Here’s how primary care physicians can participate in Value Partnerships’ quality programs

The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to better align provider reimbursement with quality of care standards, improve health outcomes and control health care costs for Blue Cross customers. We call this value-based reimbursement.

Select primary care physicians who participate in the Physician Group Incentive Program and meet the standards of quality programs developed under PGIP will, for a designated period, be eligible for reimbursement in accordance with the value-based reimbursement fee schedule.

The VBR fee schedule sets reimbursement rates for particular codes at greater than 100 percent of the TRUST/Traditional/BPP maximum or standard fee schedule. These rates apply to commercial payments only.

Participation guidelines for quality programs for primary care physicians are as follows. Doctors who have questions about participating in a quality program, or who would like more information about the opportunities described in this article, should contact their provider consultant or physician organization or email valuepartnerships@bcbsm.com. All requirements are subject to change annually.

Primary care physicians

There are five ways a primary care physician can participate in Blue Cross’ quality programs and be eligible to earn reimbursement in accordance with the value-based reimbursement fee schedule.

1. Primary care physicians designated as a Patient-Centered Medical Home are eligible for reimbursement at the VBR fee schedule rates applicable to such designations. These physicians can receive designation as a PCMH by demonstrating the following:
   
   
• Nomination from their physician organization

• Meeting the PCMH capability requirements, which are tasks that medical practices undertake to change their care processes and become more patient-centered. Examples include providing 24-hour access to a clinical decision-maker so patients can avoid emergency room visits and creating patient registries or offering access to patient web portals. In 2018, the capability requirement for PCMH designation requires 50 out of more than 150 PCMH capabilities, including six required foundational capabilities. The extent to which a provider has implemented PCMH capabilities represents 50 percent of the PCMH designation score.

• Meeting the minimum PCMH percentile ranking for quality and use criteria. Quality and use criteria are analyzed using claims data from the prior calendar year for a doctor’s attributed patient population, and the metrics for 2017 performance include 20 adult quality metrics, 15 pediatric and adolescent quality metrics, high- and low-tech radiology use and primary care sensitive emergency room visits. In 2018, the minimum percentile ranking is 20 percent. This represents 50 percent of the designation score.
  
  
2. Primary care physicians with PCMH designation who are also part of a physician organization that meets Blue Cross’ cost benchmarking criteria are eligible for reimbursement at the VBR fee schedule rates for such designations.
   
   For 2018, 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 in the top 50 percent, based on Blue Cross claims data. 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

3. PCMH-designated primary care physicians who attest that they have or do the following will receive reimbursement for Provider-Delivered Care Management according to the fee schedule.
• A qualified care manager in the office
• A provider engaged in care management and willing to refer patients to care management
• Staff working to close gaps in care
• Care management services to 3 percent of their eligible, attributed patient population

4. PCMH-designated primary care physicians who are currently eligible for reimbursement for Provider Delivered Care Management according to the fee schedule can be considered for the new advanced practice value-based reimbursement. This advanced reimbursement is available if the practice delivered care management services to at least 4 percent of patients with PDCM benefits, engaged in medication reconciliation and implemented the Admission/Discharge/Transfer PCMH capability.

5. PCMH-designated and non-PCMH-designated primary care physicians are eligible for value-based reimbursement if Blue Cross determines they’re performing well on measures of clinical quality performance related to preventive service use, chronic condition management and medication adherence. There are 30 measures in this value-based reimbursement opportunity, based on the Healthcare Effectiveness Data and Information Set measures of the National Committee on Quality Assurance. Not all measures apply to each type of primary care practice. The adult measures are used for internal medicine practitioners, the pediatric measures are used for pediatricians, and a combination of adult and pediatric measures is used for family practitioners. All measures use claims data from the prior calendar year for the providers’ attributed patient population.