Physician Group Incentive Program (PGIP) Frequently Asked Questions

Transcription

1 Physician Group Incentive Program (PGIP) Frequently Asked Questions The PGIP FAQ document is a living document, which is owned and maintained by BCBSM s Value Partnerships department. It represents a point-in-time snapshot of the PGIP program. Please be aware that the program is continually evolving, and as such, the PGIP FAQ document is updated on a continual basis. Individual questions and answers from this document may be shared externally as appropriate, but this document in its entirety SHOULD NOT be shared with non-pgip affiliated, external parties. 1 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

2 Physician Group Incentive Program (PGIP) Frequently Asked Questions Table of Contents Click on the question topics listed below to access that particular section of the PGIP FAQ document. Table of Contents Physician Group Incentive Program (PGIP) Overview... 5 PGIP Participation... 7 PGIP Funding and Reward Pool... 9 PGIP Organization and Oversight Patient-Centered Medical Home (PCMH) Overview PCMH Participation and Designation PCMH Reimbursement Procedures Organized Systems of Care (OSC) Overview OSCs and Reimbursement OSCs in Relation to PGIP and PCMH OSC Participation PO Recruitment Information Provider Delivered Care Management (PDCM) Specialist Participation and Specialist Uplifts

3 Value Partnerships What is Value Partnerships? Value Partnerships is a collection of clinically oriented initiatives that are significantly improving the quality of patient care throughout the state of Michigan. Through these initiatives, BCBSM is partnering with Michigan physicians, physician organizations, and hospitals to create an innovative and quality-based approach to reward the transformation of health care. Through collaboration and data sharing, these initiatives are: Enhancing clinical quality Decreasing complications Managing costs Eliminating errors Improving health outcomes. Value Partnerships is significantly improving the quality of patient care across Michigan and is impacting the lives of nearly two million Blues members, as well as the quality of care for all Michigan residents. Through the Value Partnerships program, BCBSM works collaboratively with the majority of the acute-care hospitals in the state and with nearly 15,500 primary care physicians and specialists to improve the health care provided to all Michigan residents. What programs comprise Value Partnerships? Value Partnerships includes the Physician Group Incentive Program (PGIP), which is comprised of 34 initiatives aimed at capability building, improving quality of care delivery, and appropriate utilization of services. PGIP initiatives are divided the following categories: Condition-Focused Service-Focused Core-Clinical Process-Focused Clinical Information Technology-Focused. Value Partnerships also encompasses the Patient-Centered Medical Home (PCMH) Designation Program, which is the largest of its kind in the country. The PCMH Designation Program has experienced steady growth, measureable results, and regional and national recognition. The number of designated PCMH physicians has grown from 1,200 in 2009 to more than 2,500 physicians in 776 practices in In addition to PCMH, Value Partnerships also includes Organized Systems of Care (OSC) and Provider-Delivered Care Management (PDCM). PGIP, PCMH, and OSC focus on incentivizing the provider community to achieve improved quality and lower cost through collaborative sharing of data and initiatives such as use of registries and alert systems to become prepared proactive practice teams. Additionally, Value Partnerships includes Hospital and Professional Collaborative Quality Initiatives (CQIs). The driving factor in framing a CQI as hospital-based or professional revolves around where the service(s) being addressed by the CQI are rendered. CQIs address some of the most common, costly areas of surgical and medical care through collaboration between Michigan providers and hospitals. Participating hospitals and providers collect, share, and analyze data through the use of clinical registries, then design and implement changes to improve outcomes associated with complex, technical areas of care. CQI registries permit a more robust analysis of the link between processes and outcomes than can be achieved by examining one group or institution. As of 2012, BCBSM is providing funding and active leadership for twelve hospital CQIs and six professional CQIs. 3

4 Value Partnerships also includes BCBSM s ongoing collaborative relationships with the Center for Healthcare Research and Transformation (CHRT), the Michigan Quality Improvement Consortium (MQIC) and the MHA Keystone Center for Patient Safety and Quality. What is the philosophy of Value Partnerships? Below are the tenets of BCBSM s Value Partnerships program: Focus on investments in transformation of care processes, rather than just top of mind behavior Recognize and reward performance of hospitals and physician organizations Reward improvement, not just highest performance to create meaningful incentives for all Focus on population-based cost measures, rather than per-episode cost to avoid micromanagement of care by the insurer and to foster development of effective systems of care which meet patients needs in an efficient manner Design and execute programs in a customized and collaborative manner rather than "one size fits all" How is BCBCSM s Value Partnerships program addressing the shrinking primary care workforce? BCBSM is helping to strengthen and transform primary care by empowering primary care physicians (PCPs) to effect change in Michigan through the Physician Group Incentive Program (PGIP). In 2005, PGIP began its health care transformation journey with a primary focus on stabilizing, strengthening, and transforming primary care in Michigan. At that time, PGIP participation was restricted to MDs or DOs who were PCPs or who were on a list of select specialties which frequently collaborate with PCPs in caring for patients with common chronic conditions. Though PGIP s scope has since broadened to include all physician specialties, the transformation of primary care remains a main focus of the program. PGIP PCPs collaborate on initiatives designed to improve and transform the health care system in the state. Each initiative offers financial incentives based on clearly defined performance improvement and program participation metrics. BCBSM s efforts to strengthen Michigan s primary care foundation are guided by the Patient-Centered Medical Home (PCMH) model. BCBSM s PCMH program is the largest of its kind in the nation. In 2011, over 2,500 PCPs in 776 Michigan practices were designated by BCBSM as patient-centered medical homes (more than double the number that were designated in 2009). The PCMH model, as embodied by BCBSM s PCMH-designated practices, has the potential to result in improved patient flow, better teamwork within primary care practices, more time with patients, higher job satisfaction for physicians and higher patient satisfaction. PGIP providers play an integral role in the development of the program and initiatives; all of our PGIP initiatives are co-developed with participating physicians throughout the state, who are empowered to have a voice in the transformation process that BCBSM is facilitating through PGIP. For nearly five years, we have been working collaboratively with the PGIP Primary Care Leadership Committee (PCLC), which provides advice and counsel on the planning, design, implementation and modification of PGIP and PGIPrelated initiatives. The PCLC also helps to define the future direction of the program. The PCLC is comprised of physician, nursing, and administrative leaders of PGIP physician organizations (POs), as well as individual PGIP physicians. PCLC members do not specifically represent their member POs but serve as overall representatives of the PGIP community. BCBSM is finding that by making primary care physicians the focal point of PGIP s health care transformation efforts within the state, and by empowering PCPs to play a key role in the development of PGIP and PGIP initiatives, PCPs are reaping financial benefits and gaining more leverage to discuss key issues such as resource utilization, the role and expectations of specialists, and care management at the individual and population level. Through PGIP, PCPs are empowered to transform their practices, establish multi-disciplinary teams and focus their energies on relationship-based care in ways which are energizing and fulfilling. 4

5 Physician Group Incentive Program (PGIP) Overview What is PGIP? BCBSM s Physician Group Incentive Program (PGIP) part of BCBSM s overarching Value Partnerships Program is an innovative incentive program that brings together physician organizations (POs) from across Michigan to encourage information-sharing about various aspects of health care. This approach supports and rewards system transformation and population level management. The program catalyzes physicians to work collaboratively with their POs to more effectively manage populations of patients and build an infrastructure to more robustly measure and monitor care quality. Program participants, including both primary care physicians and specialists, collaborate on more than 30 initiatives designed to improve the health care system in the state. Each initiative offers incentives based on clearly defined metrics to measure performance improvement and program participation. PGIP in its entirety is aimed at empowering the provider community to transform the Michigan health care system, guided by the Patient-Centered Medical Home model, in ways which allow it to better serve the whole population from a cost, quality, and experience of care perspective. Why and when did PGIP start? PGIP began in 2005 as a result of conversations between BCBSM and the Michigan State Medical Society. PGIP s collaboratively established goals are to: Transform systems of care to more effectively manage populations of patients and build the infrastructure needed to more robustly measure, monitor, and optimize quality of care Strengthen the performance improvement infrastructure available to clinicians Promote collaborative relationships with physicians, and among physician organizations, that support improved care outcomes Achieve measurable savings in specified areas including (but not limited to) pharmacy costs, diagnostic imaging and other domains of resource use Reward physicians for their improved performance and adoption of best practices in the cost-effective delivery of care while optimizing patient health outcomes What BCBSM products are in PGIP? Physicians who have PPO/TRUST and Traditional contracts are currently eligible to participate in PGIP. How do I find out more information about PGIP? The BCBSM website ( contains detailed information about PGIP. Once you are on the BCBSM website, go to the Provider area and click on Value Partnerships on the left-hand side. Then, click on the Physician Group Incentive Program (PGIP) link. Included on the website are descriptions of initiatives and program contact information. Additionally, your BCBSM Provider Consultant can provide you with PGIP information. In addition to the BCBSM website, you can also visit and click on the Physician Initiatives tab to find more information on PGIP. For further information, please review the BCBSM.com PGIP website, which can be found at Does BCBSM endorse and/or mandate the use of certain vendors for participating PGIP POs and their physicians? BCBSM s position is that the right place for discussions about particular vendors and vendor tools/offerings is with the POs, not the payer. Our programs at BCBSM place the responsibility on the provider community to establish care management systems and shared decision making approaches rather than to insert the health plan in these processes. Since PGIP catalyzes all payer system development, not payer-specific system development, and because different POs have different approaches to promoting self 5

6 management and implementing care management efforts, BCBSM leaves decisions about which tools to incorporate into PO processes up to the POs themselves. Another reason PGIP does not promote particular tool sets is because any pronouncement on our part becomes a tacit endorsement, which some POs may take to mean as an expectation that they should use that particular tool set. This is particularly a concern when the vendor is also a PGIP physician organization. Does PGIP only impact individuals who are BCBSM/BCN members? BCBSM s Physician Group Incentive Program encourages all payer collaboration, catalyzing all payer system development, rather than payer-specific system development. Through PGIP, BCBSM is helping to improve the quality of care for all Michigan residents. Patients throughout the state, regardless of payer, benefit from the improved care processes developed through the PGIP provider community. Developing systems of care which are used for all patients helps assure that providers don't have to alter care processes based on whether patients have insurance, or which insurance they have. This is an important factor in ensuring that the best practices and care processes are reliably provided to all patients, all of the time. This all-payer approach to practice transformation is good for patients with coverage from BCBSM and BCN and helps further BCBSM s social mission of cultivating a healthier future for all Michigan residents. How is PGIP affecting health care costs? PGIP is helping to reduce health care benefit costs. This is commonly known as Bending the Curve, a strategy being used by BCBSM to focus on reducing the growth of health care spending, while also improving quality. It is our belief that by working collaboratively with Michigan s physician and hospital community, we can address the process issues that currently prevent patients from consistently getting the best quality care at the lowest cost. Through PGIP, BCBSM is able to better contain rising health care costs while improving overall quality delivered to members and all other Michigan residents. What awards has BCBSM received in recognition of the Physician Group Incentive Program? BCBSM has received numerous awards for PGIP since its inception in 2005, including multiple Best of Blue Clinical Distinction Awards from the Blue Cross Blue Shield Association (BCBSA) for best practices that focus on reducing medical costs while improving quality, affordability and patient safety. Best of Blue Clinical Distinction Awards are bestowed by BCBSA through the annual BlueWorks Awards program, which ultimately recognizes the single Blue Cross and/or Blue Shield company that best demonstrates taking a leadership role in transforming the quality, affordability, and delivery of care. BlueWorks entries are reviewed by the Harvard Medical School Department of Health Care Policy and independent judges from key medical societies for their innovation, scope, approach and impact on healthcare delivery in Blue companies' local markets. By promoting evidence-based solutions to relevant challenges, the BlueWorks Awards are designed to benefit the entire Blue System and the overall health care system. BCBSM has received Best of Blue awards for PGIP, the Patient-Centered Medical Home (PCMH), and various hospital-based Collaborative Quality Initiatives (CQIs) part of BCBSM s Value Partnerships program. In 2011, BCBSM received three Best of Blue Awards: two were awarded for CQIs (the Michigan Surgical Quality Collaborative (MSQC) and the Michigan Bariatric Surgery Collaborative (MBSC)), and one was awarded for a particular PGIP initiative the Michigan Oncology Quality Consortium (MOQC). Additionally, BCBSA, in collaboration with the Harvard Medical School Department of Health Care Policy, also awarded its most prestigious award the BlueWorks Award to BCBSM in The prestigious BlueWorks Award is given annually by the Blue Cross Blue Shield Association to the top program chosen from the Best of Blue Clinical Distinction Award winners. 6

