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.

• 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.

Clinical quality measures – primary care

(2016 calendar year performance)

Category Measures PGIP Clinical Quality Value-Based Reimbursement

Adult Practices Family Practices Pediatric Practices

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

Adult

Prevention and

Screening

Measures

Adult BMI assessment ✔ ✔ ✔ ✔

Breast cancer screening ✔ ✔ ✔ ✔

Cervical cancer screening ✔ ✔

Chlamydia screening in women ✔ ✔

Colorectal cancer screening ✔ ✔ ✔ ✔ ✔

Pediatric

Prevention and

Screening

Measures

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 ✔ ✔

Category Measures PGIP Clinical Quality Value-Based Reimbursement

Adult Practices Family Practices Pediatric Practices

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

Comprehensive

Diabetes Care

Diabetes care: Retinal eye exam ✔ ✔ ✔ ✔

Diabetes care: Hemoglobin A1c

(HbA1c) control < 8.0% ✔ ✔

Diabetes care: Hemoglobin A1c

(HbA1c) control ≥ 9.0% ✔ ✔

Diabetes care: Hemoglobin A1c

(HbA1c) testing ✔ ✔

Diabetes care: Medical attention for

nephropathy ✔ ✔ ✔

Respiratory

Conditions

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 ✔ ✔ ✔

Category Measures PGIP Clinical Quality Value-Based Reimbursement

Adult Practices Family Practices Pediatric Practices

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

QRS measures

for commercial members

MA Stars measures

for MA members

Behavioral Health

Antidepressant medication

management: acute phase ✔ ✔

Antidepressant medication

management: continuation phase ✔ ✔

Follow-up care for children prescribed

ADHD medication: initial phase ✔ ✔

Follow-up care for children prescribed

ADHD medication: continuation and

maintenance phase

✔ ✔

Pharmacy

Annual monitoring for patients on

persistent medications ✔ ✔

Statins in diabetes ✔ ✔ ✔

Proportion of days covered (diabetes

all class) ✔ ✔ ✔ ✔

Proportion of days covered (RAS

antagonists) ✔ ✔ ✔ ✔

Proportion of days covered (statins) ✔ ✔ ✔ ✔

Other

Controlling high blood pressure ✔ ✔ ✔ ✔

Use of imaging studies for low back

pain ✔ ✔

Measurement period Reimbursement period

(applicable to claims for the

dates of service below)

Jan. 1, 2016 through Dec. 31, 2016 July 1, 2017 through June 30,

2018

Payment timeline

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)

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.

1. Patient-Centered Medical Home designation

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.

2. Alignment with a cost-benchmark PO

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

3. Participation in PDCM

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

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

The following is a breakdown of the opportunities available, effective March 1, 2016, to Feb. 28, 2017:

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 — non-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

Specialists — pediatric practices

For more information

If you would like more information:

Contact your provider consultant

Contact your provider organization

Go to valuepartnerships.com/

Email valuepartnerships@bcbsm.com