Areas of Development for Specialists

Blue Cross Blue Shield of Michigan (BCBSM) continues to explore and develop additional initiatives to improve quality in areas such as behavioral health, emergency medicine and low back pain, among others.

Additionally, BCBSM continues to further refine and develop approaches to specialist performance reporting and rewards, including those described below.

Specialist performance reporting and rewards

Specialist participation in PGIP enables BCBSM to identify and potentially reward specialist practice units who collaborate with their community of caregivers - including primary care physicians - to effectively and efficiently manage the care of a shared patient population. Specialist performance on measures of quality, utilization, cost and efficiency is generally assessed at the shared population level, not at the practice unit level.

BCBSM uses a number of claims-based measures of use and quality to assess population-based performance. BCBSM also uses Cave reports (CCGroup Marketbasket SystemTM) for some specialties. Cave reports are specialty-specific, condition-based episode efficiency reports. BCBSM has released physician organization-level and practice unit-level Cave reports for a number of specialty types and will continue to release reports for additional specialties. Although BCBSM releases practice unit-level reports to the PGIP physician organizations, BCBSM uses only physician organization or sub-physician organization Cave efficiency scores to assess specialist performance. BCBSM does not rely on Cave scores alone in measuring performance. BCBSM uses Cave scores in conjunction with one or more measures of population-based cost or use and, when feasible, measures of effectiveness/quality. 

In February 2012, BCBSM began providing fee uplifts to cardiology practice units that contributed to successful population-based performance.  Effective February 2013, BCBSM will offer fee uplifts to seven specialty types – oncology, cardiology, emergency medicine, obstetrics/gynecology, nephrology, gastroenterology, and orthopedic surgery. Specialist practice units must be nominated by the PO(s) with whom they have a shared population and will be selected for the fee uplifts by BCBSM based on optimization of use, cost and quality in the population of patients attributed to the primary care physicians with whom the specialists collaborate. BCBSM will offer fee uplifts to additional specialty types in 2014. 

In 2005, PGIP began its health care transformation journey with a focus on primary care. At that time, PGIP participation was restricted to MDs or DOs who were primary care physicians or who were on a list of select specialties.

The program's long-term goal, however, has always been to create high-functioning, coordinated systems of care that involve all physicians who care for patients. Toward this end, in 2011, BCBSM opened PGIP to all remaining medical/surgical specialists not previously in the program.

PGIP is now open to all MDs, DOs, podiatrists and chiropractors who participate in the BCBSM Traditional and PPO networks. All physician specialties are eligible to participate in the program except anesthesiology; however, some anesthesiologists will be eligible based on the services provided and billed.

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