7 In 2011, BCBSM was recognized with an unprecedented two BlueWorks Awards for its efforts to improve the quality of surgical care in the state of Michigan through the MSQC and MBSC. Of the 48 entries submitted by Blue Cross and Blue Shield companies nationwide, BCBSM s MSQC and MBSC programs were named the best of the best marks the second consecutive year that BCBSM has won this highly regarded award; in 2010, BCBSM was recognized with this award for the development and launch of the Patient-Centered Medical Home. PGIP Participation How do I participate in PGIP? Physicians, both primary care and specialists, participate in PGIP through a PGIP Physician Organization. There are currently 40 POs in PGIP and they are located across the state. The list of POs is available on the PGIP website at Additionally, your BCBSM Provider Consultant is familiar with PGIP POs in your area. You may contact them for information. Physicians are limited to participation in one physician organization for the program. That is, while physicians can be affiliated with more than one physician organization, they can only be associated with one for purposes of PGIP. While specialists may only participate in one PO for PGIP purposes, specialist practices may partner with more than one Organized System of Care (OSC). Physicians must be actively participating in the BCBSM PPO/TRUST or the Traditional lines of business, be in good standing with the network, and be a Medical Doctor (MD), Doctor of Osteopathy (DO), Doctor of Chiropractic (DC), or Doctor of Podiatric Medicine (DPM) in order to be eligible to participate in PGIP. This includes all physician specialties, except anesthesiology (some anesthesiologists will be eligible based on the services provided and billed.) Prior to program year 2011, PGIP was restricted to MDs or DOs whose profiling or primary specialties were on a list of PGIP Defined Specialties. Effective with program year 2011, the roster of available PGIP initiatives was robust enough to support bringing in all specialties; however, mid-level providers such as nurses, physician assistants, therapists, etc. are not eligible to participate in PGIP. Psychologists will be eligible to join PGIP in early Why doesn t BCBSM work directly with physicians like other incentive programs? To create highly functioning systems of care that reliably produce high quality, efficient care, physicians need to work with Physician Organizations that have sufficient structure and technical expertise to support the development of shared information systems and shared processes of care. Exhorting individual physicians to improve the quality and efficiency of their practice is unlikely to succeed. Individual physicians are currently challenged to find enough time in the day to do all that needs to be done in caring for patients; they rarely have the time and resources to, on their own, engage in practice transformation activities. Physician Organizations can leverage economies of scale and establish the infrastructure and processes to assist individual physicians and physician practices in managing costs while improving care delivery for patient populations, so that the burden of practice transformation does not fall on physicians individually. How is a physician organization selected to be in PGIP? POs must apply to participate in PGIP. The 2012 application period is July 1 to August 31, Please [email protected] to receive an application packet. The major events in accepting a PO into PGIP are provided below: June 2012 Announcements published in The Record and Physician Update inviting POs to apply. July to August 2012 Inquiries/Application materials accepted through Aug. 31, September 2012 Application materials reviewed by PGIP. Field Operations staff conduct initial site visit. October 2012 List of new POs finalized; accepted POs formally invited to join PGIP. NOTE: The PGIP Agreement for a new PO is not effective until the January 1 st of the following year. New POs 7

8 November 2012 December 2012 January 2013 February 2013 April 2013 July 2013 are not eligible to receive payments until their PGIP Agreement is in force. New POs receive Self-Reported Data Tool for completion; Field Operations staff conducts return visit(s) and orient PO to PGIP. New POs are formally invited to attend first PGIP quarterly meeting and select their initiatives for 2013 program year (01/01/ /31/2013). New PO s PGIP Agreement begins. New PO s providers are included in the PGIP physician list. PGIP data distribution (monthly claims feeds, datasets, etc.) begins New POs eligible to receive first PGIP reward payment. NOTE: BCBSM reserves the right to determine when the PO will be eligible to begin receiving incentive payments. The PGIP Application Overview document provides more details about the PGIP PO application process and can be accessed at How do I join a PO for PGIP? Each PO has its own criteria for working with physicians and having them join their organization. For instance, some POs may require physicians to sign with multiple health plans to be part of the PO. Furthermore, POs may have additional requirements for membership that go above and beyond what BCBSM requires. You would need to contact the PO directly to discuss their criteria. You can contact your Provider Consultant for a list of PGIP POs in your area. However, there are some general requirements that physicians must meet in order to join a PGIP PO. Physicians must: Participate with BCBSM s TRUST PPO or Traditional lines of business and be in good standing with the network/company Choose to voluntarily participate with only one physician organization for the purposes of the incentive program Choose to voluntarily participate with only one practice unit that is in turn affiliated with only one physician organization for the purposes of the incentive program Be committed to working on improving health care and outcomes for your attributed patients Agree to implement process changes using an all-payer approach (i.e. the care provided to the patients is the same despite the payer) Is there a cost associated with joining a PO? If so, what does this money go toward? It is common practice for a PO to charge a membership fee. POs do so when they have staff members who provide substantial services. For example, some POs provide their physicians access to discounted malpractice insurance, group negotiated rates with HMOs, technical support for patient and provider portals, e-rx implementation, and other technical infrastructure support. Additionally, there are costs associated with joining a physician organization. These costs relate to the organization s ability to adequately support physicians practice needs in a changing environment, as well as the need to modernize. Charging annual fees enables POs to not only support their physicians needs, but also remain competitive from a business perspective. A physician may choose to remain entirely independent and not join a group, but over time, this will marginalize the physician s practice, as it will be less likely to be included in a health plan network and less likely to be eligible for reimbursement rate increases. Changes in the environment are substantial and business as usual (or as previously carried out) is no longer an option. In the current environment, the focus is not on getting higher fees without contributing, but is instead on pooling resources to improve systems of care among communities of caregivers in service to communities. 8

9 Is there a PGIP physician organization in the Upper Peninsula (UP)? Yes, the Upper Peninsula Health Plan (UPHP) is currently the PGIP PO in the UP. Contact your BCBSM Provider Consultant for contact information regarding UPHP. PGIP Funding and Reward Pool How do I receive incentive rewards? Twice a year, BCBSM distributes incentive dollars from the PGIP Reward Pool to the POs. The PO s payment is dependent upon performance improvement and accomplishing goals that the PO has agreed to work on with their PGIP physicians for any given year. Each PO determines how they will distribute incentive dollars to their member PGIP physicians. Primary care physicians participating in PGIP can also work to become a BCBSM designated patient-centered medical home provider, which makes them eligible to receive additional reimbursement for select evaluation and management (E & M) services. See below for additional information regarding codes for PCMH designation. Additionally, physicians participating in PGIP are eligible to bill for T-codes, which are specific procedure codes delivered by ancillary providers for care management services incident to a physician s E & M services. T Code services apply to the individual care management and/or self management training of a patient with any chronic condition of sufficient complexity that warrants additional management beyond the guidance typically provided in a standard E & M visit. The ancillary provider carries out the service and the physician or physician group bills for the service. This model rewards PGIP physician groups and their community of caregivers for their investment in building the infrastructure to support efficient chronic disease management. As of April 1, 2012, physicians participating in the MiPCT Demonstration/Provider Delivered Care Management Program will be eligible to bill G-codes for care management services, rather than T-codes. However, PGIP practices that are not participating in MiPCT may continue to bill T-codes. The following ancillary provider types are acceptable disciplines to provide T Code Services: Licensed nurses (registered nurses and licensed practical nurses) Masters of social work Certified diabetes educators Registered dietitians or masters of science trained nutritionists Clinical pharmacists Respiratory therapists Certified asthma educators Certified health educator specialists (bachelor s degree or higher in health education) Licensed professional counselors and licensed mental health counselors Certified nurse practitioners or physician assistants (services by a CNP or PA may not include clinical decision making such as ordering tests, prescribing medications, or making diagnoses) How do PGIP POs use their incentive dollars? It is left to the discretion of each PO how to best utilize the incentive reward dollars that are received through PGIP; each PO determines how they will distribute incentive dollars to their member PGIP physicians. POs can use their incentive dollars to support the building of infrastructure and/or infrastructure support (such as buying particular clinical tools or information systems). POs can also use their incentive dollars to meet clinical information needs among their providers, among many other uses. These incentive dollars are intended to be used by each PO to further PGIP s goals of improving health care quality and transforming health care value. 9

10 Should physicians both specialists and PCPs view PGIP as merely a means to receive financial rewards? No, physician opportunities to participate in PGIP are in the areas of clinical integration with other physicians (PCPs and other specialists) and contributing to population level performance improvement on cost and quality measures. For physicians, the main opportunity regarding clinically integrating with other physicians is the development and implementation of structured approaches to referrals and information sharing between PCPs and specialists regarding patients that they share in common. The specifics of the granular capabilities inherent in a robust specialist referral system are included in the relevant domain of the PCMH Interpretive Guidelines. Regarding population level performance, PCP attributed populations for PGIP Physician Organizations are measured on overall cost and cost increase trends. When specialists provide care to members in such PCP attributed populations with low absolute cost and/or costs which rise at a notably slower rate than elsewhere, BCBSM rewards those specialists in future office visit payments by increasing fees. There is no pre-determined opportunity to earn rewards just by joining a PGIP Physician Organization. On my voucher it says Physician Organization Component. What does this mean? This represents the PGIP Physician Organization Component, which is currently 4.7% (as of July 1, 2012). The PGIP PO Component is used to fund the Physician Group Incentive Program. In 2004, the BCBSM Board of Directors approved the Physician Group Incentive Program with the understanding that the Board would not support an overall fee increase for physicians unless a PGIP Reward Pool and accompanying Physician Organization Component was created to support an incentive program to engage physicians, via Physicians Organizations, in healthcare quality and value transformation. To fund the PGIP Reward Pool, BCBSM commits an amount of money equivalent to a set proportion of total professional payment each year through the PGIP Physician Organization Component (formerly referred to as the Contribution to Reward Pool ).The professional fee schedule is the administrative mechanism used by BCBSM to determine the PGIP PO Component amount, and ultimately the annual PGIP Reward Pool amount. Most professional fees contain two Components a Physician Component and a PGIP Physician Organization Component. The Physician Component honors BCBSM s Approved Amount reimbursement commitment to individual physicians. The PGIP PO Component is a percentage of the Allowed Amount for most professional services. The PGIP PO Component percentage increases are approved annually by the BCBSM Chief Medical Officer, and have increased by approximately 0.5% each year. See below for an example of a standard reimbursement voucher with the PO Component included. A sample calculation for a specific procedure code (86580) is also included below the voucher. Example: Standard Reimbursement (w/ PO Component) - Calculation for Procedure Code 86580)* 10

