The Physician Alliance

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1 The Physician Alliance 2016 Infrastructure Support Distribution Model for Specialty Physicians in the Physician Group Incentive Program How To Achieve Metrics to Maximize Distribution FINAL

2 2016 Infrastructure Support Distribution Model Key enhancements to the 2016 model: Once a year distribution occurring in the fall Distribution dollars are dependent upon our physicians level of participation in coordination of care and in implementing Physician Group Incentive Program (PGIP) Patient Centered Medical Home Neighborhood (PCMH_N) processes: Improving PCMH-N standing Increasing the number of PCMH-N capabilities in each practice Increasing the number of PCMH-N capabilities in coordination of care and specialty referral domains of function Improvement in quality scores and reducing costs Actively participate in the BCBSM Specialist Value-Based Reimbursement (formally called Specialty Fee Uplift) by improving population quality scores and reducing costs.

3 Model Supports Your Success in Being a Preferred Specialist in the PCMH-Neighborhood PCMH-N capabilities positions practices for Health Care Reform Specialist with more PCMH-N capabilities in place will more likely be invited to join narrow networks and received BCBSM Value-Based Reimbursement (VBR) recognition With VBR uplift (formally Specialty Fee Uplift) specialist received 5% - 10% on BCBSM RVU billing VBR rewards specialist for collaborating with their community of caregivers to optimize use, efficiency and quality in their shared populations Improve tracking and transparency of quality scores Practices with improved care coordination and specialist referral processes are preferred partners in the PCMH-neighborhood Promotes population health strategies for all payers

4 Practice Resource Team Key to your success is your engagement with your Practice Resource Team member! Your Practice Resource Team member: Assists in completing the PCMH self assessment validation surveys twice a year (mandatory) Failure to complete the two self assessment validation surveys results in no payment Reviews quality performance reports (mandatory) Failure to identify a physician champion and meet at least biannually to review performance opportunities results in no payment

5 Practice Resource Team - continued Assesses practice engagement Identifies opportunities to implement additional PCMH-N capabilities Identifies quality metrics that apply to your specialty type and assist in developing processes to improve performance Shares best practice processes Provides many tools/resources/education

6 2016 Infrastructure Support Distribution PCMH-N capabilities do not readily apply to all specialty types such as anesthesiology, hospitalist, neonatology, pathology, radiation oncology, radiology, etc. Opportunity within the 2016 Infrastructure Support Distribution model may be limited for these specialty types. The above specialty types have their incentive opportunity in the BCBSM Value-Based Reimbursement initiative with a 5% - 10% uplift on BCBSM RVU billing. The distribution occurs once a year in the Fall of 2016 (October November*) *Payment timing varies slightly based on complexity of data and deliverables by BCBSM.

7 Specialty Practices Infrastructure Support Distribution Model Patient Centered Medical Home Neighborhood Score Weighted 100% of incentive distribution There are four incentive distribution levels by practice: 1. Basic 2. Intermediate 3. Advanced 4. Best Practice

8 PCMH- N Score Calculation There are five data points that are included in the score: 1. Number of validated PCMH-N capabilities 2. Number of PCMH-N capabilities in #13 Care Coordination Domain of Function 3. Number of PCMH-N capabilities in #14 Specialist Referral Domain of Function 4. Receiving Value-Based Reimbursement recognition (formally Specialty Fee Uplift) 5. Building new PCMH capabilities over time

9 1. Number of PCMH Capabilities There are four incentive distribution levels by practice: 1. Basic - < 22 capabilities 2. Intermediate - > 23 - < 41 capabilities 3. Advanced - > 42 - < 70 capabilities 4. Best Practice - > 71 capabilities *Payment is based on the PRT member visiting the practice to validate the number of PCMH-N capabilities with the biannual survey process. Payment level is based on the count of capabilities reporting on the Summer 2016 PCMH-N self-assessment validation survey.

10 2. Number of Capabilities in Coordination of Care There are four incentive distribution levels by practice: 1. Basic 2. Intermediate 3. Advance 4. Best Practice

11 Number of Capabilities in Coordination of Care - cont 1. Basic At least one capability must be in place in this domain 2. Intermediate Two to three capabilities must be in place in this domain 3. Advanced At least 4 capabilities must be in place in this domain plus one of those capabilities must be capability Best Practice Great than or equal to 5 capabilities must be in place in this domain plus must have both capability 13.5 plus capability 13.7 in place *Payment is based on the PRT member visiting the practice to validate the number of PCMH-N capabilities with the biannual survey process. Payment level is based on the count of coordination of care capabilities reporting on the Summer 2016 PCMH-N selfassessment validation survey.

