2013 Performance Recognition Program

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Blue Care Network of Michigan 2013
Physician Recognition Program

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2013 Performance Recognition Program

  1. 1. 2013 PerformanceRecognition ProgramApril 2013
  2. 2. Blue Care Network HMOSM(commercial)2013 PerformanceRecognition Program (PRP)2
  3. 3. BCN HMO 2013 PRP:Overview• Blue Care Network has redesigned the 2013commercial PRP program, based on industry-wideresearch conducted on plans across the countrythat performed well on HEDIS®* metrics.• The changes to the 2013 recognition program arefocused on outcome-based scores that will directlyalign with HEDIS results.3* HEDIS®is a registered trademark of the National Committee for Quality Assurance.
  4. 4. BCN HMO 2013 PRP:Summary of changes• The budget has been increased.• The pay-as-you-go component was eliminated.• An improvement on the Base PRP component isbeing introduced:Providers who do not meet the BCN plan goal ratefor a measure are eligible for a payment if theyhave improved their quality score by 5 percent ormore from their 2012 final Base PRP score.4
  5. 5. BCN HMO 2013 PRP:Summary of changes(continued)• The Base PRP will be scored and paid on eachindividual quality measure instead of an overallthreshold score.The score for each measure will fall into one of thefollowing categories:– Met Base PRP – Provider achieved the BCN plan goalrate.– Met improvement on Base PRP – Provider did notmeet the plan goal rate but improve on the Base PRPby the percentage needed.– Not met – Provider did not meet the plan goal rate orimprove on the Base PRP by the percentage needed.5
  6. 6. BCN HMO 2013 PRP:Summary of changes(continued)• BCN plan goal rate will need to be met in order to earnthe Base PRP per-service-dollar amount.• Providers who don’t meet plan goal rate may qualifyfor the Improvement on Base PRP component.• All Base PRP and Improvement on Base PRPcomponents will be scored and paid at a practicegroup level.Note: Providers who do not submit claims under apractice group will be scored and paid at theirindividual practitioner level.6
  7. 7. BCN HMO 2013 PRP:Base and Bonusmeasures72013 Base PRP measures:Quality – Preventive ScreeningWell child – 15 monthsChildhood immunizations – Combo 2Cervical cancer screeningBreast cancer screeningColorectal cancer screeningQuality – Disease ManagementDiabetes retinal eye examDiabetes A1C testingDiabetes A1C control ≤9%Diabetes LDL-C testingDiabetes LDL-C control <100 mg/dLCardiovascular disease LDL-C testingCardiovascular disease LDL-C control <100 mg/dLQuality Payout – two opportunities:Payment by measure for meeting plan goalORPayment by measure for improvement of 5% or more2013 PRP Bonus IncentivesCommercial HMO• Appropriate testing for children with pharyngitisMeasurement time frame Jan. 1, 2013 – Nov. 30, 2013$75 per eligible member per service• Appropriate treatment for children with upper respiratoryinfectionMeasurement time frame Jan.1, 2013 – Dec.31, 2013$75 per eligible member per service• Avoidance of antibiotic treatment in adults with acutebronchitisMeasurement time frame Jan.1, 2013 – Dec. 24, 2013$75 per eligible member per service• Follow up care for children with ADHD – initiation phaseJan. 1, 2013 – Dec. 31, 2013$75 per eligible member per service• Chlamydia screeningMeasurement time frame Jan. 1, 2013 - Dec.31, 2013$40 per eligible member per serviceNOTE: Please visit the home page on Health e-BlueSMfor a complete description andfor other information regarding the 2013 Performance Recognition Program.
  8. 8. BCN HMO 2013 PRP:Base PRP paymentchart8Base PRPBase PRP Incentive Measures2013Plan GoalRate$AmountPer ServicePractice group or individual provider achieved the plangoal rate, the payment is:Breast cancer screening 80% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cardiovascular LDL-C control <100mg/dL 70% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cardiovascular LDL-C testing 92% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cervical cancer screening 84% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Childhood immunization - combo 2 89% $250 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Colorectal cancer screening 72% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - A1C control ≤9% 81% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - A1C testing 93% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - LDL-C control <100mg/dL 49% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - LDL-C testing 89% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - retinal eye exam 74% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Well child visits 15 months 84% $150 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
  9. 9. BCN HMO 2013 PRP:Improvement on Base PRPpayment chart9Improvement on Base PRPBase PRP Incentive MeasuresPercentageImproved$AmountPer ServicePractice group or individual provider did not meet plangoal rate, but improved from prior year by theappropriate percentage needed, the payment is:Breast cancer screening 5% $30 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cardiovascular LDL-C control <100mg/dL 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cardiovascular LDL-C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Cervical cancer screening 5% $30 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Childhood immunization - combo 2 5% $150 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Colorectal cancer screening 5% $30 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - A1C control ≤9% 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - A1C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - LDL-C control <100mg/dL 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - LDL-C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Diabetes care - retinal eye exam 5% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)Well child visits 15 months 5% $75 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