11 Calculation Charged Amount $17.00 Allowed Amount $10.72 Copay $0.00 Benefit Cost to ASC Group Customer (Allowed Amount minus Copay) $10.72 PO Component (4.2% of Allowed Amount) $0.45 Approved to Pay Provider $10.27 *This voucher and calculation will be replaced with an updated version (reflecting the increased PGIP PO Component of 4.7%) when available. Are the PGIP incentives for primary care physicians being funded by drawing money from specialists? Alternatively, are PGIP specialty incentives drawing from primary care physician incentives? There are not two separate PGIP reward pools for primary care and specialists. Rather, there is one PGIP Reward Pool which is intended to fund practice level transformation for both PCPs and specialists. This combined reward pool provides reward opportunities for PCPs and specialists alike. I am a physician in the Upper Peninsula and previously did not have a PGIP Physician Organization Component as part of my fee. When did that change? Effective 10/1/09, the PGIP Physician Organization Component became a part of your fee; this was reflected on your vouchers. I am a physician who bills the BCBSM Traditional line of business only and previously did not have a PGIP Physician Organization Component as part of my fee. When did that change? Effective 10/1/09, the PGIP Physician Organization Component became a part of your fee; this was reflected on your vouchers. Is the PGIP PO Component applied to professional claims for BlueCard members? The PGIP PO Component is applied to BlueCard Host claims (claims received by BCBSM from Michigan providers for members of another, out-of-state Blue Cross Blue Shield plan). However, the PGIP PO Component is not applied to BlueCard Home claims (claims where a BCBSM member sees a Blues out-of-state Control Plan provider); these claims are excluded from the PGIP PO Component and fee uplifts. Are there any other BCBSM groups/products that are excluded from the application of the PGIP PO Component? The Federal Employee Program (FEP) is excluded from the PGIP PO Component. Additionally, Medicare Advantage and Medicare Supplemental claims are also excluded. Why bother with the Reward Pool? Why don t you just pay the doctors more? Physicians often contend that we should just give them the 4.7% in their fee directly and they ll improve themselves; however, BCBSM s experience shows that that model has not worked well. Further, the fact is that if we did not have a Reward Pool, those monies would not have been approved by the Board to go into physician fees. 11

12 PGIP serves as a mechanism for incremental reimbursement reform, redirecting a meaningful proportion of professional payment away from volume-based, fee-for-service (e.g., pay for production), and toward population level performance and reinvigoration of health care delivery, and ultimately towards a pay for quality system. Where is the documentation of the funds distributed in the PGIP Program? Is there a ranking of the POs? BCBSM does not have a ranking of PGIP POs that is made publicly available. All funds from the PGIP incentive pool are distributed to the POs annually; no monies are retained by BCBSM for administrative costs. Payments are made based on performance and utilization measures, as well as participation. This process is audited on a regular basis. However, details are not published externally. Have fees for (name of service) decreased or increased in recent years? Various factors are taken into consideration in determining whether fees should increase or decrease each year. For example, changes in Resource-Based Relative Value Scale (RBRVS) values can impact fees. Generally, procedure code maximum fees will increase or decrease based on the new relative value units and BCBSM s conversion factor. Each year, BCBSM conducts a comprehensive analysis of professional provider performance and current economic indicators to calculate practitioner fees, with consideration for corporate and customer cost concerns. BCBSM remains committed to reviewing professional provider performance to determine the need for increases or decreases in our maximum payment amounts. Does the PGIP PO Component only fund the PGIP Program, or are other programs funded with it as well? BCBSM is committed to putting a set amount into the PGIP Reward Pool each year to fund the PGIP Program exclusively. This amount is based on a set percent of professional payment, and each year, all the funds in the reward pool are spent. These funds are spent only on the PGIP Program, and no PGIP reward pool funds are retained by BCSBM. Because each BCBSM customer (employers who purchase insurance) is responsible for their proportionate share of professional payment, and because the only mechanism for assuring this is so is through claims payment and reporting for each BCBSM member, the accounting for the Physician Organization Component of payment (the incentive pool) is done through the claims payment system. So, for example, with a service with a payable fee of $100, BCBSM adds $4.70 to that fee creating a total of $ and then subtracts $4.70 (the same amount) as the PGIP Physician Organization component which is added to the reward pool. This is accounted for when tallying the costs for members for each group purchaser of BCBSM insurance coverage. PGIP Organization and Oversight How does a PO decide what initiatives to work on for the year? POs decide what to focus on based on an assessment of their opportunities for the greatest improvement. There are five categories of Initiatives that a PO can work on for the year: Condition-focused Initiatives Cardiac care (expanded in 2012 to include Phase III a diagnostic therapeutic cascade component) Chronic kidney disease Encouraging evidence-based utilization of hysterectomy Encouraging evidence-based utilization of labor induction Environmental cancer Michigan Oncology Quality Consortium (MOQC)/Quality Oncology Practice Initiative (QOPI) Michigan Oncology Clinical Treatment Pathways Program 12

13 Michigan Urological Surgery Improvement Collaborative (MUSIC, new for 2012) Service-focused Initiatives Advance Care Planning (new for 2012) Emergency department utilization Increasing the use of generic drugs Michigan Anticoagulation Quality Improvement Initiative (MAQI 2 ) Radiology management Core Clinical Process-focused Initiatives Coordination of care* Extended access* Individual care management* Linkage to community services* Patient provider partnership* Performance reporting* Preventive services* Self-management support* Specialist referral process* Test tracking and follow-up* Evidence Based Care Tracking Lean for Clinical Redesign CQI Michigan Transitions of Care (M-TC 2 ) Organized Systems of Care Integrated Patient Registry Organized Systems of Care Integrated Performance Measurement Organized Systems of Care Processes of Care (new for 2012) Clinical Information Technology-focused Initiatives Accelerating the adoption and use of electronic prescribing Patient web portal* Patient registry* The initiative plan and initiative fact sheet for each initiative are available on the PGIP PO Collaboration Site, on each specific initiative site. The PO Collaboration Site can be accessed through the BCBSM secured provider portal on Once in the site, click on the Initiatives tab; then select the initiative. The documents will be found under BCBSM Documentation. *These initiatives relate to the 12 Domains of Function of the Patient-Centered Medical Home. What is a Practice Unit? A Practice Unit consists of one or more physician(s) within a PGIP PO who share clinical responsibility for a group of patients and are formally organized to provide medical care, consultation, and diagnosis/treatment through joint use of clinical information and care processes. In the vast majority of practice units this collaboration occurs in the context of shared facilities/equipment/personnel. A Practice Unit is the entity that is eligible to receive Patient-Centered Medical Home designation, and is the primary point of contact between the PGIP provider community and patient/bcbsm members. 13

14 How does the PO work with its physicians? The expectation of each PO is to communicate the PGIP objectives to their physicians. A PO selects initiatives on a yearly basis and establishes goals and objectives, developing their own plans for working with their PGIP physicians. For any questions about how your physician organization works with physicians and practice units or the various PGIP units, please contact your PO. What kind of reporting or information is provided back to PGIP physicians regarding their patients? PGIP physician organizations and physicians receive both dashboards and datasets, which are designed to provide data and metrics that do the following: Identify improvement opportunities Assist in diagnosing the process problems Track progress of implementation effort Measure improvement success POs receive dashboard files semi-annually. Dashboards provide PO-level claims data organized by specific initiative metrics; dashboards are distributed to all POs regardless of participation in a particular initiative. They also include data on all POs regardless of participation in specific initiatives. Dashboards include: Physician Organization demographics and attribution volumes Risk adjustment comparisons (where applicable) Tables and figures to show POs outcomes for initiative metrics PGIP-overall and benchmark comparison Providing metrics at the PO-level allows for PO to PO comparison. Additionally, POs receive their own Microsoft Access Datasets on a quarterly basis. Datasets include practice-level and physician-level information, which allows for practice unit to practice unit and/or physician to physician comparisons within a PO. Data tables are included for member (patient) level activity information. The effective use of data (including data provided through Dashboards and Datasets) on the part of PGIP POs is essential for PGIP success. How is physician efficiency of care measured among PGIP physicians? In the fall of 2011, BCBSM introduced the CCGroup Marketbasket System, an efficiency measurement system, to PGIP POs. The CCGroup Marketbasket System, also known as CAVE, is based on longitudinal episodes of care, which allow for the assessment of global patterns of treatment for specific conditions. CAVE compares the efficiency of physicians or groups of physicians to a peer group of physicians within the same specialty. In order to create a more valid comparison among specialists or groups of specialists providing care via an organized physician practice unit, CAVE calculates efficiency based on the costs and utilization for the most common medical conditions treated by each specialty type. The CAVE methodology reduces the impact of patient case mix, cost outliers, and other non physician-related variation in practice patterns on efficiency score comparisons. To date, BCBSM has produced CAVE reports at the PO level for four specialty types cardiology, gastroenterology, orthopedic surgery and emergency medicine. BCBSM will produce practice unit level CAVE reports for the four specialty types in BCBSM also plans to release additional CAVE specialty reports in One of the foundational principles of PGIP is that communities of caregivers have shared responsibility for managing a patient population. CAVE will enable PGIP POs and specialist practice units to collaboratively manage populations by understanding variations in specialty-specific practice patterns. For this reason, and because individual physician level CAVE reports generally have insufficient sample sizes to produce valid and comparable results, BCBSM does not plan to produce CAVE reports at the individual physician level. 14

