Requirements Document for the Blue Quality Physician Program sm Criteria Effective 08/03/2015

Transcription

1 All practices must reapply to the BQPP every 18 months Criteria Definition Validation Source(s) 7 Practice Elements 3 Provider Elements Practice level points: 1. PCMH/PPC/PCSP Recognition *Mandatory 2. Provider Quality Report (PQR) *Mandatory 3. Patient Care Summary Reports 4. Behavioral Health Co-Management 5. Practice Cost Report 6. All Staff Cultural Competency 7. After Hours/Weekend Care Provider level points: 1. Optional Courses (Note: optional points cap is 40 per provider). Includes: Assessing Military Family Stress Advanced Motivational Interviewing Health Insurance Basics for Providers NCQA Diabetes (DRP) NCQA Heart/Stroke (HSRP) Mid Level Practitioners Courses Category 1 CME Practice Precepting Medical Students 2. Generic Prescribing 3. Cultural Competency *Mandatory Element for Providers on 1 st cycle 4. Mandatory Course: For Providers who have not completed at least one of the following three courses in their previous BQPP cycle: Advanced Illness Management (End of Life Care) Introduction to Motivational Interviewing Choosing Wisely (Included in the Optional Points Cap listed above if not chosen for Mandatory Element Course) Practice level: 1. NCQA Data Feed 2. PQR Attestation 3. BCBSNC Internal Data 4. Co-management agreement or practice website 5. BCBSNC Internal Data 6. Completion certificate OR BCBSNC Internal Data 7. Practice website AND/OR phone call Provider level: 1. Depends on course, see below 2. BCBSNC Internal Data 3. Depends on course, see below 1

2 Practice Level Elements 1.PCMH/PPC/PCSP Recognitions National Committee Quality Assurance (NCQA) Patient- Centered Medical Home (PCMH) *Mandatory PCMH Recognition Achieving and maintaining recognition in the PCMH is a mandatory requirement for primary care practice participation in the Blue Quality Physician Program. PCMH is appropriate for all primary care medical practices including: Family Practice, Internal Medicine, General Practice, and Pediatrics. Mid-level practitioners may achieve PCMH recognition. PCMH recognizes clinician practices functioning as medical homes by using systematic, patient-centered and coordinated care management processes. The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be." Medical homes can lead to higher quality and lower costs, and can improve patients and providers experience of care. All locations must be PCMH recognized There are three levels of NCQA PCMH Recognition (Basic, Intermediate, and Advanced). To participate in the Blue Quality Physician Program your practice must be recognized in PCMH. If your practice has multiple sites, all sites must be PCMH recognized. The BQPP awards points to practices that are recognized in PCMH based on their level of recognition. BQPP Requirements: PCMH level 1, 2, or 3 NCQA Data Feed 2

3 Please Note: OBGYN practices should seek Patient-Centered Specialty (PCSP) Recognition or Physician Practice Connection (PPC) Recognition not the Patient Centered Medical Home Recognition. PCMH recognition is only for primary care practices; NCQA considers OBGYN a specialty. Please refer to the NCQA website for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. Check out the Community Care of North Carolinas (CCNC) website for NCQA PCMH cheat sheets and tools to assist practices through the process. NCQA Patient Centered Specialty Practice Recognition (PCSP) *Mandatory NCQA PCSP is appropriate for all specialists. OBGYN practices applying for the BQPP must achieve this recognition or PPC. All locations must be PCSP recognized. This program recognizes specialty practices that have successfully coordinated care with their primary care colleagues and each other, and that meet the goals of providing timely access to care and continuous quality improvement. Practices that become recognized will demonstrate patient-centered care and clinical quality through: streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management and continuous clinical quality improvement. There are three levels of NCQA PCSP Recognition (Basic, Intermediate, and Advanced). To participate in the Blue Quality Physician Program your practice NCQA Data Feed 3