  10. 10. BCN HMO 2013 PRP:Practice group scorecardexample10EXAMPLE 2013 Commercial PRP ScorecardPractice group: Internal medical groupBase PRP MeasuresTotalMbrs EligElig MbrsMeetingCriteria2013 BasePRP Score2013 PlanGoal Rate2012 FinalBase PRPscore % improved Payment Type$/ServicemetPaymentEarnedWell Child visit 0 -15 months 5 4 80% 84% 85% -5.9% Not met $0 $0Childhood Imms Combo 2 3 2 67% 89% 62% 7.5% Met improvement $150 $300Cervical Cancer Screening 16 14 88% 84% 80% 9.4% Met Base PRP $50 $700Breast Cancer Screening 15 10 67% 80% 70% -4.8% Not met $0 $0Colorectal Cancer Screening 15 10 67% 72% 60% 11.1% Met improvement $30 $300DiabetesEye exam 8 7 88% 74% 60% 45.8% Met Base PRP $100 $700A1C Testing 8 7 88% 93% 80% 9.4% Met improvement $25 $175A1C Control ≤ 9% 8 5 63% 81% 55% 13.6% Met improvement $40 $200LDL-C 8 6 75% 89% 75% 0.0% Not met $0 $0LDL-C control <100 mg/dl 8 5 63% 49% 50% 25.0% Met Base PRP $100 $500Cardiovascular diseaseLDL-C 10 8 80% 92% 65% 23.1% Met improvement $25 $200LDL-C control <100 mg/dl 10 7 70% 70% 62% 12.9% Met Base PRP $100 $700Payment amount $3,775
  11. 11. Blues Medicare Advantage(BCN AdvantageSMandBCBSM Medicare Plus Blue PPOSM)2013 PerformanceRecognition Program11
  12. 12. Blues Medicare Advantage 2013 PRP:Base and Bonus measures2013 Base PRP Measures:Quality – Preventive ScreeningBreast cancer screeningColorectal cancer screeningQuality – Disease ManagementDiabetes retinal eye examDiabetes HbA1C level ≤9%Diabetes monitoring for nephropathyDiabetes LDL-C level <100 mg/dLDiabetes LDL-C testingCardiovascular disease LDL-C testingQuality Payout -Quality composite score 70-74%: $2.00 PMPMQuality composite score 75-79%: $3.50 PMPMQuality composite score ≥80%: $5.00 PMPM122013 Bonus IncentivesBCNA/MAPPOAnnual monitoring for patients on persistentmedicationsDiabetes treatment (ACE/ARB for hypertension)Glaucoma testingHigh-risk medicationsAdult BMI2013 Pay As You Go IncentivesBCNA/MAPPOAll 8 base PRP measuresScoring and PayoutFall 2013 and spring 2014Payment PAYG $10
  13. 13. Blues Medicare Advantage 2013 PRP:Bonus opportunitiesAdult BMI• Measurement time frame is Jan. 1, 2012 – Dec. 31, 2013.• Provider must be with BCN at time of payment to earn thepayment.• Payment will be made at the practice group level.• Potential reward to be earned = $200Annual monitoring for patients on persistent medications• Measurement timeframe is Jan. 1, 2013 – Dec. 31, 2013.• Provider must be with BCN at time of payment to earn thepayment.• Payment will be made at the practice group level.• Potential reward to be earned = $20013
  14. 14. Blues Medicare Advantage 2013 PRP:Bonus opportunities(continued)Diabetes treatment (ACE/ARB for hypertension)• Measurement time frame is Jan. 1, 2013 – Dec. 31, 2013.• Provider must be with BCN at time of payment to earn thepayment.• Payment will be made at the practice group level.• Potential reward to be earned = $200Glaucoma testing• Measurement time frame is Jan. 1, 2012 – Dec. 31, 2013.• Provider must be with BCN at time of payment to earn thepayment.• Payment will be made at the practice group level.• Potential reward to be earned = $125 - $30014
  15. 15. Blues Medicare Advantage 2013 PRP:Bonus opportunities(continued)High risk medication• Measurement time frame is Jan. 1, 2013 – Dec. 31, 2013.• Provider must be with BCN at time of payment to earn thepayment.• Payment will be made at the practice group level.• Potential reward to be earned = $450NOTE: A complete booklet about the Blues Medicare Advantage 2013 Performance Recognition Programis located on the home pages of BCN’s and BCBSM’s Health e-Blue website.15
  16. 16. Blues Medicare Advantage 2013 PRP:Diagnosis Closure IncentiveplanDiagnosis Closure Incentive highlights:• Measured at the individual physician level.• Primary care physicians with one or more Blues MedicareAdvantage patients with at least one open diagnosis gapidentified by the Blues will receive $100 per patient for closing100 percent of the patient’s diagnosis code gaps.• Suspected or historic conditions not accurately documentedand coded in the current year are diagnosis gaps.• Diagnosis gaps will be identified in the new DiagnosisEvaluation report on Health e-Blue.• Gaps identified by the Blues Jan. 1 through Sep. 30, 2013,are eligible for payment.16
  17. 17. Blues Medicare Advantage 2013 PRP:Diagnosis Closure IncentivePlan (continued)To earn payment for a patient:• All the patient’s gaps must be closed in 2013 and reported to theBlues by Jan. 31, 2014.• The gaps must be closed following a face-to-face visit.• The diagnosed conditions must be addressed at the face-to-facevisit.• Coding and documentation must follow CDC and CMSstandards.• Gaps closed by InovalonTM(vendor) will not count for the provider.NOTE: Step-by-step instructions are located in the Resources section at the bottomof the Health e Blue Homepage – Training MaterialsHealth e-Blue Phase 10.3 Enhancements March 201317
  18. 18. Blue Cross Complete ofMichigan2013 PerformanceRecognition Program18
  19. 19. Blue Cross Complete 2013 PRP:Quality PAYG measures19
  20. 20. Blue Cross Complete 2013 PRP:Quality PAYG measures(continued)20
  21. 21. Blue Cross Complete 2013 PRP:Quality PAYG measures(continued)21NOTE: Blue Cross Complete of Michigan 2013 Performance Recognition Programmaterials are located on Health e-Blue, in the bottom section on the home page.
  22. 22. QUESTIONS?22

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