15 BCBSM is also implementing CAVE to support population-based performance assessment and related payment models for specialists, such as specialist fee uplifts. BCBSM is also exploring the use of Prometheus, which provides information on potentially avoidable complications. This data could be used to assess the performance of providers such as hospital systems - but will not be used at the individual physician level. Patient-Centered Medical Home (PCMH) Overview What is the Patient-Centered Medical Home and what does it mean? The Patient-Centered Medical Home (PCMH) model is an approach developed to yield both better health care and lower costs. PCMH provides centralized, comprehensive, coordinated primary care and cultivates partnerships between patients, their personal physicians, the care giving team, and the patient's family. Where did this concept come from and who endorses this concept? The American Academy of Pediatrics introduced the concept of a medical home in Initially it referred to merely having a single source of information about a patient, but has over time grown to mean a partnership existing to provide comprehensive, coordinated medical care. The PCMH concept is supported by such diverse agencies as the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, the World Health Organization, the Centers for Medicare and Medicaid Services (CMS), the Utilization Review Accreditation Commission (URAC), and the National Committee for Quality Assurance (NCQA), among others. How do I find a PCMH Designated Physician? To find a PCMH designated physician, visit Click on Find Doctor on the top right section of the page, and then click on Designated Physicians List. There, you will find a list of PCMH-designated physicians listed by city. What are the PCMH Interpretive Guidelines and how are they used by BCBSM? The PCMH Interpretive Guidelines is a 40+ page document that provides details approximately 130 capabilities in the 12 PCMH domains. The field team uses this document in their site visits, during which they review and validate the POs twice per year selfreported PCMH implementation activity; this activity is reported at the practice unit level. The POs are held accountable for accurately reporting all their practices data; those who have systematic reporting errors have an accuracy factor applied to their PCMH Designation scores, which reduces scores in the domains with inaccurate reporting. The PCMH Interpretive Guidelines are separate from the PGIP agreements between the POs and BCBSM. PCMH Participation and Designation What is the BCBSM PCMH Designation Program? The Blue Cross Blue Shield of Michigan Patient-Centered Medical Home Designation Program, which was launched in July 2009, is a component of BCBSM s Physician Group Incentive Program. BCBSM s PCMH Designation program recognizes and supports those primary care physician offices that have made significant progress in implementing and using patient-centered clinical and administrative processes, resulting in the delivery of more coordinated, efficient, and effective health care. In addition, designated providers are those who have performed favorably on measures of quality, use and efficiency based on claims data. Designated primary care physicians receive a higher level of reimbursement for evaluation and management (E & M) services. All designees are reevaluated annually, along with all PGIP nominated practice units. 15

16 The objectives of BCBSM s PCMH Designation Program are to: Strengthen the role of primary care physicians in the delivery and coordination of care; assist them in achieving levels of patient engagement and care coordination that are consistent with the patient-centered medical home philosophy Demonstrate BCBSM s continued commitment to the improvement of core health care processes Fulfill BCBSM s responsibility, shared with health care practitioners and members, to advocate for the highest quality health care services, enabling our members to achieve and maintain optimal health Is BCBSM s PCMH program the largest in the nation? Yes, BCBSM currently has the largest PCMH program in the nation. In 2012, 994 practices representing more than 3,000 primary care physicians were PCMH designated. As of the 2012 designation cycle, more than 1 million BCBSM members are attributed to BCBSM s PCMH designated practices (please note: the number of subscribers that BCBSM claims is based on a conservative attribution model which does not attribute over 30 percent of members to PCP practices). BCBSM s PCMH program is not only larger than others in the nation, but it is also quite different from other health plans PCMH programs. Many other health plans hire care managers to support their practices, but do not support practices in establishing their own care management programs. Additionally, many other health plans deem practices to be PCMH practices if they merely sign up to participate and agree to take a risk. However, BCBSM helps physicians organizations build PCMH practices, and BCBSM calls practices PCMH-designated only when have they have achieved a critical mass of verifiable PCMH capabilities. These differences make BCBSM s PCMH program unique from other health plans PCMH programs throughout the nation. Does BCBSM s PCMH Program address and track the adoption and use of Electronic Medical Records (EMRs)? Our PCMH program supports IT infrastructure development, but not EMRs specifically. Thus, we do not have a fully comprehensive understanding of the number of EMRs in practices. We do, however, track the use of electronic prescribing and registry tools. Through the PCMH program, BCBSM encourages the use of a variety of technology tools including EMRs, disease registries, electronic prescribing, etc. Additionally, BCBSM is promoting/supporting health information technology development through our OSC initiatives. Health information technology is integral to supporting improvements in health care safety, quality, efficiency, and access and is the foundation of an effective system of care. How do I get my practice unit designated? Consistent with PGIP s partnership philosophy, the PGIP PCMH Designation selection process is highly collaborative and begins when the PGIP PO nominates Practice Units that it recognizes as having strong performance metrics and significant application of Patient- Centered Medical Home concepts. Practice units are eligible to be nominated for PCMH Designation by their PO if they meet the following criteria: Physicians are PGIP members in good standing Practice is functioning as a primary care practice Practice has at least one physician who is functioning as a PCP Practice has a minimum of 30 attributed BCBSM members Sufficiently robust claims data is available for at least 3 of the 7 metrics analyzed by BCBSM PCMH validation visits are conducted at random to ensure that each PO s assessment of its practice unit s PCMH functionality is aligned with the collaboratively developed definitions (see the PGIP PCMH Interpretive Guidelines document for additional information). For detailed information about nomination and scoring processes, please contact your PO. They have been provided with the BCBSM PGIP Patient Centered Medical Home Designation Program Objectives and Selection Process (Summer 2011) document. 16

17 What happens if the practice unit I am in gets designated as a BCBSM PCMH? PGIP-enrolled primary care physicians who are members of a designated PCMH Practice Unit will receive a higher level of reimbursement for office-based evaluation and management codes from July 1 of the designation year through June 31 of the following year. PCMH review and selection will occur annually. You must have been a member of that designated Practice Unit during the review period to be eligible for the higher reimbursement. POs and Practice Units are expected to continue to implement additional PCMH initiatives and capabilities. Why doesn t BCBSM recognize PCMH designation by other parties, such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Committee (URAC)? The standards and requirements used by these parties for designation differ from those employed by BCBSM. For instance, these other designation programs do not have a quality/use/efficiency component, which is 50 percent of BCBSM s PCMH designation score. Additionally, other designating parties do not conduct onsite validation visits (which BCBSM does annually) or emphasize the improvement of care processes to the extent that BCBSM does. BCBSM s PCMH Program is just one component of our overall PGIP strategy for practice transformation, whereas the NCQA and URAC designation programs are stand-alone programs. BCBSM s PCMH Program is also constantly evolving; the interpretive guidelines are updated each year in order to catalyze practice participation and transformation in the entire PGIP Program. Are all physicians eligible for PCMH designation? It should be noted that individual physicians are not designated. Only practice units are designated; individual physicians may be eligible for increased E&M fee reimbursement as a member of a PCMH Designated Practice. Only physicians with a primary care focus who are functioning as a PCP as determined by their PO, who are in good standing with the BCBSM network, and who were in the practice unit at the time it was evaluated for PCMH Designation are eligible for the increased E & M fees. Can specialists participate in PCMH? Specialists are able to participate in each of the 12 Patient Centered Medical Home Initiatives, provided their affiliated POs foster opportunities to do so. POs and their specialists are rewarded for developing PCMH capabilities at the practice unit (i.e. physician office) level and PGIP rewards go to the PO to recognize these improvements. However, a specialist practice cannot be designated as a patient-centered medical home. Why can t a specialist practice be considered a patient-centered medical home? A specialist practice cannot be considered a Patient-Centered Medical Home because the role of being a central hub for all patient information and care is optimally handled by the primary care provider a belief that is consistent with the philosophy of the Joint Principles of a Patient-Centered Medical Home, developed by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) in These Joint Principles form the basis of our program. However, specialists are welcome to participate in Patient-Centered Medical Home initiatives to develop PCMH capabilities for their office. What happens if I share a practice unit with specialists? While your practice unit may receive PCMH Designation, the only physicians eligible to receive additional E & M reimbursement are the primary care physicians. Primary Care Physicians are defined as physicians with a primary care focus who are determined by their PO to be functioning as a PCP. Example #1: There are 3 PCPs (Dr.s V, W, & X) and 2 Specialist physicians (Dr.s Y & Z) in one Practice Unit B. All physicians in Practice Unit B are in PGIP. 17

18 Practice Unit B is a PCMH Designated practice. PCPs V, W, & X will receive the higher level of reimbursement for E & M services. Specialists Y & Z will not receive the higher level of reimbursement. **Specialists are not eligible for the higher level of reimbursement even if they are in PGIP and are members of a PCMH Designated practice** Example #2: There are 3 PCPs (Dr s X, Y, & Z) in Practice Unit A. Drs. X & Y are in PGIP; Dr. Z is not in PGIP. Practice Unit A is a PCMH Designated practice. Drs. X & Y will receive the higher level of reimbursement; Dr. Z will not receive the higher level of reimbursement. **Physicians and practice units must be enrolled in PGIP to be eligible for the PCMH Designation Program**. Only PGIPenrolled primary care physicians within a PCMH Designated practice unit are eligible to receive the higher level of reimbursement for E & M services. In 2010 and 2011, how many specialist practices were participating in PGIP and PCMH initiatives? In 2010, there were 3,178 practice units in PGIP 929 specialist practice units in PGIP (29% of all practice units in PGIP) 497 specialist practice units not participating in PCMH (53% of all specialist PUs) 432 specialist practice units participating in PCMH (47% of all specialist PUs) In 2011, there were 4,192 practice units in PGIP 1,685 specialist practice units in PGIP (40% of all practice units in PGIP) 852 specialist practice units not participating in PCMH (51% of all specialist PUs) 833 specialist practice units participating in PCMH (49% of all specialist PUs) Despite adding 756 additional specialist practice units into PGIP in 2011 by the addition of new specialty types (including Gastroenterologists, Neurologists, Orthopedic Surgeons, Radiation Oncologists, etc.), BCBSM was able to attract an even larger percent of specialist practice units into PCMH from 2010 up to 49% of all specialists in PGIP. This translates into 401 additional specialist practice units over a year period that participated in PGIP s PCMH program working to build PCMH capabilities in their practices. In which PCMH initiatives are specialists participating? Specialists are participating in all 12 PCMH initiatives at varying levels. In 2011, the five PCMH initiatives with the highest number of specialists practice units participating were as follows: Extended Access (418 specialist practice units); Linkage to Community Services (393 specialist practice units); Patient Web Portal (379 specialist practice units); Test Tracking and Follow-up (368 specialist practice units); and Individual Care Management (366 specialist practice units). Please refer to the following graph for an overview of specialist practice units participating in all PCMH initiatives in 2010 and

19 PCMH Reimbursement Procedures What are Evaluation & Management Procedure Codes? Evaluation and Management (E&M) Codes are Current Procedural Terminology (CPT) procedure codes (office visits, hospital visits, and consultations). CPT values for E&M codes are What E & M codes will receive higher reimbursement? For PCMH designated practices, the following E&M procedural code ranges receive the E&M Uplift: Office visits ( ) Preventive ( ) What places of service are eligible for the higher level of reimbursement? The following Place of Service (POS) codes will receive the increased reimbursement: POS 2 = Hospital, Outpatient (HIPAA value 22) POS 3 = Doctor s office (HIPAA value 11) 19

