Blue Cross and Blue Shield of Texas New Physician Cost ... · Network effective 12/31/10 ... Level 3 – services provided by ParPlan or non-contracting providers. Experience

Blue Cross and Blue Shield of Texas

New Physician Cost Assessment for BlueCompare and BlueOptions

December 22, 2010

Experience. Wellness. Everywhere. 2

Topics

• BlueChoice� Solutions & BlueOptions• Physician Cost Assessment (PCA) Methodology• Secure Provider Portal• PCA Reports• Reviews and Opt-Outs• Milestone and Target Dates • Online Resources


BlueChoice Solutions and BlueOptions


BlueChoice Solutions Network and Product Retirement

• Retiring the BlueChoice Solutions High-Performance Network effective 12/31/10

• Marketing and Producers were informed October 2009• BlueChoice Solutions groups cannot renew past 1/1/11


What’s Next?

In line with new National Guidelines and new law, we created a new Physician Cost Assessment (PCA) methodology.

We must measure quality before cost, therefore the physicians we will measure under the new PCA will be those recognized for Evidence Based Measures (EBM) performance.

This will accomplish two goals:


Cost Transparency - BlueCompare 2011

1. Cost TransparencyIn March 2011, TWO blue ribbons in PPO Provider Finder� for physicians that meet

both surrogate quality and new cost efficiency standards

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New Product – BlueOptions

2. Support FUTURE Product

� The recognized ‘2 Blue Ribbon’ physicians will be the Benefit Level 1 physicians for the new BlueOptions product (subject to regulatory approval)

� Earliest possible BlueOptions group effective date is 3/1/11 for self-funded groups and 7/1/11 for fully insured groups

� BlueOptions is not a network, rather a multi-level benefit plan that offers different benefits depending on the physician used:

� Level 1 – reduced copay/co-insurance for services provided by measured BlueChoice network physicians who meet both quality and cost standards

� Level 2 – services provided by any other BlueChoice network provider. Includes non-measured physicians or measured physicians who:

� did not meet quality standards (EBM) or� met quality standards but did not meet cost efficiency standards or� did not have enough quality and/or cost data to analyze

� Level 3 – services provided by ParPlan or non-contracting providers


Example of BlueOptions Plan

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BlueChoice PPO Network


Example of BlueOptions Plan (cont)

Benefit Level 1

Benefit Level 2

Benefit Level 3


BlueOptions ID Card Sample

PTXOA=BlueChoiceProduct name

Co-pay Differences

Benefit Levels Explained


BlueOptions in Provider Finder

1/1/11-Will remove this network.

3/1/11-Will say BlueOptions and contain BlueChoice providers.


BlueOptions in Provider Finder

BlueOptions Hover Text: Meets or exceeds expected quality related and cost efficiency performance compared to other doctors. Enhanced benefits may apply when BlueOptions members use physicians with 2 Blue Ribbons.

Physicians with 2 Blue Ribbons will appear at top of list


Physician Cost Assessment (PCA) Methodology


NCQA PHQ1: Measuring Physician Performance

Major elements followed


14 Measured Specialties

Approx 13,000 Blue Ribbon Physicians in one of the following specialties:

• Allergy-Immunology• Cardiovascular Disease-Interventional• Cardiovascular Disease-Non-Interventional• Endocrinology• Family Practice• Geriatric Medicine• Internal Medicine• Nephrology• Neurology• Obstetrics-Gynecology• Pediatric Allergy-Immunology• Pediatric Pulmonary Disease• Pediatrics• Pulmonary Disease

EBM Low Data or

EBM Below Threshold

will not be measured for PCA


Platform of Analysis

• We determine the 'modeled' working specialties by those for which we can measure quality.

• Calculations will include two incurred years of episode data.• 6/1/2007 – 5/31/2009 with 3 months run out

• Data will be trimmed for outliers.

• Episodes will be risk and severity adjusted.

• Indices will be created relative to the working specialty and rating area of the physician.

• Eligibility will be created at the Practice Evaluation ID / Working Specialty level.


PCA : Data Set Used

• BlueCross BlueShield of Texas PPO membership• Excludes: HCSC employees, BlueCard Host, Rx Benefit claims

• Includes episodes with end date 6/1/07 – 5/31/09

• Member’s risk score based on 12 months of claims ending 5/31/08 or 5/31/09

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Episode Basics

An episode of care is composed of one or more encounters or visits, procedures or inpatient admissions. It is built by linking sets of health care services provided to a patient over time to treat a specific disease or health status. It continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status.