4 must be recognized in PCSP. If your practice has multiple sites, all sites must be PCSP recognized. The BQPP awards points to practices that are recognized in PCSP based on their level of recognition. BQPP Requirements: PCSP level 1, 2, or 3 Achieving and maintaining recognition in the PCSP is a mandatory requirement for OBGYN participation in the Blue Quality Physician Program. Please refer to the NCQA website for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. NCQA Physician Practice Connection (PPC ) *Mandatory PPC is appropriate for OBGYN. This program recognition has ended and will not be accepting any new applications. OBGYN Practices that are already PPC recognized can apply for BQPP. All locations must be PPC recognized. A Recognition Program developed by the National Committee for Quality Assurance (NCQA) designed to recognize practices that use systematic processes and information technology to enhance the quality of patient care. Meeting PPC standards shows practices have established connections to information, patients and other providers that allow them to: Know and use patient histories Follow up with patients and other providers Manage patient populations and use evidence based care NCQA Data Feed 4

5 Employ electronic tools to prevent medical errors. Among the aspects of care measured by PPC are: Access and Communication, Patient Tracking and Registry Functions, Care Management, Patient Self- Management Support, Electronic Prescribing, Test Tracking, Referral Tracking, Performance Reporting and Improvement, and Interoperability. Please refer to the NCQA website for more information. There are three levels of NCQA PPC Recognition (Basic, Intermediate, and Advanced). To participate in the Blue Quality Physician Program your practice must be recognized in PPC. If your practice has multiple sites, all sites must be PPC recognized. The Program awards points to practices that are recognized in PPC based on their level of recognition. The Joint Commission Primary Care Medical Home (PCMH) *Mandatory Primary Care Medical Home (PCMH) Certification for Joint Commission accredited ambulatory care organizations focuses on care coordination, access to care, and how effectively a primary care clinician and interdisciplinary team work in partnership with the patient (and where applicable, their family). The PCMH certification option is consistent with the new federal health care reform efforts to improve health outcomes and the continuity, quality and efficiency of health care services. To find out more information on PCMH Certification please visithttp:// This recognition is equivalent to a NCQA PCMH level 3. Primary Care and OBGYN practices can apply for The Joint Commission PCMH Certification. Joint Commission Data Feed 5

6 Provider Quality Report (PQR) *Mandatory 2. Provider Quality Reports (PQR) BCBSNC is utilizing administrative claims data to provide our physicians and provider groups member specific care gap reports and an analysis of their performance against nationally recognized measures. Beginning in July of 2015, we are providing one single Provider Quality Report that will replace previous care gap reports. This new report will be provided on a monthly basis and will show care gaps on a practice level. he report will provide two different views of care gaps. The first is a 12 Month Rolling view which shows the practice their standing as of the current date (i.e. if the report were to run in March of 2015, it would contain data from March 2014 through February of 2015). This view will allow practices to see where they currently are and how they have performed over the most recent 12 months. The second view will show prospective care gaps. This Prospective view will be based on current HEDIS measures for the calendar year (January 1 st through December 31 st ) and will show which gaps are currently open and how the practice is trending on closing all 2015 care gaps. All primary care practices that were continuously contracted with BCBSNC during the measurement period will receive these reports. This will include Internal Medicine, Geriatrics, Family Practice, Pediatrics, and OBGYN practices, as well as any Multispecialty practices that include any of the aforementioned specialties. The Blue Quality Physician Program will award points to the practices that send their PQR Attestation to BCBSNC confirming that one practice staff and one provider have viewed the Provider Quality Report video training, accessed and reviewed the Provider Quality Report on Blue e. Provider Quality Reports signed attestation received from the practice. The PQR Attestation is located on the website. 6