20 How much will the E & M increased reimbursement be? That will be determined on a yearly basis. For 2010 it was 10%. In 2011, an additional level was added to recognize those practice units who showed exceptional cost and use containment while maintaining or improving quality of care. These practice units received a 20% fee increase for E & M services. What are the applicable product lines that have the elevated E & M payment applied? PPO products (e.g. Community Blue, MIChild, Flexible Blue, Blue Preferred Plus (BPP)) BlueCard Host (out-of-state control plan member sees MI physician) Traditional Blue Choice PPO (formerly Point of Service) Federal Employee Program What product lines are excluded from additional E & M reimbursement? Pay Subscriber Blue Card Home Medicare Supplemental COB, except where BCBSM is primary Vision and Hearing (stand-alones) Ambulance Services Anesthesia Services Durable Medical Equipment Prosthetics and Orthotics Services billed by physician extenders (i.e. Certified Nurse Practioners, Independent Physical Therapists, and Physician Assistants) Will I have to follow any special billing requirements? No. Follow your normal billing procedures. No special modifiers are needed. Is there any member cost-sharing? Yes, if applicable. This won t affect flat co-pays (e.g., office visit copay = $10), but any co-insurance or deductibles will still be applicable at the standard amount or percentage of the higher E&M fee. Is the lesser of charges or standard reimbursement fee rule still applicable with the additional E & M reimbursement? Yes, claims where the providers charge is less than or equal to the BCBSM Allowed Amount are excluded from the fee uplifts. What will my voucher look like if I am receiving the E & M uplift? See below for an example of a PCMH Uplift reimbursement voucher. A sample calculation for a specific procedure code (99213) is also included below the voucher. 20

21 Example: PCMH Uplift Reimbursement - Calculation for Procedure Code 99213* Calculation Charged Amount $85.00 Allowed Amount $76.53 Physician Fee Uplift (10%) $7.65 New Allowed Amount $84.18 Copay ($30.00) Benefit Cost to ASC Group Customer (New Allowed Amount minus Copay) $54.18 PO Component (4.2% of Allowed Amount) $3.54 Approved to Pay Provider $50.64 *This voucher and calculation will be replaced with an updated version (reflecting the increased PGIP PO Component of 4.7%) when available. Organized Systems of Care (OSC) Overview What is an Organized System of Care? An Organized System of Care is the term BCBSM uses to describe a community of caregivers that has a shared commitment to a defined population. OSCs are established to care for a patient population attributed to a group of primary care physicians. They use coordinated care processes, striving to achieve benchmark performance in quality and cost. OSCs are responsible for identifying the population they serve, tracking and assessing performance and establishing performance goals. 21

22 When did BCBSM first introduce the concept of Organized Systems of Care? The plans to catalyze the creation of OSCs by the provider community began in as BCBSM developed the Physician Group Incentive Program, before Accountable Care Organizations (ACOs) came on the scene. BCBSM uses different language in part because it has been in use so long in Michigan and in part because the term OSC encompasses a before the fact responsibility to create a highly functioning system of care as well as an after the fact responsibility for population performance on quality, patient experience, and cost. In contrast the term Accountable Care Organization refers only to the dimension of accountability. We know, however, from extensive experience in supporting the provider community in developing Patient-Centered Medical Home practices and linking their information systems and care processes through shared systems, that as much attention has to be paid to developing systems as to measuring performance and tying reimbursement to that performance if we want to achieve the best outcomes possible. What is a community of caregivers and what are the rules that will be used by BCBSM to define this organization? BCBSM is not being highly directive or prescriptive in the way we set up rules for the OSC; the OSC will define the natural community of caregivers with affiliations between PCPs, specialists and facilities. The key is that the community of caregivers shares responsibility for population level performance for the patients attributable to the PCPs. In addition, another key organizing concept is that the affiliations in an OSC should actually reflect natural communities of providers with a shared commitment to a population in common. An OSC which covers a very large geographic area beyond what any reasonable person would consider a natural community of caregivers really doesn t fit well at all with this organizing concept. Our hope is that POs won t create convenience OSCs in order to be in the program as that won t lead to the creation of clinically integrated provider communities which are closely connected and aligned with the interests of a well defined community of patients. Why does BCBSM use the term OSC and not ACO? BCBSM has chosen to use the term Organized Systems of Care, or OSC, rather than Accountable Care Organizations, also called ACOs, to allow more flexibility in how the communities of caregivers are identified, defined and organized. Rather than being bound by nationally defined parameters for ACOs, BCBSM is collaboratively developing its OSC program in partnership with our PGIP physician organizations. Also, with an OSC, the principle of accountability is expanded to include both responsibility for creating shared systems and processes, as well as effective management of the health of the patient population. BCBSM began using the term OSC in What issue/problem is the OSC designed to address? BCBSM s OSC program is designed to address problems related to the delivery of fragmented, uncoordinated, inefficient and costly health care services that fail to meet the needs of a patient population. OSCs will serve the needs of patients in an effective and efficient manner across care settings. What are the essential elements of an OSC? The OSC core workgroup, which is comprised of nine Michigan professionals from PGIP physician organizations throughout the state, has identified the following as essential elements of an OSC: 1. The OSC patient population includes a minimum of 20,000 BCBSM PCP-attributed patients. (The minimum standard may be adjusted for rural areas.) 2. Primary care practices that define the OSC agree to participate within a common organizational framework for population management that includes systems for communication, coordination of care, performance measurement and improvement. 22

23 3. A majority and, ultimately, all primary care practices are designated as patient-centered medical homes with patient registries and a proactive care process. 4. The OSC has shared information systems and processes to communicate and coordinate care that involves all relevant participants in the process of care for the population served. This involves identifying the specialists, hospitals and ancillary providers important to the care to the population. The OSC actively works with these providers to create a seamless care process with well-managed processes for communication and coordination of care. (Geographic proximity of caregivers is not an OSC requirement; however, geographically dispersed OSCs may face greater challenges incorporating the essential elements of an OSC.) 5. Over time, the OSC will accept accountability for management of financial risk associated with population-based measures of system performance. The OSC must establish a process for making investments in system infrastructure, aligning incentives, measuring provider performance, providing feedback and distributing payment to providers in a manner that supports its broader purpose. Who is the target population for the development of the OSCs? The target population for the OSC will be PGIP-participating POs and their primary care practice units. It is expected that these providers, in addition to affiliated specialists, BCBSM-participating hospitals and other providers, will form communities of caregivers and will be responsible for the care provided to an attributed common population of BCBSM members. How are OSCs formed? The foundation for the OSCs is the patient population attributed to a group of PCPs. PCPs can form an OSC in partnership with hospital and specialist providers who serve a common population. The essential expectations include: Responsibility for population level performance regarding use, cost and quality Commitment to developing and using shared information systems and processes of care Integrated across settings and over time. Collaboration and cooperation are essential to achieving system and performance goals. How this collaboration is achieved will be determined by the community of providers. It could include contractual affiliation or non-contractual alignment, and may change over time. Providers contributing meaningfully to population level performance will receive enhanced reimbursement regardless of how they are affiliated. The overarching goal is to keep the focus on the patients and to ensure that their care is coordinated and effective. What is primary goal of building Organized Systems of Care? The primary goal in developing OSCs is to identify natural communities of caregivers in which providers share responsibility for a common patient population and work with one another in caring for patients. Geography, referral relationships, shared coverage, and hospital staff membership are some of the defining variables for OSCs. The goal is to come together to create an integrated (information system, care coordination and care management process integration) system of care which develops continually improving systems to better serve the population and which is willing to accept shared responsibility for population level performance (i.e., a commitment to manage a population from a cost, quality and patient experience perspective). Any artificial groupings aimed at stratifying by performance will foster continued fragmentation rather than coordination and clinical integration. 23

24 OSCs and Reimbursement How will the development of OSCs change BCBSM s reimbursement to physicians (PCPs and specialists)? In 2011, neither PCP nor specialist reimbursement from BCBSM will change due to development of OSCs. However, the development of OSCs will, in the future, help to shape BCBSM provider payment policies. Payment policies will incorporate components that redirect providers efforts away from volume-driven care toward value-driven care. Increases in reimbursement will be structured so that an increasing proportion of professional reimbursement is tied to incentivizing and rewarding the development of highly effective systems of care. These systems would be based on the PCMH model, clinical integration of the systems across provider types and settings of care, and performance. Does BCBSM intend to eliminate fee-for-service payments to professional providers when OSCs are fully developed? BCBSM is transitioning to a process of rewarding value through tiered fees based on population-level performance, which will promote both detailed reporting and a focus on population management and performance improvement. FFS payments will continue to be used as a foundational element of professional reimbursement as it provides key information (e.g., diagnoses, services provided) needed to assess the effectiveness and efficiency of care. BCBSM payment policies for OSCs will incorporate components that redirect providers energies away from volume-driven care toward value-driven care. For example, future increases in reimbursement will not solely be based on price inflation. Instead, FFS will be structured so that an increasing portion of professional reimbursement is tied to incentivizing and rewarding the development of highly effective systems of care based on the PCMH model, clinical integration of the systems across provider types and settings of care, as well as the results of provider performance for an identified population of members. OSCs in Relation to PGIP and PCMH How is the OSC program related to PGIP? Health care delivery transformation requires a new orientation toward population management, a new infrastructure, a new process of care and, frequently, new organizations. PGIP enables providers to transform health care delivery while balancing investments in longterm capabilities with the need for short term savings. OSC is a PGIP strategic initiative and represents the further transformation of health care delivery to emphasize population management. What PGIP incentives will be available to support the development of OSCs? Two new PGIP Initiatives were launched in mid-2011 to support development of OSCs: OSC Integrated Patient Registry Initiative OSC Integrated Performance Measurement Initiative A third OSC initiative Process of Care - is also being developed for a late 2011/early 2012 launch. Additionally, OSC Structural Initiatives, addressing such issues as organizational capabilities and cost management, will be introduced later. Is the cost and trend benchmark performer analysis extra 10-percent uplift part of the OSC program reimbursement? No. The additional 10-percent PGIP uplift is based on a total cost and trend benchmark performance analysis. The Blues began paying the additional amount in 2010 to focus attention on the importance of lowering costs, as well as improving quality and efficiency. In 24