Episode Grouping Logic

Lab Test

Office Visit

Hospital Admission

Office Visit

PT

Episode

The complete episode ranges in time between the lab test and thefinal office visit. A lab or x-ray cannot initiate an episode. However, the look back period can incorporate them.


Episode Grouping Logic

• Classification - Diagnosis codes from healthcare claims and other administrative data are grouped into one of the over 550 Disease Staging disease categories and severity stages.

• Beginning and Ending Episodes - Clean periods unique to each disease category are used to groupeach claim into an episode.

• A "clean period" is a specific length of time assigned to a disease condition during which no claims for that condition are received. The condition's contribution to an episode is considered to have ended at the end of the "clean period."

• An episode is complete in absence of a new cluster for the condition’s clean period.• The more chronic a condition, the longer the clean period for a MEG.

• Acute Sinusitis-60 days• Chronic Sinusitis-180 days

• Inclusion Logic - Less specific episode groups occurring in close proximity to specific episodes are combined with the specific episodes, e.g. “other gastrointestinal or abdominal symptoms" and "appendicitis".

• Lookback Procedure - Lab and diagnostic imaging claims preceding an episode are examined to determine whether they should be combined with the episode.

Appendicitis — Coded Criteria

Stage

1.1 Appendicitis

2.1

2.2

2.3

2.4

Appendicitis with:

localized peritonitis or abscess

intestinal obstruction

perforation and generalized peritonitis

pylephlebitis or liver abscess

3.1

3.2

Appendicitis with:

sepsis

septic shock


Risk Categories Risk Score 55 year old male .45

Health Care Conditions Diabetes with renal manifestations 5.71 Type 1 diabetes .95 Congestive heart failure 1.84 Acute myocardial infarction .92 Vascular disease with complication 1.20 Vascular disease 0 (h) Dialysis status 18.09 Diabetes with congestive heart failure .46 29.62

Calculating a Member’s Risk Score

Used with permission of DxCG


Three Hypertensive Members

Bowens disease, actinic/arsenic keratosis, squamous cell CIS, leukoplakia1.01

Vaccination, exam, screening for disease conditions1.01

Lumbago/sciatica/torticollis, oth back symptoms/disorders, spine curvature1.01

Osteoarthritis of the ankle and foot1.04

Partial tear of knee ligament1.01

Lens opacity; nonsenile, traumatic, after-cataract; congenital lens anomaly1.01

Hypertension, minimal1.01

Arrhythmias: paroxysmal atrial fibrillation or flutter2.01

Episode Group and Stage DescriptionStage

Patient 3Gender – MaleAge – 65Member’s Risk Score – 27.9Hypertension – Very SevereActual Payment - $276.40Expected Payment - $472.50$472.50Concurrent Episodes:

Local skin infections, dermatitis, pruritis, scars, ingrown nails, alopecia1.01

Sporadic atypical nevus1.01

Sporadic atypical nevus1.01


Administrative encounters1.01

Osteoarthritis of the ankle and foot1.04

Sprains of shoulder and upper arm1.01

Closed phalangeal fractures1.02

Acute calcareous tendonitis with bursitis1.02

Minor disorder of globe, cysts, foreign body in eye, other visual problems1.01

Asymptomatic diabetes mellitus type 21.03

Hypertension, very severe2.01

CAD/asymptomatic chronic ischemic heart disease or old MI1.01


Patient 2Gender – FemaleAge – 67Member’s Risk Score – 5.37Hypertension – MinimalActual Payment - $258.30Expected Payment - $317.72Concurrent Episodes:

Patient 1Gender – FemaleAge – 65Member’s Risk Score – .29Hypertension – MinimalActual Payment - $146.00Expected Payment - $148.07Concurrent Episodes:

Acute sinusitis with one sinus1.01


Hypertension, minimal1.01



Attribution: One Responsible Physician per Episode

The Responsible Physician of an episode is determined by the:

� Physician with the highest total RVUs billed; if none, then� Physician with the greatest number of E&M services billed; if none, then� Physician with the highest allowed dollars.

This assignment is made without regard to the physician’s contract status with BCBSTX.