7 We encourage practices to utilize these reports to close care gaps. For instructions on how to view the report and detailed information view: For questions concerning the Provider Quality Reports please contact Quality Management (919) (or) The PQR Attestation is located on the website. Patient Care Summary (PCS) Behavioral Health Co- Management 3.Patient Care Summary (PCS) The Patient Care Summary Report provides physicians and office staff with a patient specific summary report. This report will utilize BCBSNC claims data to provide: member diagnosis and provider history (including place of service- ER, Inpt, Office etc), prescription history, and actionable care alerts. This report is a single page and can be accessed and uploaded to an Electronic Health Record or printed from Blue e. The Blue Quality Physician Program will award points to practices that pull five (5) PCS reports for every provider in the practice per month. (i.e. 4 provider practice must pull 20 reports 4x5=20); a 6 provider practice must pull 30 reports (6x5=30). These numbers are averaged over a 3 month period. 4.Behavioral Health Co-Management Coordinated care between the primary care and behavioral health providers leads to enhanced screening and care of patients with mental health and/or substanceabuse issues. This results in better health outcomes for the member. To provide this care, increased coordination between these providers should take place in one of the following ways: A behavioral health provider is employed by or contracted with the BCBSNC Internal Data A copy of the Behavioral Health Co-Management Agreement is sent to BCBSNC or the Behavioral Health Provider is listed on the 7

8 practice. The practice partners with a behavioral health provider with the use of a Co-Management Agreement to provide mental health/substance abuse treatment and care coordination for the patients of the practice. practice website as being a part of the practice. Behavioral Health Co-Management Attestation is located at Practice Cost Reports Cultural Competency Training 5. Practice Cost Reports Evaluation of the cost efficiency & utilization metrics of a practice in comparison to peer groups across the state of North Carolina. Peer groups are determined by the practice specialty. Member total cost includes: office visits, ER, Urgent Care, inpatient, imaging and prescription drug. The cost index is the practice data divided by the peer practice data. The Blue Quality Physician Program awards points to practices that have a cost index < 1.1. Practice Cost Reports will be sent to practices every 6 months. If a practice's cost index is higher than 1.1 they will be placed on a cost improvement plan for a year. 6. All Staff Cultural Competency Complete interactive training focused on cultural competency in medical practice. The purpose of this training is to help enhance skills toward the BCBSNC Internal Data For All staff please sign and return the attestation. Physician, nurse 8

9 * Mandatory for all providers *All Staff Optional provision of care in a culturally competent clinical practice. Culturally competent care includes providing patient-centered care, tailoring delivery to meet patients' social, cultural, and linguistic needs; identifying and applying appropriate strategies to reduce racial and ethnic healthcare disparities; understanding the impact that stereotyping can have on medical decision making; and identifying techniques to deal with language barriers and other communication needs, including working with interpreters. Cultural Competency course options are: Cultural Competency course through BCBSNC- free online course. The link is on the landing page of the BQPP website 1 hour The Blue Quality Physician Program awards points to providers/practices that have completed the Cultural Competency course above. Completion of one of the above Cultural Competency training course is a mandatory requirement for the Blue Quality Physician Program. This course must be added to new hire orientation. Courses must be completed by all nurse practitioners, physician assistants, and physicians. Cultural Competency for All Staff- Cultural competency course completed by all existing and newly hired staff that interacts with patients on the phone or face to face such as receptionists and practice managers. Cultural Competency Course for All Staff Attestation All physicians and mid-levels that didn t complete the cultural competency course in the first BQPP cycle must complete it in the second cycle and ongoing. practitioner, and physician assistant in the practice must submit a certification of completion of the course. This course is tracked through BCBSNC. The practice does not have to send in the certificates. 9

10 After Hours Care Weekday Weekend Office Hours 7.After Hours Care Regularly scheduled weekday office hours between 5:00 pm and 8:00 am, in addition to 35 hours of regularly scheduled weekday hours between 8:00 am and 5:00 pm. The Blue Quality Physician Program awards points to practices that have 7 or more regularly scheduled office hours after 5:00 pm and before 8:00 am in addition to 35 hours of regularly scheduled weekday hours between 8:00am and 5:00pm. Regularly scheduled office hours on Saturdays and/or Sundays The Blue Quality Physician Program awards points to practices that have 7 or more regularly scheduled weekend office hours in addition to 35 hours of regularly scheduled weekday hours. Practice Website and/or confirmatory phone call to the practice. Practice Website and/or confirmatory phone call to the practice. Provider Level Elements (All Optional) 1.Optional Courses 1.Assessing Military Assessing Military Family Stress Course - BCBSNC is offering our providers Family Stress free access to a variety of training opportunities addressing the stressors experienced by both military members and their families. 3 modules must be completed. BCBSNC Internal Data These training modules incorporate Motivational Interviewing techniques and cover topics including: Taking a Military History (this module is mandatory for this course) VA

