Why is BCBSTX creating the Physician Cost Assessment (PCA ....doc
1. Why is BCBSTX creating the Physician Cost Assessment (PCA) and
Continued escalation of health care costs has driven premiums and medical expenses
to higher and higher levels each year. This, in turn, has motivated employers and
consumers to search for information about the value (quality and cost) they receive for
their health care dollars. These stakeholders have asked Blue Cross and Blue Shield of
Texas (BCBSTX) to support their purchasing decisions by identifying the providers who
offer the best value for their health care. These stakeholders also want consumer
friendly tools and benefit products to support their health care purchasing decisions.
BCBSTX must pay attention to the needs of its employers and members.
Thus the objective of adding the PCA to the BlueCompare Physician Designation
Program is twofold. The first objective is to provide PPO members with quality related
and cost efficiency performance designations in our online Provider Finder® for use in
their health care purchasing decisions.
The second objective is to support a new benefit plan product called BlueOptions.
Subject to regulatory approval, BlueOptions will include enhanced benefits for members
who obtain care, when possible, from BlueCompare physicians recognized for both
quality and cost efficiency. BlueOptions is not a network, rather it is a product. The
BlueOptions product will use all BlueChoice® network providers. Competitors have
similar benefit products in the marketplace.
2. How is the PCA different from past physician cost assessment methodologies
such as the Risk Adjusted Cost Index (RACI)?
The PCA utilizes national published guidelines (NCQA PHQ, Patient Charter) and
requirements regarding provider evaluation methodologies and programs in accordance
with recently enacted Texas law (Texas Insurance Code Chapter 1460). We have
taken care to incorporate these guidelines and requirements into a redesigned
BlueCompare Physician Designation Program as we strive to meet the demand for
information on provider performance. BCBSTX involved practicing physicians in the
development of the PCA and has developed meaningful reporting to explain the major
cost component driver of the PCA to physicians.
Other major differences in the methodology include:
• Per NCQA PHQ, the cost efficiency is measured only for specialties that can also
be measured for quality related performance.
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• Per NCQA PHQ, a confidence interval is used when determining the
• Episode sets used to create new cost index are restricted to episodes where one
clinician drives at least 80% of the care as measured by RVUs.
• Episodes containing ER revenue codes, or ER place of service codes, or ER
Evaluation and Management codes are excluded.
• Preventive care episodes are excluded.
• A “specialty of care basket” approach is incorporated into the trim points.
PCA will also:
• Evaluate results at the Practice Evaluation ID/working specialty level.
• Assure that episodes are risk and severity adjusted, specific to the working
• Create indices that are relative to the working specialty and rating area of the
• Calculate results based on two incurred years of complete episode data.
Incomplete episodes are trimmed.
• Trim data for outliers.
3. What are the state and national guidelines and requirements that BCBSTX is
• The quality related assessment will utilize Evidence Based Measures (EBMs) from
nationally recognized entities such as the National Quality Forum (NQF), the
Ambulatory Care Quality Alliance (AQA), and the National Committee for Quality
• The BlueCompare program will adhere to nationally recognized transparency
methodology and program standards and guidelines (NCQA Standards and
Guidelines for the Certification of Physician and Hospital Quality) and will comply
with Texas Insurance Code Chapter 1460.
• Please visit these sites for more information:
NCQA Standards and Guidelines for the Certification of Physician and Hospital
Ambulatory Care Quality Alliance http://www.aqaalliance.org/performancewg.htm
National Quality Forum
Patient Charter for Physician Performance Measurement, Reporting and Tiering
Programs: Ensuring Transparency, Fairness and Independent Review
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4. Did BCBSTX have any experts review the EBM and new PCA methodologies?
BCBSTX worked closely with a Physician Advisory Committee on Measures of
Performance. This Committee helped BCBSTX select appropriate Evidence Based
Measures. An external statistician, with extensive experience in biostatistics, reviewed
and validated the EBM scoring methodology for appropriateness.
BCBSTX developed the PCA in accordance with national guidelines discussed in
Question 3. We engaged physicians currently in clinical practice to assist us in building
this new methodology.
5. Is BCBSTX going to measure all specialties or only certain ones?
The redesigned BlueCompare program will measure physicians for both quality related
performance (based on EBM) and cost efficiency in the following fourteen working
Cardiovascular Disease-Non-Interventional Neurology
Cardiovascular Disease-Interventional Obstetrics-Gynecology
Endocrinology Pediatric Allergy-Immunology
Family Practice Pediatric Pulmonary Disease
Geriatric Medicine Pediatrics
Internal Medicine Pulmonary Disease
6. What is a Working Specialty?
A specialty designation derived by utilizing the physician’s primary, secondary and
tertiary specialties on record, practice limitations, physician type, and in certain cases,
primary place of service.