Data Scrubbing

• Episodes that are incomplete

• Episodes that are high or low cost outliers

• Episodes for members with fewer than 9 member months

• Episodes belonging to a MEG/Substage with low volume

• Episodes where the responsible physician has less than 80% of the RVUs driving utilization

• Episodes containing Emergency Room revenue codes or place of service

• Episodes for preventive care

• Episodes in MEG categories not usually provided by a particular specialty


Geographic Comparison Areas


Physician Cost Assessment

Based on the average cost of qualified episodes partitioned by • episode group• severity of illness for the episode• relative risk of the patients • time period of episode• working specialty of the physician • geographic area of the physician

PCA =Sum across episodes: Actual Allowed Costs

Sum across episodes: Expected Costs


Confidence interval

• PCA results will be cited at the physician/practice, working specialty level in conjunction with a 90% confidence interval relative to 1.00.

• If the lower bound of the confidence interval is higher than 1.00, then the physician/practice is determined to have costs that are higher than their peers.

• If a physician/practice’s confidence interval contains 1.00, then the physician/practice is determined to have costs that are neither higher nor lower than their peers. Therefore, costs are similar to their peers.

Because the lower bound of the confidence interval is below 1.00, the physician in this example would meet the cost efficiency performance threshold.

Because the lower bound of the confidence interval is above 1.00, the physician in this example would not meet the cost efficiency performance threshold.

Because the lower bound of the confidence interval is below 1.00, the physician in this example would meet the cost efficiency performance threshold.


Eligibility Note

• Benefit Level 1 eligibility and qualification are created at the Practice Evaluation ID/working specialty level

• This means that a group practice may have physicians in both Benefit Levels for different specialties


Differences: Former Cost Assessment and New PCA

Excludes episodes containing ER revenue codes, or ER place of service codes, or ER Evaluation and Management codes.

Episodes could include costs for ER services.

Restricts episode set used to episodes where there is one clinician that is driving at least 80% of the care as measured by RVUs.

Episodes could include costs generated by other physicians/professional providers other than the physician/professional providers that was attributed the episode.

Assessment conducted at the Practice Evaluation ID / working specialty level, therefore results can differ within thepractice for different specialties.

Assessment conducted at the Practice Evaluation ID level / modeling status level, therefore the entire practice shared the same results.

Per national guidelines, we must measure quality before cost, therefore the list of modeled working specialties is dictated bywhich working specialties are measured for quality. This includes physicians only.

The list of modeled working specialties was extensive and primarily determined by specialties where sufficient and meaningful data was available for analysis. This included professional providers.

Created an advisory committee of practicing physicians to assess methodology, communication materials and reports.

The development of methodology and communications did not involve extensive consultation with the provider community.

New methodology was created in accordance with new National Guidelines (NCQA and Patient Charter) and complies with TX Insurance Code Chapter 1460.

National Guidelines and laws were not available when the methodology was created.

Current Physician Cost Assessment (PCA) ProgramFormer Cost Assessment Program


Differences: Former Cost Assessment and New PCA (cont.)

Created a suite of meaningful PCA supporting reports to help physicians understand cost drivers.

Basic reporting available.

PCA includes a confidence interval, therefore it is expected that there will be less variation from year to year with regard to BlueOptions Benefit Level assignment and BlueCompare cost efficiency designation in Provider Finder.

The score or value by entity changed year to year.

All BlueChoice network physicians are in-network for the new BlueOptions product (subject to regulatory approval). We are not using PCA results to remove or exclude any physicians from either the BlueOptions product or the BlueChoice network.

Results determined eligibility for the BlueChoice Solutions network.

Incorporates ‘specialty of care basket’ approach into trim points in order to limit the possible effect of episodes that are not common to a specific specialty.

Episode set included all episodes that passed through trim logic. This included some episodes that are not common to a specific specialty.

Current Physician Cost Assessment (PCA) ProgramFormer Cost Assessment Program


Secure Provider Portal


PCA Results Letters & Reports

• Complete suite of reports available for those physicians with 1 blue (quality) ribbon and with sufficient data to measure PCA

• Some physicians with insufficient PCA data will have some of the PCA reports available• Reports available in secure online portal used for EBM reports - portal.revelationmd.com• For those practices with PCA reports, PCA results letters also in secure online portal • PCA results letters and separate temporary password letter will be mailed to either the individual

physicians or the group practice administrator

Contact your local Network Rep:

Group Administrator needs log-in for each doc in group:• We can generate and securely email a spreadsheet containing individual NPI logins for

physicians in the group

Group where physicians received individual letters and the Group Administrator needs a log-in to access all physicians’ reports:

• We can generate a password letter for the Group Admin and securely email it


portal.revelationmd.com

When logging in first time, enter your NPI (solo practice) or Group’s Practice Evaluation ID (usually the Tax ID) and Temporary Password from the 2nd letter.