11 Traumatic Brain Injury This course through BCBSNC on the BQPP website landing page Each module is about 1 hour 2.Advanced Motivational Interviewing 3.Health Insurance Basics for Providers Motivational Interviewing: An Advanced Course for Clinicians Faculty: Chip Watkins, MD This course teaches and demonstrates the use of Motivational Interviewing for physicians and other healthcare professionals. The course includes a brief overview of Motivational Interviewing principles, skills, and applications for primary care providers. It also includes four demonstrations of a physician using Motivational Interviewing to engage patients with specific diseases: depression, hypertension, diabetes, and tobacco addiction. Users of this course are advised to download a handout to guide their viewing of the demonstrations. CME credit is awarded for taking all 4 modules listed above. Cost - $75.00 Link- Introduction to Motivational Interviewing online course must be completed before taking the Advanced Motivational Interviewing course. Health Insurance Basics for Providers Course Interactive course educating providers on Healthcare Reform, benefits, flex spending, HSA, etc). This course is free online through BCBSNC on the landing page of the BQPP website BCBSNC Internal Data 11

12 4.NCQA Diabetes Recognition Program (DRP) & Education A Recognition Program developed by the National Committee for Quality Assurance (NCQA) in partnership with the American Diabetes Association (ADA) designed to recognize physicians and mid-level practitioners who use evidence-based measures and provide excellent care to their patients with diabetes. The DRP Program has 10 measures which cover areas such as: NCQA data feed HbA1c control Blood Pressure control LDL control Eye examinations Nephropathy assessment Smoking status and cessation advice or treatment 5.NCQA Heart/Stroke Recognition Program (HSRP) Please refer to the NCQA website for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. The Blue Quality Physician Program awards points to Physicians & Mid-levels that are recognized in DRP. A Recognition Program developed by the National Committee for Quality Assurance (NCQA) in partnership with the American Heart Association (AHA/ASA) designed to recognize physicians and mid-levels practitioners who use evidence-based measures and provide excellent care to persons with cardiovascular disease (CVD) or who have had a stroke. The HSRP assesses key quality performance measures for secondary prevention NCQA Data Feed 12

13 of cardiovascular disease and stroke. Program measures include: Blood pressure control Complete lipid profile Cholesterol control Use of aspirin or another antithrombotic Smoking status and cessation advice or treatment 6. Mid-level Practitioners Courses Please refer to the NCQA website for more information. NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. Blue Cross Blue Shield of North Carolina is considered your sponsor. Please enter the NCQA code- CNCBCA on your NCQA application to receive the discount. The Blue Quality Physician Program awards points to Physicians & Mid-levels that are recognized in HSRP. Any organization granting AANP, ANCC, ACCME, AAPA, AMA, AOA or AAFP Category 1 CME courses for Mid-level Practitioners is acceptable. The North Carolina Area Health Education has courses on their website that meet this requirement. The EQIPP courses can also meet this requirement. The EQIPP courses that are also located on this document give AMA PRA Category 1 Credit. The Blue Quality Physician Program will award points to mid-level practitioners that submit a certificate of completion of AANP, ANCC, ACCME, AAPA, AMA, AOA or AAFP Category 1 CME course (at least 10 credit hours per course). Mid-level Practitioners Certificate indicating successful completion. 7. Medical Students During the previous 12 months, if a minimum of 60 days was spent precepting Confirmation of 13