25 2010, BCBSM calculated the total per member per month expenditure for each PO or sub-po (depending on the size of the attributed member population). In 2011 and 2012, the cost and trend performance analysis will be calculated for each OSC (if the attributed member population is sufficiently large), in addition to each PO or sub-po. A PCMH-designated PCP may qualify for the additional 10 percent based on the cost performance of his or her PO, sub-po or planned OSC. How is the OSC program related to PGIP s Patient-Centered Medical Home? The OSC program builds on PGIP s PCMH program to promote the establishment of systems of care that coordinate delivery of health care services across the health care spectrum. OSCs are held accountable for the management of a defined population. The PCMH model is a comprehensive organizational structure for guiding the creation of highly effective systems of care. These systems are designed to meet patients needs in a timely and efficient manner, while assuring optimal quality of care. In an OSC, many PCMH-based PCP practices will be integrated into a system of care in partnership with specialists practices, hospitals and, eventually, other facilities and non-facility based providers, such as home health care agencies. All of the providers will share information systems and care processes to ensure proactive, effective and efficient care management across settings and over time. Will PGIP develop an OSC designation program with criteria similar to the Patient-Centered Medical Home Program? Currently, BCBSM does not plan to develop an OSC designation program. We expect, however, that there will be criteria (not yet defined) that an OSC will be required to meet in order to earn financial rewards. What about the extra 10 percent uplift for PCMH-designated PCPs that belong to POs that are cost benchmark performers? Is that part of the OSC program? No. The additional 10 percent uplift, based on a total cost and trend benchmark performance analysis, was implemented in 2010 to focus attention on the importance of lowering costs, as well as improving quality and efficiency. The total Per Member Per Month (PMPM) expenditure was calculated for each PO or sub-po (depending on the size of the attributed member population). The only adjustment to the performance analysis in 2011 will be that total PMPM will be calculated for each OSC (if the attributed member population is sufficiently large), in addition to each PO or sub-po. A PCMH-designated PCP may, therefore, qualify for the additional 10 percent uplift based on the cost performance of their PO, sub-po or planned OSC. When an OSC or PO/subPO is identified as a Benchmark Performer (i.e., the extra 10% uplift for PCMHdesignated PCPs that practice within a benchmark performer PO, subpo or OSC) does this mean that they are a designated or recognized OSCs? No, the cost/trend benchmark performer analysis is not an OSC designation program. The analysis identifies PCMH PCPs who practice within organizations (i.e., OSCs, POs or subpos) that have met either a cost or trend benchmark. An OSC designation or recognition program, which is not currently in place, would likely include multiple criteria including a variety of cost, trend, efficiency and quality (i.e., structure, process and outcomes) of care criteria and guidelines. If an OSC or PO is identified as a Benchmark Performer, can the OSC or PO publicize that its physician members are receiving elevated fees due to their association with the PO and/or publish the names of the PCPs (i.e., publicly recognize) in the OSC or PO that will receive the 20% benchmark performer uplift? No, PGIP does not want OSCs or POs to publicly recognize PCPs who practice within an OSC or PO that was recognized as a benchmark performer. The rationale for this decision lies in the fact that the success of the PGIP program is based in part on PO/OSC 25

26 collaboration designed to promote high-quality, cost-effective care; publicly recognizing the benchmark performers or other PGIP metrics that compare one PO s or OSC s performance to another will undermine the collaborative nature of the program. OSC Participation Who are the patients that will comprise the OSC patient population? The population for which the OSC is responsible is defined as the patients attributable to PCPs in the OSC. Can a PCP belong to more than one OSC? No. Each PGIP PCP practice may belong to only one OSC. Can a PCP belong to an OSC and an ACO? Yes. PCPs may belong to a PGIP OSC as well as to another payer s ACO. Can specialists and hospitals partner with more than one OSC? Yes. Hospitals and specialist practices may partner with more than one OSC. Do PCPs have to participate in PGIP to be in an OSC? What about specialists? Yes. A PCP must be in PGIP to be part of an OSC. Currently, BCBSM is not collecting OSC membership information for specialists. Do PCPs have to be PCMH-designated to be in an OSC? No. PCPs do not have to be PCMH-designated to be in an OSC. PO Recruitment Information As a PO, are there certain types of specialists I should recruit? If so, which ones? All practitioners who are Doctors of Medicine (MDs), Doctors of Osteopathy (DOs), Doctors of Chiropractic (DCs), or Doctors of Podiatric Medicine (DPMs) are eligible to participate in PGIP, but greater opportunities for participation exist for cardiologists, oncologists, gastroenterologists, orthopedic surgeons, emergency medicine specialists, among others. Certain other specialists (e.g., pathologists, geneticists, anesthesiologists, etc.) by nature of their practices, have very limited opportunities for participation. While the latter are not excluded from PGIP, we recommend that POs focus on enrolling those specialists who can best assist the PO with their work on the various current and planned PGIP initiatives. What are the standard expectations for PO recruitment for both PCPs and specialists? PGIP POs are expected to work collaboratively while registering physicians. Physician participation with any particular group for the purposes of PGIP must be entirely voluntary. Physicians must have the freedom to choose which group they wish to participate with for incentive purposes. Physicians should not be pressured to participate with a particular physician organization in any way. For purposes of this program, physician organizations may not: Communicate with individual physicians informing them that they must be in that particular physician group to participate in the BCBSM incentive program. 26

27 Communicate with individual physicians stating if they do not affiliate with that particular group for the purposes of the physician incentive program, they will be excluded from affiliation with that physician group for other purposes (e.g., participation with other payer contracts). Knowingly create an issue by requiring a physician to sign a form stating s/he belongs to that physician organization for incentive participation purposes while knowing the physician is already affiliated with another PGIP PO, unless they communicate to the individual physicians that they may voluntarily choose which PO they prefer to affiliate with. Imply or state (either verbally or in writing) that the physicians will lose income or will not be able to participate in other health plan networks and/or contracts if they do not affiliate with that particular physician group for purposes of the BCBSM incentive program. Imply or state (either verbally or in writing) that greater financial reward will be available to the physician if s/he joins their group in preference to another participating physician organization. These rules apply to the recruitment of both primary care physicians and specialists. Any and all questions about the above expectations should be directed to the PGIP Field Team. Opportunities for Specific Specialties Why is BCBSM opening PGIP to non-md/do health professionals? PGIP began in 2005 with the overall goal of improving the system of health care in Michigan. The program began with a focus on primary care, because primary care is the foundation of health care, and transformation must begin in primary care. However, the long term goal has always been to create high functioning, coordinated systems of care that involve all who care for a patient. In 2011, BCBSM opened the PGIP program to all medical/surgical specialists, and chiropractors and podiatrists. As of 2012, psychologists are eligible to join the program as well. This also supports our development of Organized Systems of Care. In an OSC, participants act as a community of caregivers who have shared responsibility for managing a specific population of patients. Ideally, all providers who care for a patient should be coordinating with others along the spectrum, to create a seamless experience for the patient. How will psychologists, chiropractors and podiatrists earn incentives for participating in PGIP? To join PGIP, the physician or practitioner must participate in a PGIP physician organization. The PO selects which of its physicians will participate with the various PGIP initiatives. BCBSM works directly with the PO and distributes earned incentives back to the PO. Each PO then determines how to use or distribute their earned incentives. Many POs use some of the funds to support infrastructure building, such as purchasing electronic medical record or clinical information systems for their members. The intention of the earned incentives is to further PGIP s goals of improving health care quality and transforming the system of health care. What opportunities for participation currently exist for psychologists, chiropractors, and podiatrists within PGIP? Physician specialist opportunities to participate in PGIP are in the areas of clinical integration with other physicians (PCPs and other specialists) and contributing to population level performance improvement on cost and quality measures. For psychologists, chiropractors, and podiatrists (as well as other specialists), the main opportunity regarding clinically integrating with other physicians is the development and implementation of structured approaches to referrals and information sharing between PCPs and other specialists regarding shared patients. The specifics of the granular capabilities inherent in a robust specialist referral system are included in the relevant domain of the PCMH Interpretive Guidelines. Regarding population level performance, PCP attributed populations for PGIP Physician Organizations are measured on overall cost and cost increase trends. When specialists (e.g. chiropractors) provide care to members in such PCP attributed populations with low absolute cost and/or costs which rise at a notably 27

28 slower rate than elsewhere, BCBSM rewards those specialists in future office visit payments by increasing fees. There is no predetermined opportunity to earn rewards just by joining a PGIP Physician Organization. Psychologists, chiropractors, and podiatrists are encouraged to become engaged in existing PGIP POs. BCBSM is currently in the process of addressing various ways to engage specific specialists, such as these. The first opportunity for engagement is in the specialty referral capabilities in PCMH. Articles about engaging specialists continue to be forthcoming in our provider communications as additional improvement opportunities are introduced. Additionally, we will continue to broadly communicate the importance of POs engaging all of their attributed patients care providers in the care management strategies. Provider Delivered Care Management (PDCM) What is Provider Delivered Care Management? In the past, care management services have been provided by Blue Cross Blue Shield of Michigan (BCBSM) through the BlueHealthConnection suite of wellness and care management programs. There is now a Provider Delivered BlueHealthConnection option, called Provider Delivered Care Management. Starting on April 1, 2012, Michigan-based primary care practices participating in the Michigan Primary Care Transformation Project (MiPCT) began billing new Provider Delivered Care Management codes for care management and care coordination services delivered by qualified non-physician providers. Provider Delivered Care Management enables patients to receive care management through the BlueHealthConnection benefit from a trained clinician care manager in the physician office. Studies have found that care management delivered in-person, under the guidance of the patient s primary care physician, is highly effective. 1, 2 When motivated patients and highly engaged providers have a positive relationship, it leads to better health outcomes for patients, which can ultimately lower health care costs. How does Provider Delivered Care Management fit with Patient Centered Medical Homes? Provider Delivered Care Management is a core component of the Patient-Centered Medical Home model. BCBSM s award-winning Patient Centered Medical Home (PCMH) program, a collaborative effort with physician organizations and providers across Michigan, is the largest in the country, with approximately 6,700 Primary Care Physicians participating, of which over 3,000 are PCMH Designated. The Patient Centered Medical Home Model transforms primary care practices in Michigan; providers focus on improving quality and patient care. A growing number of studies report that the PCMH model reduces inpatient admissions (16-40%) and emergency department use (29-50%). 3 In 2012, PGIP PCMH Designated providers had 24% fewer ambulatory care sensitive condition admissions compared to non-designated providers. 1 Brown, R. The promise of care coordination: Models that decrease hospitalization and improve outcomes for Medicare beneficiaries with chronic illness. (2009) 2 Sochalski J, Jaarsma T., Krumholz, HM, Laramee A, McMurray JJV, Naylor MD, Rich MW, Riegel B, Stewart S. What works in chronic care management: The case of heart failure. Health Affairs, 28(1), Kevin Grumbach, MD, Paul Grundy, MD, MPH; Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence From Prospective Evaluation Studies in the United States; Updated November 16,

29 Provider Delivered Care Management was piloted with over 250 providers across Michigan. The pilot started on April 1, 2010 and ended March 31, Are there any results from the Provider Delivered Care Management Pilot? Preliminary results of the two-year pilot program show that patients were more likely to engage with a nurse care manager aligned with a practice. That means that they were more motivated to improve their health. Specifically: Between 40 and 50 percent of patients contacted about the program decided to participate. Each patient participating in the pilot had, on average, six to seven care management encounters. The encounters were primarily in-person, but some were by telephone. Physician organizations reported that the program had a positive impact on patient health, based on clinical indicators. Additional results from the pilot will be forthcoming early in What is MiPCT? The Michigan Primary Care Transformation Project (MiPCT) is a three-year Center for Medicare and Medicaid Services (CMS) multipayer demonstration project to test the Patient-Centered Medical Home model. MiPCT participants are those primary care providers who have been BCBSM Patient Centered Medical Home Designated for two years in a row (2010 and 2011), and who retain their PCMH designation for the duration of the demo. The MiPCT-participating providers are the only providers eligible to bill for Provider Delivered Care Management Services in Approximately 400 practices representing nearly 1,700 providers across the state are participating in MiPCT. CMS is requiring that the demonstration be cost-neutral within 3 years. What are the qualifications of the providers delivering care management? The providers delivering care management services are specially trained care managers and other clinical team members under the direction of a physician. The care manager works in the physician practice, or with the practice via their affiliated Physician Organization, to provide in-person care management that is responsive to the patient s needs. Non-physician providers qualified to perform patient assessments and bill the initial patient evaluation code (G9001) are registered nurses, clinical licensed master s social workers, certified nurse practitioners and physician assistants. Non-physician providers who are qualified to bill all other care management codes are registered nurses, clinical licensed master s social workers, certified nurse practitioners, physician assistants, licensed practical nurses, certified diabetes educators, registered dieticians, master s of science-trained nutritionists, clinical pharmacists, respiratory therapists, certified asthma educators, certified health educator specialists (with a bachelor s degree or above in health education), licensed professional counselors and licensed mental health counselors. What are the interventions for Provider Delivered Care Management? The interventions for Provider Delivered Care Management will be a combination of individual and group face-to-face visits, with some telephone follow-up. Who is eligible to receive Provider Delivered Care Management services? Reimbursement for care management services will be available for patients who meet the following eligibility criteria: 29

