measures are based on claims data for the relevant performance
period for the practice’ attributed patient population
• Different measures apply to different practice types — adult practice,
family practice or pediatric practice — and to different populations
(Commercial and Medicare)
The chart on the next three slides breaks down the measures.
Category
Measures
PGIP Clinical Quality Value-Based Reimbursement
Adult Practices
Adult
Prevention and
Screening
Measures
Pediatric
Prevention and
Screening
Measures
Family Practices
QRS
measures
for
commercial
members
MA Stars
measures
for MA
members
QRS
measures
for
commercial
members
MA Stars
measures
for MA
members
Adult BMI assessment
✔
✔
✔
✔
Breast cancer screening
✔
✔
✔
✔
Cervical cancer screening
✔
✔
Chlamydia screening in women
✔
✔
Colorectal cancer screening
✔
✔
✔
✔
Pediatric Practices
QRS
measures
for
commercial
members
✔
Childhood immunization status
(combination 10)
✔
✔
HPV vaccination for female
adolescents
✔
✔
Immunization for adolescents
(combination 1)
✔
✔
Weight assessment and counseling for
nutrition and physical activity children
and adolescents: BMI percentile
✔
✔
Weight assessment and counseling for
nutrition and physical activity children
and adolescents: counseling and
physical activity
✔
✔
Weight assessment and counseling for
nutrition and physical activity children
and adolescents: counseling for
nutrition
✔
✔
Well-child visits in the first 15 months
of life (6 or more)
✔
✔
Well-child visits for the third, fourth,
fifth and sixth year of life
✔
✔
MA Stars
measures
for MA
members
Category
Measures
PGIP Clinical Quality Value-Based Reimbursement
Adult Practices
Comprehensive
Diabetes Care
Respiratory
Conditions
Family Practices
QRS
measures
for
commercial
members
MA Stars
measures
for MA
members
QRS
measures
for
commercial
members
MA Stars
measures
for MA
members
Diabetes care: Retinal eye exam
✔
✔
✔
✔
Diabetes care: Hemoglobin A1c
(HbA1c) control < 8.0%
✔
Diabetes care: Hemoglobin A1c
(HbA1c) control ≥ 9.0%
✔
Diabetes care: Medical attention for
nephropathy
✔
QRS
measures
for
commercial
members
✔
✔
Diabetes care: Hemoglobin A1c
(HbA1c) testing
Pediatric Practices
✔
✔
✔
✔
Appropriate testing for children with
pharyngitis
✔
✔
Appropriate treatment for children with
upper respiratory infection
✔
✔
Avoidance of antibiotic treatment in
adults with acute bronchitis
✔
✔
Medication management for people
with asthma
✔
✔
✔
MA Stars
measures
for MA
members
Category
Measures
PGIP Clinical Quality Value-Based Reimbursement
Adult Practices
QRS
measures
for
commercial
members
Behavioral Health
✔
✔
Antidepressant medication
management: continuation phase
✔
✔
MA Stars
measures
for MA
members
Pediatric Practices
QRS
measures
for
commercial
members
Follow-up care for children prescribed
ADHD medication: initial phase
✔
✔
Follow-up care for children prescribed
ADHD medication: continuation and
maintenance phase
✔
✔
✔
Statins in diabetes
Other
QRS
measures
for
commercial
members
Antidepressant medication
management: acute phase
Annual monitoring for patients on
persistent medications
Pharmacy
MA Stars
measures
for MA
members
Family Practices
✔
✔
✔
✔
Proportion of days covered (diabetes
all class)
✔
✔
✔
✔
Proportion of days covered (RAS
antagonists)
✔
✔
✔
✔
Proportion of days covered (statins)
✔
✔
✔
✔
Controlling high blood pressure
✔
✔
✔
✔
Use of imaging studies for low back
pain
✔
✔
MA Stars
measures
for MA
members
Payment timeline
Measurement period
Jan. 1, 2016 through Dec. 31, 2016
Reimbursement period
(applicable to claims for the
dates of service below)
July 1, 2017 through June 30,
2018
Additional opportunities for value-based
reimbursement
In addition to clinical quality performance, there are opportunities for
primary care physicians to earn value-based reimbursement as part of
the Physician Group Incentive Program:
1. Designation as a PCMH practice
2. Alignment with a physician organization that meets cost benchmark
criteria (as a designated PCMH practice)
3. Participation in provider-delivered care management (as part of a
PCMH practice)
1. Patient-Centered Medical Home designation
To earn PCMH designation, a practice must:
• Be nominated by their physician organization
• Meet at least 50 of the 148 PCMH capabilities. PCMH capabilities
require care processes to become more patient-centered. For
example:
– Providing 24-hour access to a clinical decision-maker so patients can
avoid emergency room visits
– Creating patient registries or offering access to patient Web portals.
2. Alignment with a cost-benchmark PO
Specific cost-benchmarking metrics include:
• Cost of care
• Overall cost of care per member per month for the previous calendar
year
• Overall monthly trend in cost of care per member per month for the
calendar year two years prior
• Combined performance measure for cost of care per member per
month and monthly trend in cost of care per member per month
For 2016, cost benchmark performers are defined as sub-physician organizations or
Organized Systems of Care that are in the top 15 percent for total per member per month
cost or trend, or groups that have combined cost and trend performance above a certain
threshold, based on Blue Cross claims data.
3. Participation in PDCM
A practice should:
• Have PCMH designation and attest to having a qualified care
manager in the office
• Have a provider who is engaged in care management and willing to
refer patients to care management
• Have staff working to close gaps in care
• Deliver care management services to a proportion of their eligible,
attributed patient population
Value-based reimbursement for specialists
Specialist practitioners
Specialists in PGIP who meet defined performance criteria also can
earn value-based reimbursement.
The criteria
Specialists must:
• Be a physician, chiropractor, podiatrist or fully licensed psychologist
• Be nominated by their physician organization
• Be in PGIP for at least one year
• Meet the performance rankings on measures of quality and cost set
by Blue Cross Blue Shield of Michigan
Population and performance
measures for specialists
Specialists are ranked according to at least three population-level
measures of cost and quality.
•
•
•
A population-level per member per month cost measure
A population-level cost difference measure (the change in population-level cost from
the prior measurement year)
A population-level global quality index, a single composite score based on numerous
measures of quality of care
Additional performance measures for 13 specialties: allergy, cardiology,
emergency medicine, endocrinology, gastroenterology, nephrology,
neurology, obstetrics and gynecology, oncology, orthopedics,
otolaryngology, pulmonology and rheumatology.
Value-based reimbursement
opportunities for specialists
The following is a breakdown of the opportunities available, effective
March 1, 2016, to Feb. 28, 2017:
Specialists — non-pediatric practices
Practice ranking
What they can receive
Practices ranking in top third by specialty type
110 percent of standard fee schedule
Practices ranking in middle third by specialty type
105 percent of standard fee schedule
Note: If fewer than 20 percent of the Blue Cross participating specialists of a particular specialty type are in PGIP, practices ranking in the top two-fifths
can receive 110 percent of the standard fee schedule, and practices ranking in the next two-fifths can receive 105 percent of the standard fee schedule.
Specialists — pediatric practices
Practice ranking
What they can receive
Practices ranking in top half
110 percent of standard fee schedule
Practices ranking in second half
105 percent of standard fee schedule
For more information
If you would like more information:
Contact your provider consultant
Contact your provider organization
Go to valuepartnerships.com/
Email [email protected]