You’ll be prompted to reset your Password

If you have logged in before, use that log-in.


Terms of Use and Privacy

To proceed, click


Initial Log-in


Change Temporary Password


Change Your Online ID or Contact Information (optional)


Add Additional Users

Have Admin function to add additional users to view reports


Create a New User

Adds additional users to view practice data


Create a New User

The new user will have the same viewing access as the physician or group’s administrator.

Adding a new user is best for Practice Administrators and Assistants.

The Administrator role allows the

user to manageall other users.

The Standard User can only view reports.


Create a New User

Create the online ID and the password for the new

user

Suggestions for the online ID and the rules for

passwords

If checked, the new user will have to change their password at first sign-in.


Create Another New User

Choose to create another user or Return

to confirm the user created


PCA Reports


Group Practice


Group Level Reports


Report 8 – Provider Finder BlueCompare Display

Produced for all Tax IDsin measured specialties with more than 1 working specialty


Report 9 – BlueCompare Group Specialty

Roster produced for all Tax IDs in measured specialties with more than 1 physician


Group Practice


Specialty PCA Reports


Individual Physician


PCA Reports


Report 1 – PCA Results

This report provides the Physician Cost Assessment (PCA) by working specialty and rating area for the practice or group.

The PCA (at a 90% level of confidence) reflects differences in the cost of care managed by physicians relative to peers within the same specialty, in the same geographic region and in the same time period, when treating patients with similar conditions.

Similar clinical conditions are episodes of care within the same level of severity, in the same Medical Episode Group (MEG), for patients with similar comorbidity.


Report 2 – PCA Summary Chart

The PCA with 90% Confidence Interval reflects differences in the cost of care managed by physicians, relative to peers within the same specialty in the same geographic region, in the same time period, when treating patients with similar clinical conditions.

�The bar indicates the 90% confidence interval for the working specialty in the practice.�The numerical value on the bar indicates the PCA for the working specialty in the practice.

The Comorbidity Index summarizes the disease burden in a practice.�The bar indicates the range of values of the Comorbidity Index for the working specialty in the rating area.�The numerical value on the bar indicates the Comorbidity Index for the working specialty in the practice.


Report 2 – PCA Summary Chart

Cost and UtilizationComparisons indicatethe contribution thatvarious componentsmake to differences inthe PCA. • Values greater than

zero indicate components that increase the PCA.

• Values less than zero indicate components that lower the PCA.


Report 3 – PCA Utilization Summary


Report 4 – PCA Place of Service Detail

This report is a companion to Report 3 that provides place of service detail for the services provided.


Report 4 – PCA Place of Service Detail


Report 5 – PCA Top 10 MEGs

This report is a companion to Report 6 that provides a summary of the MEGs (up to 10) that have the greatest impact on the PCA result.

�The MEGs selected are based on greatest difference between Total Cost and Total Expected Cost, compared to peers within the same specialty and area.

�The data for each MEG from the Complete MEG Listing Report is combined for all severities, time periods, and comorbidities.


Report 6 – PCA Complete MEG Listing

This report provides a summary of the information underlying the PCA which reflects differences in the cost of care managed by physicians, relative to peers within the same specialty, in the same geographic region, in the same time period, when treating patients with similar clinical conditions.

Similar clinical conditions are episodes of care within the same level of severity in the same Medical Episode Group (MEG) for patients with similar Comorbidity.


Report 7– PCA CPT Codes in Percent of Episodes Compared to Peers

This report provides more detailed information about the factors that influence the costs attributed to the working specialty in the practice or group.

It shows what services (CPT and HCPCS codes) appear in higher or lower proportions in the episodes compared to peers.


Report Guide and Definitions


FAQs


Reviews and Opt-OutsMilestone and Target Dates

Online Resources


Review Requests

• Affected physicians who are dissatisfied with their PCA results have the right to request a review in writing.

• There are 2 processes - the Written Fair Review Reconsideration process and the Fair Reconsideration Proceeding.