30 Active BCBSM coverage that includes the BlueHealthConnection program One or more conditions that indicate that care management services have the potential to improve a patient s well-being and functional status A referral for care management services from a physician, certified nurse practitioner or physician assistant in a participating Provider Delivered Care Management practice at which the patient has an established care relationship. In lieu of a referral, there may be a formalized standing order in place between the clinician and care management team. Agree to actively participate in a Provider Delivered Care Management plan Blue Cross Blue Shield of Michigan Federal Employee Program (FEP) members are not eligible for Provider Delivered Care Management at this time. For Provider Delivered Care Management services to be payable by BCBSM, the services must be: Based on patient need and tied to patient care goals Ordered by a physician, physician assistant or certified nurse practitioner in a practice that has been approved to offer Provider Delivered Care Management (The practice must have an established relationship with the patient and be accountable for the clinical management of the patient.) Billed by the approved practice or physician organization responsible for the care management team, in accordance with BCBSM billing guidelines Performed by a qualified non-physician care management team member employed by or under contract with an approved Provider Delivered Care Management practice or its affiliated PO. Physicians will work with the qualified non-physician providers to ensure that patient care is integrated and well-coordinated. Currently, BCBSM underwritten business is automatically included in Provider Delivered Care Management; ASC (self-funded) groups have a choice about whether or not to participate. BCBSM Account Managers are reaching out to self-funded groups to educate them about Provider Delivered Care Management. How is participation in Provider Delivered Care Management being recorded? The services must be ordered by a physician, PA or CNP and there must be documentation in the patient record indicating that the patient has agreed to participate (in the EMR, patient record, visit note, et cetera). The same mechanism that practices use for documenting the patient-provider partnership may also be used for indicating participation in Provider Delivered Care Management. What is the Patient List and how do I obtain it? The Monthly Patient List is what providers should use to verify patient eligibility for Provider Delivered Care Management. Each month BCBSM will send Physician Organizations a list of patients who are eligible for care management and are attributed to a MiPCT Physician based on BCBSM data. The list includes information about patients health status and recent health care use, such as emergency department visits. If a patient is included on the monthly list, practice unit staff can assume they are eligible to receive care management services. In addition, we encourage the practice to use either Web-DENIS or CAREN to check that the patient has active BCBSM coverage before delivering care. Physician Organizations will obtain the list which includes information on both commercial and MA members from their EDDI folders once they receive an from BCBSM indicating the list is available. The list should then be distributed to participating practices as soon as possible. 30

31 How does Provider Delivered Care Management work? Once POs have distributed the list of eligible patients to participating practices, the practices will review the list. The list, which uses data from the previous month, will be used in conjunction with the provider s clinical information and knowledge of the patient to decide which patients should be offered care management. Once a patient has been identified as being eligible for care management, they will be contacted by phone or mail to set up appointments for in-person meetings at the office. What kind of services are included in Provider Delivered Care Management? Provider Delivered Care Management will provide services to patients based on their conditions and level of need: for moderately complex patients, services will include goal-setting, self-management support, and care transitions. Services for medically complex patients will also include care coordination and comprehensive care planning. The following approved services will be payable as part of Provider Delivered Care Management: HCPCS codes G9001 (initial patient evaluation for moderate or complex patients; may be billed only once per year; may also encompass multiple visits, at least one of which must be face-to-face) and G9002 (face to face follow-up visit for moderate or complex patients; may be billed more than once per year). It is not a requirement that G9001 be billed first. There may be instances where a telephone call is made prior to completing the initial assessment (i.e. Care Transitions to Home). CPT codes 98961, 98962, 98966, 98967, (group education and telephone assessment for moderate or complex patients; may be billed more than once per year). Please note that telephone calls with the patients caregiver, if they include a substantive, focused discussion pertinent to the patient s care plan and goal achievement, warrants the reporting of or 98967, even if the patient was not directly spoken to during the encounter. Please also note that phone calls to specialists and/or other health care facilities for the purposes of coordinating patient care are not billable at this time. G9001, the initial Provider Delivered Care Management visit, should include the following components for all Medicare Advantage patients in order to be compliant with the Medicare Star program: Review of all active diagnoses with reporting back to BCBSM Functional assessment Review of all medications Urinary Incontinence screen Do the services differ for Medicare Advantage patients? It is expected that Medicare Advantage patients will receive an annual Wellness Visit (code G0438), and a comprehensive assessment if needed. The wellness visit (code G0438) is mandatory for MA patients. It is performed by a physician for planning and preventive care purposes The comprehensive assessment (code G9001) is optional for MA patients. It is performed by a non-physician care manager to determine whether care management is appropriate for the patient What is the reimbursement for Provider Delivered Care Management codes? The following chart shows the fees paid to physicians as of July 2012 (net of the physician organization component) payable at 100 percent of our approved amount for each of the care management codes. The dollar amounts listed reflect the amount indicated in the payment voucher BCBSM remits for each service. 31

32 Procedure Code Description Fee G9001 Coordinated Care Assessment (limited to one per year per pt) $ G9002 Coordinated Care Fee, maintenance rate $ Face-to-face with the patient, each 30 minutes; 2-4 patients $ Face-to-face with the patient, each 30 minutes; 5-8 patients $ Phone: 5-10 minutes of medical discussion $ Phone: minutes of medical discussion $ Phone: minutes of medical discussion $41.16 Provider Delivered Care Management codes are among those subject to the enhanced compensation provisions of the Physician Group Incentive Program. For example, if the provider is a PCMH-designated physician and therefore is eligible for an additional evaluation and management fee the additional amount will be applied to our fee for the Provider Delivered Care Management service. If the provider is a qualified non-physician provider, the service will be paid at 85 percent of BCBSM s fee for the service, indicated in the chart above. Will the program work the same way for Medicare Advantage members as it does for patients covered under our commercial plans? If a patient is a BCBSM Medicare Advantage member with the BlueHealthConnection benefit, the patient is eligible to receive Provider Delivered Care Management services from an approved provider, and BCBSM will pay for these services. However, if a Medicare Advantage member is not eligible for these services, any Provider Delivered Care Management claims will be denied. The amount paid for Provider Delivered Care Management services delivered to Medicare Advantage members, as of April 2012, is reflected in the chart below. Medicare Advantage claims are not subject to the physician organization component or the additional evaluation and management fees. Code Fee G9001 $ Coordinated Care Assessment (limited to one per year per pt) G9002 $64.69 Coordinated Care Fee, maintenance rate $16.17 Face-to-face with the patient, each 30 minutes; 2-4 patients $12.02 Face-to-face with the patient, each 30 minutes; 5-8 patients $16.59 Phone: 5-10 minutes of medical discussion $31.93 Phone: minutes of medical discussion $47.28 Phone: 21+ minutes of medical discussion 32

33 Who can bill for Provider Delivered Care Management? Reimbursement for Provider Delivered Care Management services will be handled on a fee-for-service basis and is payable only to practices or POs that are specifically approved by BCBSM to receive payment for these services. This year, only MiPCT-participating providers are eligible for care management reimbursement, after completing care management training from a MiPCT approved training program appropriate to their patient population. The reimbursement amount will vary based on whether the rendering field on the claim indicates the provider is a physician or a qualified non-physician provider, as well as whether the provider is a PCMH designee. BCBSM will reject Provider Delivered Care Management claims for patients who do not have coverage for these services. There is no copayment or deductible cost to patients for the Provider Delivered Care Management services, so patients should not be billed for these services. However, if a patient has a high-deductible health plan with a Health Savings Account, you may bill the patient for the care management services as you would bill any other patient with a high-deductible health plan. How do physician organizations ensure they can bill for Provider Delivered Care Management? Physician Organizations will need to obtain an NPI and register with Blue Cross Blue Shield of Michigan in order to bill for Provider Delivered Care Management. In addition, all physicians participating in Provider Delivered Care Management must also be registered with BCBSM. Please contact the BCBSM Provider Consulting area at Blue Cross Blue Shield for more information on the enrollment and registration process. If I work in a pediatric practice, is there anything I need to do differently? The Michigan Care Management Resource Center is currently working with a pediatrician in the state to develop a training curriculum for care managers in pediatric practices. Education which will include separate breakout sessions at the MiPCT Care Manager training sessions - will begin in September When evaluating pediatric patients, the child must attend at least a portion of the initial assessment, regardless of their age. Is there overlap between Provider Delivered Care Management and BlueHealthConnection? Provider Delivered Care Management is an expansion of Blue Health Connection, which focuses on adults with one or more of the five most common chronic conditions and provides primarily telephonic services. Provider Delivered Care Management is intended for anyone with a condition that would benefit from care management services, including children, and will be primarily in-person. Individuals who are engaged in Provider Delivered Care Management are still eligible to receive other BlueHealthConnection services, including wellness, the 24/7 hotline, Quit the Nic, and Complex Care Management. In addition, individuals who need extra-contractual benefits will receive services through BlueHealthConnection as they do today. In some cases, individuals receiving care management through Provider Delivered Care Management may also receive care or case management services through BlueHealthConnection. These patients will be co-managed, and their Provider Delivered Care Management provider and BlueHealthConnection Case Manager will ensure that interventions are coordinated. Can providers continue to bill t-codes if they also bill g-codes? G-codes are intended to take the place of T-codes for patients who are attributed to MiPCT-participating providers. Providers should not bill Provider Delivered Care Management codes and T-codes for the same patient. 33