7. How will the PCA be used differently than past cost efficiency performance
From a historical perspective, the primary difference is that the PCA is not being used
for determination of eligibility for a specific network as was the case with the previous
cost efficiency performance methodology used for the BlueChoice Solutions network.
8. How does the PCA relate to the BlueCompare Physician Designation
The BlueCompare Physician Designation Program is being enhanced to include a cost
efficiency assessment that will be called the Physician Cost Assessment (PCA).
Specifically the PCA results will be coupled with the existing Evidence Based Measures
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(EBM) component of the BlueCompare Physician Designation Program to recognize
and designate physicians who practice in working specialties that can be measured and
meet standards for both quality related performance and cost efficiency. The results of
the BlueCompare Physician Designation Program’s quality related (EBM) and cost
efficiency (PCA) assessments will be displayed in the online Provider Finder® tool at
9. Is BCBSTX going to incorporate the Bridges to Excellence®’ recognized
physicians into its programs?
BCBSTX has implemented a program to reward physicians recognized by the Bridges
to Excellence®’ Diabetes Care Link or Cardiac Care Link programs because they
demonstrate sound management of complex patients and deliver safe, timely, effective
and efficient patient-centered care. Therefore, physicians who practice in one of the
BlueCompare measured working specialties that are currently recognized by the
Bridges to Excellence organization in their Diabetes Care Link or Cardiac Care Link
programs, will be recognized and display a BlueCompare Blue Ribbon.
10. When will I receive my performance results? When will the new Cost and
Quality designations be displayed on the online Provider Finder?
The results of the quality related measurement program that uses Evidence Based
Measures were mailed in March 2010. There are no significant changes to that
program. The cost performance assessment is currently underway, and we expect to
mail results in the fall of this year to physicians who practice in one of the fourteen
measured working specialties. This will include the new BlueCompare cost efficiency
These are BlueCompare communications and events target dates:
March 2010 - EBM results mailed
May 2010 - Announcement letter to provider community
July 2010 - Updated BlueCompare quality designations in the online PPO Provider
Fall 2010 - PCA results mailed to those physicians that can be measured
1st Quarter 2011 - New BlueCompare Ribbon (for PCA) in the online PPO Provider
11. How do I formally request a review of my performance designation(s)?
Affected physicians who are dissatisfied with their BlueCompare results have the right
to request a review in writing. In addition to the written fair review reconsideration
process, BCBSTX also provides a fair reconsideration proceeding as described below:
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• When a physician requests a review, BCBSTX will provide a fair reconsideration
proceeding. This proceeding will be conducted by teleconference or in person, at
the physician’s option.
• A physician requesting a review has the right to provide information, to have a
representative participate, and to submit a written statement at the conclusion of the
• BCBSTX will communicate the outcome of the reconsideration proceeding in
writing, including the specific reason(s) for the final determination.
A detailed explanation of the current EBM review process is on our Web site at
12. Where can I find out more about the new PCA?
For more information, you can visit our Web site:
13. What will happen to the BlueChoice Solutions network?
We have discontinued sales and renewals of the BlueChoice Solutions products and will
end its corresponding BlueChoice Solutions network effective January 1, 2011. Current
BlueChoice Solutions members will continue to utilize this product through the
remainder of 2010. Our broad BlueChoice network and associated products remain in
14. Do I need to do anything about the BlueChoice Solutions network going
There is nothing that you need to do. Existing BlueChoice Solutions members will be
transitioned to another PPO product that uses the BlueChoice network.
15. Where will the BlueChoice Solutions members go?
All of the existing BlueChoice Solutions groups and members will renew and transition
to another PPO product. There will be no active BlueChoice Solutions membership by
16. What are the details about the new product BlueOptions?
Subject to regulatory approval, we will add a new benefit plan called BlueOptions to our
product portfolio. Unlike our BlueChoice Solutions product, BlueOptions will not use its
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own separate network. Instead the BlueOptions product will use all BlueChoice network
providers, and it will include enhanced benefits for members who obtain care, when
possible, from BlueCompare physicians recognized for both quality and cost efficiency.
Here is a basic overview of BlueOptions:
Member Receives Services From: Member Pays:
BlueChoice Physicians who have met established Lowest copayment/coinsurance
standards for both quality and cost efficiency
BlueChoice Physicians and Professional Providers Middle copayment/coinsurance
• do not practice in one of the 14 measured
• do not have enough data for an assessment to
be performed or
• do not meet standards for both quality or cost
Physicians and Professional Providers who are not Highest coinsurance
in the BlueChoice network
17. Do I need to apply to participate in BlueOptions?
There is no need to apply to participate in BlueOptions. All BlueChoice providers will be
considered in-network for BlueOptions. Contract rates for network physicians and
professional providers under BlueOptions will be the same as BlueChoice.
18. How can I find out more details? Who do I talk to if I have additional
Your local Professional Provider Network Representative is here to help. Please visit
www.bcbstx.com/provider/contact_us.htm#localnetwork and contact the appropriate
local office for assistance.
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