The PGIP evolution: New and revised participation and quality expectations

As the Physician Group Incentive Program enters its 20^th year, we’re supporting the ongoing development of stronger systems of care, resulting in better clinical outcomes for Blue Cross Blue Shield of Michigan members and Michigan residents. The goals are to see our members in high-performing care relationships and our health care providers well-supported by their PGIP physician organizations, which will allow them to deliver the transformed models and improved quality outcomes we expect.

As we work toward raising the bar, Blue Cross will continue to review and elevate our expectations, PGIP physician organization eligibility requirements and associated incentives. We’re also working to ensure the program, POs and practices continue to excel so Blue Cross members and customers receive the highest quality and most cost-effective care possible.

Eligibility requirements

Here are the eligibility requirements for PGIP physician organizations as announced at the PGIP Quarterly on Sept. 8:

• POs must have 75 or more TRUST panel physicians or Traditional participating physicians, 50 of whom must be practicing as primary care providers in internal medicine, pediatrics, family practice or general practice and have at least 12,500 attributed combined commercial PPO and Medicare Advantage PPO members. 
• The board of the PGIP physician organization must be comprised of 51% or more Michigan-licensed practicing physicians who are members of the PPO TRUST or TRAD network and contribute to the PGIP Reward Pool.
• POs must have contractual authority to represent their physicians for this program and coordinate and facilitate practice improvements and program administration on behalf of the physicians.
• POs must continue to meet and comply with program standards, including Standards for Maintaining Quality Health Care, Standards for Health Information Privacy and Security, Standards for Controlling Health Care Costs, Standards for Assuring Appropriate Utilization of Health Care Services, and Standards for Assuring Reasonable Levels of Access to Health Care Services.
• POs must meet the minimum IT and analytic enablement requirements to actively and appropriately participate in our program. POs must meet the minimum requirements for the sharing of data between the PO and their practices, including a registry, data warehouse, Michigan Health Information Network connectivity and risk stratification tools. 

Note: All POs will be expected to comply with the new and enhanced requirements by the Fall 2024 PGIP Snapshot in preparation for the 2025 PGIP program year.

Quality expectations

PGIP Evolution focuses not only on PO eligibility requirements and the support that POs provide to their physician members, but also on ensuring appropriate levels of clinical quality performance. As shared during the PO collaboration call on Oct. 25, Blue Cross is continuing to focus on multiple components that contribute to the high performance of PGIP physician organizations, particularly as they relate to our Clinical Quality Initiative, or CLQI, which focuses on HEDIS^® and its stars metrics.

PGIP physician organizations are evaluated on their commercial PPO and Medicare Advantage PPO performance through this longstanding initiative.​ As part of PGIP Evolution, we’re addressing how POs are engaging and performing in CLQI. Beginning with the 2024 program year, Blue Cross will be engaging POs that have fallen into the bottom quartile of performance in four out of the past five years. We’ll work with these POs on quality improvement plans to increase their performance.​

For the 2024 program year, these POs will need to:​

• Submit action plans to Value Partnerships detailing efforts and planned resources to address performance issues and close gaps in care for each measure that falls below NCQA 75th percentile benchmark performance​.
• Submit quarterly progress reports.
• Meet in person with Blue Cross leadership three times a year.
• Meet with an assigned mentor PGIP physician organization to address concerns and brainstorm solutions​.

On an annual basis, we’ll be assessing all PGIP physician organizations to ensure no POs have multiple successive years of less-than-acceptable performance.

This information will be recirculated through PGIP communication channels as the Fall 2024 PGIP Snapshot nears. If you have questions, reach out to your field team representative or email valuepartnerships@bcbsm.com.

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.