Value-based reimbursement: Partnering for high-quality care. April 2016 Value Partnerships Team

Transcription

1 Value-based reimbursement: Partnering for high-quality care April 2016 Value Partnerships Team

2 Background and goals Now in its 11th year, the Physician Group Incentive Program continues to focus on transitioning Blue Cross Blue Shield of Michigan from a fee-for-service to a value-based payment model. PGIP has significantly transformed the state s health care delivery system into one where providers are earning more for achieving improvements in quality, safety and outcomes. Physician Group Incentive Program goals: Better align provider reimbursement with quality of care standards Improve health outcomes Control health care costs for Blue Cross customers

3 Value-based reimbursement fee schedule Practitioners who meet certain criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule The VBR Fee Schedule sets fees at greater than 100 percent of the Standard Fee Schedules

4 Value-based reimbursement for primary care physicians

5 Value-based reimbursement for primary care physicians We re changing our value-based reimbursement structure for primary care physicians who participate in the Physician Group Incentive Program, effective July 1, Primary care physicians can receive value-based reimbursement of 105 percent to 140 percent of the Standard Fee Schedules for certain procedure codes, depending on the program(s) in which they participate and the criteria they meet.

6 VBR Fee Schedule

7 Clinical quality value-based reimbursement for primary care physicians Effective July 1, 2016, three tiers of clinical quality value-based reimbursement will be available for all PGIP-participating primary care physicians. Previously, only one tier was available. The three tiers for clinical quality performance and their value-based reimbursement are: Ranking in the 95th to 100th percentile percent of the Standard Fee Schedules Ranking in the 85th to 94.99th percentile percent of the Standard Fee Schedules Ranking in the 80th to 84.99th percentile percent of the Standard Fee Schedules

8 Clinical quality measurement Performance is measured for the calendar year For calendar year 2016 performance, value-based reimbursement on that performance is effective July 1, For calendar year 2016 performance, are aligned with Medicare star ratings, Quality Rating System and HEDIS and performance is measured across all populations. The revised quality incentive structure aligns with Blue Cross shared emphasis on collaboration, coordination and population management. Practices will be measured on performance and improvement over time, consistent with PGIP principles.

9 Clinical quality primary care (2016 calendar year performance) Twenty-seven Based on the from Medicare star ratings, Quality Rating System and HEDIS All are based on claims data for the relevant performance period for the practice attributed patient population Different apply to different practice types adult practice, family practice or pediatric practice and to different populations (Commercial and Medicare) The chart on the next three slides breaks down the.

10 Category Measures PGIP Clinical Quality Value-Based Reimbursement Adult Practices Family Practices Pediatric Practices QRS for commercial MA Stars for MA QRS for commercial MA Stars for MA Adult BMI assessment QRS for commercial MA Stars for MA Adult Prevention and Screening Measures Breast cancer screening Cervical cancer screening Chlamydia screening in women Colorectal cancer screening Childhood immunization status (combination 10) HPV vaccination for female adolescents Immunization for adolescents (combination 1) Pediatric Prevention and Screening Measures Weight assessment and counseling for nutrition and physical activity children and adolescents: BMI percentile Weight assessment and counseling for nutrition and physical activity children and adolescents: counseling and physical activity Weight assessment and counseling for nutrition and physical activity children and adolescents: counseling for nutrition Well-child visits in the first 15 months of life (6 or more) Well-child visits for the third, fourth, fifth and sixth year of life

11 Category Measures PGIP Clinical Quality Value-Based Reimbursement Adult Practices Family Practices Pediatric Practices QRS for commercial MA Stars for MA QRS for commercial MA Stars for MA Diabetes care: Retinal eye exam QRS for commercial MA Stars for MA Diabetes care: Hemoglobin A1c (HbA1c) control < 8.0% Comprehensive Diabetes Care Diabetes care: Hemoglobin A1c (HbA1c) control 9.0% Diabetes care: Hemoglobin A1c (HbA1c) testing Diabetes care: Medical attention for nephropathy Appropriate testing for children with pharyngitis Respiratory Conditions Appropriate treatment for children with upper respiratory infection Avoidance of antibiotic treatment in adults with acute bronchitis Medication management for people with asthma

12 Category Measures PGIP Clinical Quality Value-Based Reimbursement Adult Practices Family Practices Pediatric Practices QRS for commercial MA Stars for MA QRS for commercial MA Stars for MA QRS for commercial MA Stars for MA Antidepressant medication management: acute phase Antidepressant medication management: continuation phase Behavioral Health Follow-up care for children prescribed ADHD medication: initial phase Follow-up care for children prescribed ADHD medication: continuation and maintenance phase Annual monitoring for patients on persistent medications Statins in diabetes Pharmacy Proportion of days covered (diabetes all class) Proportion of days covered (RAS antagonists) Proportion of days covered (statins) Other Controlling high blood pressure Use of imaging studies for low back pain

13 Payment timeline Measurement period Jan. 1, 2016 through Dec. 31, 2016 Reimbursement period (applicable to claims for the dates of service below) July 1, 2017 through June 30, 2018

14 Additional opportunities for value-based reimbursement In addition to clinical quality performance, there are opportunities for primary care physicians to earn value-based reimbursement as part of the Physician Group Incentive Program: 1. Designation as a PCMH practice 2. Alignment with a physician organization that meets cost benchmark criteria (as a designated PCMH practice) 3. Participation in provider-delivered care management (as part of a PCMH practice)

15 1. Patient-Centered Medical Home designation To earn PCMH designation, a practice must: Be nominated by their physician organization Meet at least 50 of the 148 PCMH capabilities. PCMH capabilities require care processes to become more patient-centered. For example: 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.

16 2. Alignment with a cost-benchmark PO 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 For 2016, 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 above a certain threshold, based on Blue Cross claims data.

17 3. Participation in PDCM A practice should: Have PCMH designation and attest to having a qualified care manager in the office Have a provider who is engaged in care management and willing to refer patients to care management Have staff working to close gaps in care Deliver care management services to a proportion of their eligible, attributed patient population

18 Value-based reimbursement for specialists

19 Specialist practitioners Specialists in PGIP who meet defined performance criteria also can earn value-based reimbursement. The criteria Specialists must: Be a physician, chiropractor, podiatrist or fully licensed psychologist Be nominated by their physician organization Be in PGIP for at least one year Meet the performance rankings on of quality and cost set by Blue Cross Blue Shield of Michigan

20 Population and performance for specialists Specialists are ranked according to at least three population-level of cost and quality. 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 of quality of care Additional performance for 13 specialties: allergy, cardiology, emergency medicine, endocrinology, gastroenterology, nephrology, neurology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, pulmonology and rheumatology.

21 Value-based reimbursement opportunities for specialists The following is a breakdown of the opportunities available, effective March 1, 2016, to Feb. 28, 2017: Specialists non-pediatric practices Practice ranking Practices ranking in top third by specialty type Practices ranking in middle third by specialty type What they can receive 110 percent of standard fee schedule 105 percent of standard fee schedule Note: If fewer than 20 percent of the Blue Cross participating specialists of a particular specialty type are in PGIP, practices ranking in the top two-fifths can receive 110 percent of the standard fee schedule, and practices ranking in the next two-fifths can receive 105 percent of the standard fee schedule. Specialists pediatric practices Practice ranking Practices ranking in top half Practices ranking in second half What they can receive 110 percent of standard fee schedule 105 percent of standard fee schedule

22 For more information If you would like more information: Contact your provider consultant Contact your provider organization Go to valuepartnerships.com/