14 and/or Mid-level Students Generic Prescribing medical students and mid-level students, 10 points will be awarded to providers (if the providers in the practice precept more than 60 days (120), two or more providers will receive 10 points). Please fill out the Precepting Medical Students Attestation on the BQPP website. 2.Generic Prescribing Generic Prescribing refers to prescriptions written that are dispensed as generics. The Blue Quality Physician Program awards points to physicians when the physician generic dispensing rate (average for the past three months) is equal to or greater than the percentage in the chart below. BQPP goals for generic dispensing rates by specialty: Pediatrics 62% Family Medicine 72% Internal Medicine 72% General Medicine 72% Obstetrics & Gynecology 69% Providers meeting the goal above will receive 5 points Providers with percentage of 75% or higher will receive 10 points Providers with percentage of 80% or higher will receive 15 points BCBSNC receipt of Medical Students & Midlevel Students Attestation on website. BCBSNC Internal Data 1. Mandatory Course Elements (For Providers who have not completed at least one of the following three courses in their previous BQPP cycle) Practices applying to the BQPP for their renewal application must have all nurse practitioners, physician assistants, and physicians complete one of the below elements. This is a mandatory element. Advanced Illness Management Introduction to Motivational Interviewing for Healthcare Providers American College of Physicians Choosing Wisely- Online High Value Care Cases 14

15 When it is time for the practice to renew their application again, providers must complete one of the courses listed above that they have not already received credit for. Advanced Illness Management -End-of - life (EPEC) *Mandatory for practices applying for renewal application to BQPP that have not yet completed it. Advanced Illness Management is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from symptoms, pain, and stress of a serious illness- whatever the diagnosis. The physician must complete the online course through Education in Palliative and End-of-life (EPEC). Or ABFM Hospice and Palliative Medicine To use your BCBS2012 promo code to receive 4 modules for $96, follow these four steps: 1. Create an EPEC website account at: 2. Go to the EPEC Distance Learning page at: 3. Click on EPEC under available curricula and pick at least 4 modules 4. From the list of modules, select the modules you would like to purchase and click add to cart. 5. Click proceed to the check-out, review your selected modules and enter your promo code BCBS2012 in the bottom right hand corner. The discount will allow the purchase of 4 modules for $ EPEC certificate. 15

16 The Blue Quality Physician Program awards points when each physician, nurse practitioner, and physician assistant in the practice submits a certification of completion (4 modules) of the course. Introduction to Motivational Interviewing for Healthcare Providers * Mandatory for practices applying for renewal application to BQPP that have not yet completed it. Motivational Interviewing (MI) is a client-centered directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence. MI has also been shown to improve the doctor patient relationship while increasing the efficiency of the consultation. By completing this training you will be given an opportunity to practice this guiding style; add practical tools to your toolbox, and respond to your patients using reflective listening and strategies to elicit change talk language from the patient. This is an online course through Benchmarks. More information on the website. The length of the course is approximately 2 hrs Cost - $50 Confirmation of BCBSNC receipt of MI certificate. The Blue Quality Physician Program awards points when each physician, nurse practitioner, and physician assistant in the practice submits a certification of completion of the course. American College of Physicians Choosing Wisely- Online High Choosing Wisely - Online High Value Care Cases- Learn how to eliminate unnecessary healthcare costs while improving patient outcomes with these Confirmation of High Value Care Cases certificate 16

17 Value Care Cases *Mandatory for practices applying for renewal application to BQPP that have not yet completed it. interactive cases on high value care. The 30- to 60-minute topics can be completed on your desktop, laptop, tablet, or Smartphone. Review the cases, answer the associated multiple-choice questions, and read through the critiques. You can also download the take-home tools to help you incorporate HVC principles into your practice. The cases offer free online CME, including patient safety credits and MOC medical knowledge points (submitted to the ABIM for approval). Choosing Wisely Course Free online course Must pick 3 topics: Avoid Unnecessary Testing Use Emergency and Hospital level Judiciously Improve Outcomes with Health Promotion and Disease Prevention Prescribe Medications Safely and Cost Effectively Overcome Barriers of High Value Care * 1 AMA PRA Category 1 CME Credit is awarded for each minute case. Non-ACP customers will need to fill out a quick registration form. 17