The Written Fair Reconsideration:• Physicians who did not meet the PCA Threshold for Recognition may request a review by submitting a

written request to the local BCBSTX Network Representative• Contact list found in the PCA results letter or on our website

www.bcbstx.com/provider/contact_us.html#localnetwork

The request should include:• The date of the request • Physician name and address • The Practice Evaluation ID number (found on the PCA letter and reports) • A statement of the reason(s) for requesting a review• Any relevant, supporting information• A contact name and phone number


Review Process

• BCBSTX reviews the request, additional information provided, and the PCA data with an Internal Review Committee

• If a change is warranted, we send a letter and update all systems• If no change is warranted, we send a letter regarding the second-level Physician

Committee review rights• The Physician Committee is either the Texas Medical Advisory Committee

(TMAC) or the Texas Peer Review Committee (TPRC) of BCBSTX.• Both committees’ members are practicing physicians and other health care

providers who also participate in networks serving members of BCBSTX health programs.

• The second level review is final


Fair Reconsideration Proceeding

Fair Reconsideration Proceeding:• In addition to the Written Fair Reconsideration Review process, physicians may request

a Fair Reconsideration Proceeding within 30 days of receiving the PCA results letter.

• The Proceeding will be • Via teleconference, or, • In person at the BCBSTX Headquarters building, located at 1001 E. Lookout Drive,

Richardson, TX 75082, • At an agreed upon time between the hours of 8:00 AM and 5:00 PM, Monday

through Friday

• You may• Provide additional information for a determination by BCBSTX, • Have a representative participate in the reconsideration proceeding, • Submit a written statement at the conclusion of the reconsideration proceeding.


Fair Reconsideration Proceeding request should include:• The date of the request • Physician name and address • The Practice Evaluation ID number (found on the PCA letter and reports) • A statement of the reason(s) for requesting a Reconsideration Proceeding• Supporting information you want to submit prior to the Reconsideration Proceeding• A contact name and phone number

• Fax, email or mail the request to Kathleen Leifker, R.N. • Fax: 972-766-1103 • Email: [email protected] • Address: 1001. E. Lookout Drive, Tower B.11, Richardson, TX 75082

Details at www.bcbstx.com/provider/training/inquiry_review.html

Fair Reconsideration Proceeding


Opt-Out

Opt-out rights• A physician may opt-out of the BlueCompare ribbon display (quality – 1 ribbon or quality and cost – 2

ribbons). • Opting out of both the BlueCompare quality and cost (2 ribbons), will remove the physician from the

BlueOptions Benefit Level 1. The physician can see BlueOptions members under Benefit Level 2 as long as the physician is contracted under the BlueChoice PPO.

• A physician cannot opt-out of BlueOptions Level 1 and keep the BlueCompare symbol in Provider Finder.

How to Opt-out• Quality 1 ribbon – No change in procedure - use existing Opt-Out Form online.

• Quality and Cost 2 ribbons:• Letter instructs to write to local Network Rep:

• “You may voluntarily elect to opt-out of the BlueCompare Physician Designation program by mailing a written notice to your local Professional Provider Network representative within thirty days of receipt of this letter. This action will remove the quality related and cost efficiency BlueCompare Blue Ribbons. Although your patients will not be eligible for enhanced BlueOptions benefits, we will process claims for BlueOptions members at the usual in-network level of benefits.”


Milestones and Target Dates

March 2010 • Met with TMA and various specialty societies to review the plan

May 2010• Mailed letter to all BlueChoice physicians and professional providers regarding BlueChoice Solutions

retirement, new PCA in support of transparency and BlueOptions product• Published BlueCompare (EBM and PCA) details and Q&As on web

http://www.bcbstx.com/provider/bluecompare2011.htm

December 2010• Mail results letters to physicians in measured specialties• Public webinar

January 2011 – February 2011 • Physician review period

March 2011• Provider Finder changes - new BlueCompare cost ribbons in PPO products • New BlueOptions product in Provider Finder for first possible self-funded group

July 2011• 1st possible fully insured group effective on BlueOptions product


Online Resources

www.bcbstx.com/provider/training/bluecompare2011.html


Online Resources

Documents

Blue Cross and Blue Shield of Texas New Physician Cost ... · Network effective 12/31/10 ... Level 3 – services provided by ParPlan or non-contracting providers. Experience