Rewards for Specialists

Blue Cross Blue Shield of Michigan identifies and rewards practices that collaborate with their community of caregivers to effectively manage care for their shared patients. Specialists in the Physician Group Incentive Program can receive reimbursement in accordance with the Value-Based Reimbursement Fee Schedule if they collaborate with their Physician Group Incentive Program PO and other practitioners and if they’re associated with populations of patients receiving high-quality, cost-effective care.

We sometimes refer to this approach as population-based specialist value-based reimbursement. The Value-Based Reimbursement Fee Schedule sets reimbursement rates at greater than 100 percent of the standard fee schedule.

Our goals in extending the Value-Based Reimbursement Fee Schedule to specialists include:

  • Transforming reimbursement from traditional fee-for-service to fee-for-value
  • Encouraging conversations and collaboration among practitioners, especially between specialists and primary care physicians
  • Accelerating the adoption of Patient-Centered Medical Home-Neighbor principles
  • Supporting and promoting Organized Systems of Care
  • Assessing and improving quality, use and cost performance

All physician specialty types, as well as chiropractors, podiatrists and fully-licensed psychologists are eligible to be considered for population-based specialist value-based reimbursement. POs nominate specialists who are engaged with their PO community and acting as PCMH-Neighbors. We choose which specialists receive reimbursement based on optimization of use, cost and/or quality in the PO populations they serve.

We determine eligibility for value-based reimbursement on an annual basis with an effective date of March 1 to Feb. 28, or 29 on a leap year. To be considered for it, specialists need to participate in PGIP for at least one year.

We only apply value-based reimbursement to PPO and Traditional commercial professional claims. We don't apply reimbursement to claims for ambulance, durable medical equipment, prosthetics and orthotics, immunizations, most injections, or hearing, lab, dental or routine vision services.

Value-based reimbursement opportunities for specialists participating in CQIs

Effective March 1, 2019, BCBSM will be continuing the Collaborative Quality Initiative value-based reimbursement opportunity, known as CQI VBR. Specialists participating in CQIs will have the opportunity to be rewarded for improving quality of care through engagement and performance in a CQI.

Value Partnerships initially launched the CQI VBR in 2017 with the Michigan Urology Surgery Improvement Collaborative. In 2018, a total of 13 CQIs have implemented CQI VBR for the 2019 VBR reimbursement period, as listed below.

  • Anesthesiology Surgery Performance Improve & Reporting Exchange Collaborative, ASPIRE
  • Blue Cross Blue Shield of Michigan Cardiovascular Consortium, BMC2
  • Michigan Anticoagulation Quality Improvement Initiative, MAQI2
  • Michigan Arthroplasty Registry Collaborative, MARCQI
  • Michigan Bariatric Surgery Collaborative, MBSC
  • Michigan Emergency Medicine Improvement Collaborative, MEDIC
  • Michigan Oncology Quality Consortium, MOQC
  • Michigan Radiation Oncology Quality Collaborative, MROQC
  • Michigan Surgical Quality Collaborative, MSQC
  • Michigan Spine Surgery Improvement Collaborative, MSSIC
  • Michigan Society of Thoracic and Cardiovascular Surgery Collaborative, MSTCVS
  • Michigan Trauma Quality Improvement Program, MTQIP
  • Michigan Urological Surgery Improvement Collaborative, MUSIC

Performance is measured and scored at one or more of the following levels:

  • Affiliated hospital — Physician performance is grouped by the collective average of the physicians at their primary hospital (affiliation determined by the coordinating center and consortium members).
  • Affiliated physician organization — Physician performance is grouped by the collective average at the PO.
  • Collaborative-wide — Physician performance is based on the collective average of all physicians.
  • Regional — Physician performance is assessed at a regional level.
  • Physician practice — Physician performance is based on the collective average at the physician practice.

As with population-based specialist VBR, the physician must be in PGIP for at least one year. Physicians who meet the performance expectations of their affiliated CQI will receive CQI VBR, which is in addition to any population-based specialist VBR opportunity. The CQI VBR reimbursement period follows the same reimbursement period as population-based specialist VBR.

Unique to CQI VBR are the following guidelines:

  • The physician must be contributing data for at least two years in the respective CQI’s clinical data registry (with at least one year worth of baseline data) to be considered eligible (specific to CQI VBR).

The physician isn’t nominated by the physician organization for CQI VBR. Instead, the CQI coordinating center notifies Blue Cross of which physicians meet the performance targets based on the scoring entity mentioned above (for example, affiliated hospital, affiliated PO). The PO is responsible for notifying physicians who receive value-based reimbursement, similar to the specialist VBR.