12 3. Number of Capabilities in Specialist Referral Domain 1. Basic At least one capability must be in place in this domain 2. Intermediate Two to three capabilities must be in place in this domain 3. Advanced At least 4 capabilities must be in place in this domain plus one of those capabilities must be capability Best Practice Great than or equal to 5 capabilities must be in place in this domain plus must have both capability 14.1 plus capability 14.7 in place *Payment is based on the PRT member visiting the practice to validate the number of PCMH-N capabilities with the biannual survey process. Payment level is based on the count of coordination of care capabilities reporting on the Summer 2016 PCMH-N self-assessment validation survey.

13 Specialist Valued-Based Reimbursement Specialist are recognized once a year (March 2016) with a VBR status PO nominate specialist yearly for VBR and BCBSM determines status by using three metrics: Per member per month (PMPM) costs per specialty type Global Quality Index Score 32 HEDIS measures and 3 PQRS measures at the population level Cost difference calculation There are four incentive distribution levels by practice: 1. Basic no VBR status in Intermediate, Advanced & Best Practice physicians in the practice have VBR status in 2016

14 5. Building New PCMH Capabilities Over Time There are four incentive distribution levels by practice: 1. Basic no new capabilities in place 2. Intermediate one new capabilities in place 3. Advanced 2 new capabilities in place 4. Best Practice - > 3 new capabilities in place *Payment level is based on the PRT member visiting the practice to validate the number of PCMH capabilities with the biannual survey process. For the fall 2016 payment, calculation is based on a comparison of the Summer 2015 survey count to the Summer 2016 survey count to determine the number of new capabilities.

15 PCMH-N Score Data Points Criteria BASIC INTERMEDIAT E ADVANCED BEST PRACTICE # of PCMH Capabilities < 22 > 23 and < 41 > 42 and < 70 > 71 # of Capabilities in Coordination of Care Domain #13 # of Capabilities in Specialist Referral Domain #14 Has BCBSM Specialist Valued Based Reimbursement Recognition Building PCMH Capabilities Over Time (Summer 2015 compared to Summer 2016) 1 capability in place 1 capability in place 2 or 3 capabilities in place 2 or 3 capabilities in place 4 capabilities in place plus 13.5 must be in place 4 capabilities in place plus 14.7 must be in place > 5 capabilities in place plus 13.5 and 13.7 must be in place > 5 capabilities in place plus 14.1 and 14.7 must be in place No Yes Yes Yes No new caps in place 1 new capability in place 2 new capabilities in place > 3 new capabilities in place For Basic: 3 of the 5 metrics must be in basic. For Intermediate: must have 3 of 5 metrics in place to remain in Intermediate rating. If less than 3, then the practice will move back to Basic. If has scoring in a category higher than intermediate such as advanced for a metrics, that metrics can be used to reach the 3rd metrics for an intermediate score. For Advanced: must have 3 of 5 metrics with one of the metrics being the # of capabilities within Coordination of Care Domain in place to remain in Advanced. If not, then the practice will move back to Intermediate. If has scoring in a category higher than advanced such as Best Practice for a metrics, that metrics can be used to reach the 3rd metrics for an Advanced score. For Best Practice: must 4 of 5 metrics in place. Additional requirements for this rating are: met the # of PCMH-N capabilities and the # of capabilities in Coordination of Care, and two of the other three to remain in Best Practice rating. If not met, then the practice will move back to Advanced.

16 Physician Group Incentive Program 1. Meet with your Practice Resource Team (PRT) member at least quarterly. 4. Focus on metrics that have the biggest opportunity for improving quality overall scores. 2. Use your electronic registries at the point of care and perform patient outreach to improve quality. 5. Complete a practice PCMH-N self assessment validation survey twice a year with PRT member. 6. Develop a plan to continue to implement at least 3 new PCMH capabilities yearly and maintain current capabilities. 7. Work with PRT to assure yearly nomination for Specialist Valued-Based Reimbursement. 3. Identify a physician champion to review performance reports at least biannually to identify opportunities for improvement. 8. Focus on coordination of care and specialist referral processes. Send key quality data to primary care physicians to improve quality reporting.

17 Physician Group Incentive Program Expectations for Specialist Complete a self assessment validation survey twice a year Maintain capabilities that are reported in place and implement at least 2 new capabilities every 6 months Work towards Valued-Based Reimbursement nomination Meet with your PRT member at least quarterly Review performance reports, identify opportunities and develop process improvement plans Attend educational sessions Review practice data on TPA secure physician portal

18 Incentive Model Resources Contact your Practice Resource Team member at Or Contact The Physician Alliance at We want you to be successful!