Here’s what you need to know about participating 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, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement,” formerly called “fee uplifts.”

Select primary care and specialist physicians who participate in the Physician Group Incentive Program and meet the standards of particular 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 >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule. The VBR Fee Schedule rates apply to commercial payments only.

The following are participation guidelines for Quality Programs. Providers 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, provider 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’ PGIP Quality Programs and be eligible to earn value-based reimbursement in accordance with the VBR Fee Schedule.

1. Primary care physicians designated as a Patient-Centered Medical Home are eligible for reimbursement at the rates applicable to such designations on the VBR Fee Schedule. Primary care physicians can receive designation as a PCMH through nomination from their physician organization by demonstrating the following:
• Meeting the PCMH minimum capability requirement. PCMH capabilities are tasks physician organizations and medical practices undertake to change their care processes and become more patient-centered. Examples of PCMH capabilities include, without limitation, 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. In 2015, the capability requirement for PCMH designation was 40 out of 145 PCMH 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 include emergency room use, high- and low-tech radiology use, high- and low-tech standard cost per member per month, primary care sensitive emergency room visits, generic dispensing rate, and ambulatory care sensitive inpatient discharges. In 2015, the minimum percentile ranking was 20 percent. This represents the other 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 rates for such designations on the VBR Fee Schedule. For 2015, 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 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. Primary care physicians with PCMH designation who have continuously taken part in the Michigan Primary Care Transformation Project since 2012 are eligible for reimbursement at the rates for such designations on the VBR Fee Schedule.
4. PCMH designated and non-PCMH designated primary care physicians who Blue Cross determines are performing well on measures of clinical quality performance related to preventive service use, chronic condition management and medication adherence are eligible for reimbursement at rates for such designations on the VBR Fee Schedule. There are 28 measures in this value-based reimbursement opportunity, based on the Healthcare Effectiveness Data and Information Set measures used for National Committee on Quality Assurance accreditation. All measures use claims data from the prior calendar year for the providers’ attributed patient population.

Specialists

Specialists are eligible for the VBR Fee Schedule if they meet all of the following:

1. Are a physician, chiropractor, podiatrist or fully licensed psychologist
2. Are a member of a PGIP physician organization for at least one year
• Every PGIP-participating doctor is entered into a database by his or her PO. At regular intervals, Blue Cross takes a snapshot of the database. For value-based reimbursement, a specialist is considered to be in a PGIP physician organization for at least one year if the doctor is listed on the winter and summer snapshot of the year before the quality program year. In the 2016 quality program year only, anesthesiologists are exempt from the one-year requirement.
3. Are nominated by and have a signed a primary care-specialist agreement with his or her member PO. (Blue Cross has a template agreement but doesn’t require its use. Standard employment agreements don’t constitute primary care-specialist agreements.) Also, if a substantial proportion of the specialist’s patients are attributed to a PO other than his or her member PO, nominated by and have a signed primary care-specialist agreement with a non-member PO (i.e., a principal-partner PO).
   • Each PO establishes its own criteria for nominating member and principal partner specialist practices within broad parameters set by Blue Cross. Nominated member practices must be actively engaged with their nominating member PO. Active engagement can be demonstrated by progress toward one or more of the following:
     • Involvement in managing the use of services and optimizing the quality of care
     • Collaboration with primary care physicians to develop and improve shared processes of care
     • Collaboration on efforts to coordinate care across settings and over time
     • Implementing Patient-Centered Medical Home-Neighbor capabilities in the specialist practice

   The PO’s criteria for principal partner practices may be the same as or different than those for member practices. All specialist practices — regardless of their membership status — must have an equal opportunity to be considered for nomination. Each PO must document the nomination criteria and process in writing and disclose it to the other physician organizations on the shared PO website maintained by Blue Cross. And, POs must make the documented process available to practices upon request. Blue Cross reviews the documented nomination criteria and process to make sure it’s fair to principal partner practices.

4. Meet the population-based performance rankings on measures of quality, cost and efficiency set by Blue Cross
• Blue Cross uses population-based measures of quality, cost and efficiency to evaluate and rank nominated practices. Each performance measure is assigned a weight. Within each specialty type and within all pediatric specialties, specialist practices are ranked based on the weighted average of the relevant performance measures. For specialists who treat adult patients, the top two-thirds of ranked, nominated specialists are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule. For specialists who primarily serve pediatric patients, all ranked, nominated specialists are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule.
  
  In 2016, Blue Cross will use three population-based performance measures to determine eligibility for VBR Fee Schedule reimbursement for all specialty types:
  • 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

  Also, Blue Cross has developed specialty-specific performance measures for 13 specialties: allergy, cardiology, emergency medicine, endocrinology, gastroenterology, nephrology, neurology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, pulmonology and rheumatology.

Note: Oncologists participating in the Provider Delivered Care Management–Oncology program are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule. To be eligible for the PDCM-O program, practices must have a physician champion for care management and a lead oncology care manager who has gone through Blue Cross-sponsored training. Also, the practice must meet a minimum number of core PCMH-N capabilities and be submitting claims for at least 2 percent of its eligible attributed members.