Blue Cross Blue Shield of Michigan

Transcription

1 Blue Cross Blue Shield of Michigan Provider Delivered Care Management Program Thomas Simmer, MD Sr. Vice President and Chief Medical Officer January 18, 2013

2 PGIP: Catalyzing Health System Transformation in Partnership with Providers Physician Group Incentive Program Chronic Care Model Partner with Physician Organizations to create high-performance healthcare system Build registry and reporting capabilities to manage populations of patients Transform payment for medical services to support and maintain a highperformance system PCMH Primary care transformation Implement the Patient Centered Medical Home Practice Model Create a payment model that aligns payment with PCMH designation and performance Reward population management success for all services, not just the services delivered by the practice unit OSCs Organized Systems of Care Support creation of systems of care that are accountable for services rendered to a defined population of patients across all locations of care Expand PGIP to include specialists involved in chronic care Implement PCMH and Specialtybased CQIs Tier PCP payments based on population measures Add new specialties to PGIP Tier Specialist payments based on population measures 2 2

3 2 Year PDCM Pilot Paved Way for Expansion of PDCM Health Plan and Provider Delivered Care Management Most health plans offer telephonic care management to coordinate care and support patients in carrying out the physician s care plan. Some health plans have begun to embed their care managers in clinical practice sites. BCBSM uses a different model Provider Delivered Care Management (PDCM)---where care managers are employed by the practice or physician organization and are paid fee-for-service. On April 1, 2012, BCBSM began paying for PDCM service for 1,500 physicians in 400 practice as part of the Michigan Primary Care Transformation (MiPCT) program under a federal grant awarded to the Michigan Department of Community Health (MDCH). In 2013, the same services will become payable to oncology practices for eligible BCBSM members 3

4 Practice sites* participating in Michigan Primary Care Transformation Demonstration (MiPCT) as of September 2012 *sites with identical zip codes appear as one star (196 unique zip codes) 4

5 Provider Delivered Care Management The care manager is generally a registered nurse with additional training in care coordination, motivational interviewing, and supported by care management software. The care manager is a practitioner with a schedule, patient care space, after-hours communication support, electronic connectivity. Pro-active support of care manager productivity and billing is critical. This includes active patient outreach. Billed services must meet service descriptions and BCBSM coding guidelines, just as other billable services. 5

6 The Process for PDCM Practices receive a monthly list of patients eligible for PDCM with risk scores, utilization history and other relevant information. Services rendered to non-eligible patients are rejected with no patient financial responsibility. Care managers can refer patients to pharmacists, diabetes educators, nutritionists, and social workers. These practitioners can also bill for services for eligible patients. BlueHealthConnection and PDCM care managers communicate and coordinate to avoid duplication of services. BlueHealthConnection nurses are available to consider payment for extra-contractual benefits for PDCM patients. 6

7 Current Care Management Codes & Fees Code Fee G9001 $ Coordinated Care Assessment (limited to one per year per pt) G9002 $59.10 Coordinated Care Fee, maintenance rate $14.77 Group Visits: face-to-face with the patient, each 30 minutes; 2-4 patients $10.98 Group Visits: face-to-face with the patient, each 30 minutes; 5-8 patients $15.16 Phone: 5-10 minutes of medical discussion $29.18 Phone: minutes of medical discussion $43.19 Phone: minutes of medical discussion 7

8 Additional Care Management Codes The following care management codes will be payable for PDCM services effective 4/1/2013: Code Fee G9007 TBD Coordinated care fee, scheduled team conference G9008 TBD Physician coordinated care oversight services TBD Complex Chronic Care services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face to face visit, per calendar month TBD Complex Chronic Care services; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month 8

9 Key considerations Many BCBSM customers have not added PDCM services to their benefits so checking program eligibility is crucial. PDCM needs to evolve and improve to contribute to the broader goal to create a high performance healthcare system. Ongoing communication/interaction between physicians and care managers; and among oncology and PCP care managers and practices will be essential. BCBSM looks forward to collaborating with Oncologists to support a more effective and satisfying care model that increases the financial success of practices and achieves better outcomes for patients. 9