34 Who pays for Provider Delivered Care Management services? Provider Delivered Care Management is included in the current administrative fee for underwritten employer groups that have BlueHealthConnection. For ASC (self-funded) groups, costs will be incurred based on claims submitted for eligible patients who receive services related to the Provider Delivered Care Management codes listed in this document. Please note that there will not be any out of pocket cost to patients for the care management services provided in the office; patients should therefore not be billed for services related to Provider Delivered Care Management. However, BCBSM is legally obligated to apply a cost share for patients who have a Qualified High Deductible Health Plan with a Health Savings Account. How will Provider Delivered Care Management be evaluated? BCBSM will track patient experience in the program based on claims submitted by providers for care management/care coordination services. Reporting on program activity will be available in 2012; program results, including impact on use and cost, will be available in In addition, researchers at Michigan State University are conducting a comparative effectiveness evaluation of the two-year pilot program under a grant from the Agency for HealthCare Research and Quality (AHRQ). Findings from that evaluation, along with early results of the expanded PDCM program, will be available in Additional Information - The website for the Michigan Primary Care Transformation Project. This is where you can sign up for care management training, link to the Care Management Resource Center, sign up for the weekly Flash s, obtain payment updates, and access all the latest information about the program. Specialist Participation and Specialist Uplifts Are specialty-only POs permitted to participate in PGIP? No, based on the espoused values and purposes of PGIP namely, clinical integration POs comprised exclusively of specialists are not allowed to participate in PGIP. In order to participate in PGIP, POs must have a foundation of primary care physicians. We encourage providers to enter into the program through the PO that best meets their needs perhaps a regional PO, a statewide PO, or the PO with which they most routinely interact. One of PGIP s core principles is to create clinically integrated communities of caregivers who share responsibility for a population of patients. We want these communities of caregivers to collaborate on improving systems of care and on improving care coordination and management processes; these improved processes are intended to benefit individual patients and the community as a whole. This goal is best achieved by collaboration and clinical integration, rather than by fragmenting care that is fostered by separate efforts in siloed specialty practices. Isn t PGIP primarily for PCPs? What can specialists work on in PGIP? It is not our intent to develop a separate specialist initiative for each specialty. Physician specialist opportunities to participate in PGIP are often in the areas of clinical integration with other physicians (PCPs and other specialists) and contributing to population level performance improvement on cost and quality measures, especially through participation in PCMH initiatives and Organized Systems of Care. There are numerous PGIP initiatives available to specialists and many others targeting specialty care in development. To view a list of specialist initiatives, refer to the Specialist page on the PGIP website at 34

35 BCBSM encourages PCPs and specialists that haven t yet joined a PO to consider joining one so that they may begin participating in current and new PGIP initiatives as they become available. When joining a PO, specialists should form practice units that correlate with their patient care patterns and community of caregiver affiliations, because all specialists in a given practice unit will be expected to affiliate with the same OSC(s). How are behavioral health specialties being integrated into PGIP? Active collaboration between PCPs and behavioral health specialists is actively encouraged in the context of PGIP, which rewards POs and their member PCP practices for establishing explicit, structured referral arrangements to assure timely and effective collaboration between PCPs and specialists including behavioral health specialists. Psychologists are now able to join Physician Organizations so as to be able to more actively collaborate with PCP and other specialist colleagues in sharing responsibility for caring for a population of patients in common. Psychiatrists are also able to join PGIP Physician Organizations. These collaborative relationships foster both the creation of systems which support more effective communication and collaboration and also provide the context and systems needed to allow for more effective bi-directional communication between behavioral health specialists, other specialists and PCPs caring for patients in common. How are new PGIP opportunities to engage specialists communicated to specialists? Articles about engaging specialists continue to be forthcoming in our provider communications (e.g. PGIP Matters, The Record, etc) as additional improvement opportunities are introduced. Additionally, we will continue to broadly communicate the importance of POs engaging all of their attributed patients care providers in the care management strategies. Why can specialists be in only one PO, but more than one Organized System of Care (OSC)? PGIP participation rules for Physician Organizations require that all PCPs and Specialists belong to one PGIP PO. The reason is that one PO should be responsible to work with the PCP or Specialist to help them improve quality, efficiency, etc. This rule does not mean that specialists cannot receive referrals from other POs (i.e., not their affiliated PO). PGIP participation rules for Organized Systems of Care require that PCPs belong to only one OSC while Specialists can belong to multiple OSCs because they often are involved in caring for patients across multiple systems. What are the participation rates of specialists in PGIP? Below are the percentages of eligible specialists participating in PGIP as of February 2012 (listed by specialty): 80 percent of eligible cardiologists 74 percent of eligible dermatologists 41 percent of eligible emergency medicine physicians 69 percent of eligible family medicine physicians 81 percent of eligible gastroenterologists 86 percent of eligible hematologists/oncologists 67 percent of eligible internal medicine physicians 82 percent of eligible nephrologists 75 percent of eligible neurologists 74 percent of eligible OB/GYNs 62 percent of eligible orthopedic surgeons 70 percent of eligible otolaryngologists 78 percent of eligible pediatricians 86 percent of eligible radiation therapy physicians 74 percent of eligible rheumatologists 35

36 These percentages are based on the Winter 2011 SRD. What are specialist fee uplifts and why is BCBSM implementing fee uplifts? BCBSM is transitioning from a payment approach based solely on fee-for-service to an approach that layers fee-for-value upon the feefor-service foundation. In the past, increases in specialist fees were based on price inflation. Increasingly, a portion of professional reimbursement is tied to incentivizing and rewarding specialists for collaborating with primary care practitioners and POs and supporting the PCMH model, as well as population-based performance and improvement. PGIP-enrolled specialists who are members of a practice unit selected for the fee uplifts receive a higher level of reimbursement for select relationship-based Evaluation & Management procedure codes from February 1 of the selection year through January 31 of the following year. The uplift selection process will take place annually. Which specialties are eligible for fee uplifts? Currently, two specialty types are eligible for fee uplifts cardiology and oncology/hematology. Effective February 1, 2013, five other specialties may be eligible for fee uplifts: gastroenterology, orthopedic surgery, emergency medicine, obstetrics/gynecology and nephrology. How do I become eligible for a specialist fee uplift? In order to be eligible for fee uplifts, a specialist must 1) be a member of a PGIP physician organization (PO), 2) be nominated by and have a signed Primary Care-Specialist agreement with their member PO, and 3) be nominated by and have a signed Primary Care- Specialist agreement with their principal partner PO, if applicable. (See schematic in the question below regarding how BCBSM selects specialists to receive the uplift.) How does BCBSM define a member PO, a partner PO and a principal partner PO? If your name appears on the list of specialist physicians that the PO submits to PGIP, you are a member of that PO and that PO is your member PO. (Each physician can be a member of only one PO for purposes of PGIP.) If you provide care to patients attributed to PO's other than your member PO, those POs are considered your partner POs. If a partner PO s attributed patients represent the highest proportion of your professional services, you are a principal partner of that PO and that PO is your principal partner PO. If your member PO accounts for the highest proportion of your professional costs, you do not have a principal partner PO. How do I know which PO is my principal partner PO? In the second quarter of 2012, BCBSM will provide the POs with information on the specialist practice units that provide a substantial proportion of professional services to patients attributed to a PO other than their member PO. BCBSM will strongly encourage the principal partner POs to reach out to these specialist practice units (and their member POs) to begin conversations about nomination and signing Primary Care-Specialist agreements. BCBSM will also strongly encourage the member POs to notify their member specialist practice of the name of their principal partner PO, if applicable. How does BCBSM select the specialists who receive the fee uplift? Nomination is a necessary, but not sufficient, factor for receipt of the uplift. BCBSM uses measures of quality, utilization, efficiency and/or cost to rank and select some of the nominated specialist practice units to receive the uplift. Although the measures used to assess performance will vary by specialty type, and may include some Practice Unit-specific measures, the general approach to determining a practice unit s performance score is population-based, i.e., based on the weighted average of the PO (or sub-po) scores, as demonstrated in the schematic below: 36

37 Percent of Professional Costs Associated with Attributed PO Members PU A s Performance Score Based on the Weighted Average of the PO s Scores PO 3 10% PO 2 35% PO 4 10% PO 1 45% Practice Unit A (PU A) If PU A is a member of PO 2, PO 1 is a principal partner (because it accounts for the highest proportion of professional costs) and PU A must be nominated by both PO 1 and PO 2. If PU A is a member of PO 1, PU A has no principal partner and must be nominated only by PO 1. The measures that will be used in selecting specialists for fee uplifts in 2013 are under development. What is a Primary Care-Specialist agreement? A Primary Care-Specialist agreement (also referred to as a PCMH-N agreement or an OSC compact) is a signed agreement between a specialist (or specialist practice unit) and a PO or Organized System of Care (OSC) to collaborate with provider partners in developing systems and care processes that support coordination and management of patients care across settings and over time. The agreement focuses on adopting processes consistent with the principles of the American College of Physician s Patient Centered Medical Home-Neighbor (PCMH-N) model, which include: ensuring effective communication and coordination with PCMH practices, providing timely consultations and referrals, supporting high quality safe care and enhanced access, and recognizing that the PCMH practice has overall responsibility for coordination and integration of care provided to the patient. The Primary Care-Specialist agreement may be between the specialist Practice Unit (or the individual physicians within the Practice Unit) and an OSC if the nominating PO is actively engaged with the OSC that has signed the agreement. A copy of a template Primary Care-Specialist agreement can be found on the PGIP PO Collaborative site; POs and OSCs may use the template but are not obligated to do so. The PO Collaboration Site can be accessed through the BCBSM secured provider portal on Once in the site, click on the Analytics tab; then select Uplift. The template can be found under BCBSM Documentation. Nominated PUs must be actively engaged with the nominating PO. Active engagement is demonstrated by progress toward 1) involvement in managing the use of services and optimizing quality of care, 2) collaboration with primary care physicians in their PO to develop and improve shared processes of care, and 3) collaboration on efforts to coordinate care across settings and over time. The POs approach to nominating specialist practice units must be fair, equitable and transparent. Each PO s process may focus on different attributes and capabilities for member and partner specialists, but all specialists regardless of their member status must have an equal opportunity to be considered for nomination. Each PO must document the nomination process in writing and disclose the process on the PGIP PO Collaboration site. 37

38 What can I do to increase my chances of receiving the fee uplift? Specialists can start by actively engaging with their member PO and collaborating with the PO to achieve better care for their patients. This often involves implementing a more structured and consistent communication and care coordination process between specialists and primary care physicians consistent with the PCMH-N principles noted above. Specialists can also examine their prescribing patterns to identify if their practice unit is making optimal use of generic drugs, since a generic drug metric may be used in the uplift methodology. Specialists can also work with their member PO to review the CAVE reports to identify areas of possible improvement. If I received a fee uplift this year, will I receive the fee uplift next year? Receipt of an uplift in one year does not guarantee receipt of an uplift in the following year. The nomination and selection process for the fee uplifts take place annually. To receive a fee uplift, specialists must first be nominated by one or two POs with which they have a signed Primary Care-Specialist agreement. The specialist Practice Units are then evaluated by BCBSM according to the uplift methodology applicable to their specialty type. A subset of the nominated specialist Practice Units are selected based on their performance results. Will BCBSM share the uplift methodology with the POs and specialists prior to implementing the uplifts? Some physicians have asked to review the methodology prior to its application for purposes of the uplift. The measures to be used for the uplifts are currently under development and review. BCBSM must balance the request s for advance review of the methodology against the calls for expeditious implementation of the specialist fee uplifts. Were BCBSM to offer physicians the opportunity to review the methodology in advance, the fee uplifts would be significantly delayed. BCBSM will share the methodology with the POs and specialists with the final uplift selections. The uplift methodology will undergo continuous improvement based on BCBSM analyses and provider feedback. 38