1. Why is BCBSTX creating the Physician Cost Assessment (PCA) and
   BlueOptions Product?

Continued escalation of health ...
•   Per NCQA PHQ, a confidence interval is used when determining the
        eligibility/qualification.
    •   Episode se...
4. Did BCBSTX have any experts review the EBM and new PCA methodologies?

BCBSTX worked closely with a Physician Advisory ...
(EBM) component of the BlueCompare Physician Designation Program to recognize
and designate physicians who practice in wor...
• When a physician requests a review, BCBSTX will provide a fair reconsideration
    proceeding. This proceeding will be c...
own separate network. Instead the BlueOptions product will use all BlueChoice network
providers, and it will include enhan...
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Why is BCBSTX creating the Physician Cost Assessment (PCA ....doc

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Why is BCBSTX creating the Physician Cost Assessment (PCA ....doc

  1. 1. 1. Why is BCBSTX creating the Physician Cost Assessment (PCA) and BlueOptions Product? 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. Page 1 of 6 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
  2. 2. • Per NCQA PHQ, a confidence interval is used when determining the eligibility/qualification. • 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 specialty. • Create indices that are relative to the working specialty and rating area of the physician. • 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 following? • 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 Assurance (NCQA). • 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 Quality: http://www.ncqa.org/tabid/740/Default.aspx  Ambulatory Care Quality Alliance http://www.aqaalliance.org/performancewg.htm  National Quality Forum http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.as px  Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf Page 2 of 6
  3. 3. 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 specialties: Allergy-Immunology Nephrology 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 measures? 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 Program? 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 Page 3 of 6
  4. 4. (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 bcbstx.com. 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 designation. 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 Finder  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 Finder 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: Page 4 of 6
  5. 5. • 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 reconsideration proceeding. • 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 http://www.bcbstx.com/provider/inquiry_review.htm 12. Where can I find out more about the new PCA? For more information, you can visit our Web site: http://www.bcbstx.com/provider/bluecompare2011.htm 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 tact. 14. Do I need to do anything about the BlueChoice Solutions network going away? 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 1/1/11. 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 Page 5 of 6
  6. 6. 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 performance BlueChoice Physicians and Professional Providers Middle copayment/coinsurance who: • do not practice in one of the 14 measured specialties or • do not have enough data for an assessment to be performed or • do not meet standards for both quality or cost efficiency performance 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 questions? 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. Page 6 of 6

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