2014 Specialist Fee Uplifts Frequently Asked Questions Updated January 2014

Transcription

1 2014 Specialist Fee Uplifts Frequently Asked Questions Updated January 2014 What are specialist fee uplifts and why is Blue Cross Blue Shield of Michigan implementing fee uplifts? Blue Cross Blue Shield of Michigan (BCBSM) is transitioning from a payment approach based solely on fee-for-service to an approach that layers fee-for-value upon the fee-for-service foundation. In the past, increases in specialist fees were typically based on price inflation. Increasingly, a portion of professional reimbursement is tied to incentivizing and rewarding specialists for supporting the Patient Centered Medical Home (PCMH) model as PCMH-Neighbors, and for collaborating with their community of caregivers to optimize use, efficiency and quality in their shared patient population. Eligible Physician Group Incentive Program (PGIP)-enrolled specialists who are members of a practice unit selected for the fee uplifts receive a higher level of reimbursement for a wide range of service codes from February 1 of the selection year through January 31 of the following year. The fee uplift selection process takes place annually. Which specialties are eligible for fee uplifts? Effective February 1, 2014, 24 specialties are eligible for fee uplifts. (There were seven specialty types eligible for fee uplifts in 2013: cardiology, emergency medicine, gastroenterology, nephrology, obstetrics/gynecology, oncology/hematology, orthopedic surgery.) In order to be eligible for fee uplifts, a specialist must be: 1) A member of a PGIP physician organization (PO)

2 2) Nominated by, and have a signed Primary Care-Specialist Agreement with, their member PO 3) Nominated by, and have a signed Primary Care-Specialist Agreement with, their principal partner PO, if applicable. The Primary Care-Specialist Agreement must have been signed within the past two years. In addition, practitioners must appear on the Practitioner Alignment (PA) tool the data system used to collect information on the practitioners in PGIP in the summer prior to the beginning of the fee uplift period and have a primary specialty or a functioning as specialty eligible for a fee uplift. Effective February 1, 2015, virtually all specialty types except anesthesiology will be eligible to receive fee uplifts. What are the 2014 specialist fee uplift percentages? For each specialty type, the top third of nominated practices receive a 10 percent fee uplift and the middle third of nominated practices receive a 5 percent fee uplift. Nominated pediatric practices for all specialty types except neonatology and OB/GYN receive a 10 percent uplift; neonatology and OB/GYN practices are ranked into thirds as described above. Oncologists not selected for a performance-based fee uplift are eligible for a 5 percent fee uplift if they do one of the following: Participate in both the Michigan Oncology Clinical Treatment Pathways Program and the Michigan Oncology Quality Collaborative Achieve certification through the Quality Oncology Practice Initiative, also known as QOPI To what codes are the fee uplifts applied? In a change from 2013, the fee uplifts apply to most procedure codes, except those for ambulance, durable medical equipment, prosthetics and orthotics, anesthesia, immunizations, hearing, vision and most injections. Note: claims for the Federal Employee Program are excluded from the Physician Group Incentive Program PO component. How does BCBSM define a member PO and a principal partner PO? If your name appears on the PA tool your PO submits to PGIP, you are a member of that PO and that PO is your member PO. (Each practitioner can be a member of only one PO at any given time for purposes of PGIP.) BCBSM members are not required to choose a primary care physician. However, for purposes of PGIP, patients are attributed to the primary care physician from whom they have received the most recent services and to the member PO of their attributed primary care physician. Your practice has a principal partner PO if: Patients attributed to a PO other than your member PO account for a substantial proportion of the patients your practice serves The non-member PO represents a greater share of the patients who receive services from your practice than the member PO

3 Your practice provides services to at least 50 unique patients from the non-member PO The non-member PO represents at least 20% of the total BCBSM patients who receive services from your practice How do I know which PO is my principal partner PO? BCBSM provides the PGIP physician organizations with information on the specialist practices that provide a substantial proportion of services to patients attributed to a PO other than their member PO. BCBSM strongly encourages the principal partner POs to reach out to these specialist practices (and their member POs) to begin conversations about nomination and signing Primary Care-Specialist Agreements. BCBSM also strongly encourages the member POs to notify their member specialist practices of their principal partner PO, if applicable. BCBSM provides the POs with a list of preliminary principal partners in the spring and a list of final principal partners in September. Do the principal partner nomination requirements apply to all specialty types? No. For the 2014 specialist fee uplifts, the requirement to obtain principal partner nominations is being postponed for some specialty types to: Reduce the burden on the POs associated with nominations Offer the POs the opportunity to focus on engaging with current principal partners Allow the POs the time to develop effective approaches to collaborating with principal partners Provide the POs the time needed to educate specialists about Patient Centered Medical Home-Neighbor (PCMH-N) concepts, principal partners and population-level performance Assure that the process of requesting nominations from principal partners for a large number of new specialty types is orderly, meaningful and fair The following table provides a summary of the requirements for principal partner nomination and the relevant fee uplift metrics. New for 2014 Fee Uplifts Specialty Type Nomination Required? Member PO Principal Partner PO (if applicable) Cardiology Emergency Medicine Gastroenterology Nephrology Obstetrics/Gynecology Orthopedics Oncology Fee Uplift Metrics Comprehensive metrics (same or similar to those used for 2013 fee uplifts)

4 New for 2014 Fee Uplifts Specialty Type Nomination Required? Member PO Principal Partner PO (if applicable) Fee Uplift Metrics Endocrinology New comprehensive metrics based on literature Otolaryngology review, consultation with subject matter experts Pulmonology and feasibility (to be developed during 2013) Allergy Chiropractic Critical Care Infectious Disease Neonatal Care Neurology Pain Management Physical Medicine Podiatry Psychiatry Psychology Rheumatology Sports Medicine Urology Population-level per member per month cost metric BCBSM may require that more specialty types be nominated by their principal partners for 2015 and beyond. What is the PCMH-Neighbor model? The principles of the PCMH-N model include: Ensuring effective communication and coordination with PCMH practices. Providing timely consultations and referrals. Supporting high quality safe care and enhanced access. Recognizing that the PCMH practice has overall responsibility for coordination and integration of care provided to the patient. What is a Primary Care-Specialist agreement? A Primary Care-Specialist agreement (previously 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

5 principles of the American College of Physician s PCMH-N model. Additional information about the PCMH-N model can be found at Field Code Changed A copy of a template Primary Care-Specialist agreement can be found on the PGIP Collaborative site; POs and OSCs may use the template but are not obligated to do so. The PGIP Collaboration Site can be accessed by PGIP participating POs 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. Who must sign a Primary Care-Specialist agreement? All specialist practitioners regardless of employment status must have a signed agreement to be eligible for specialist fee uplifts. Agreements can also be signed by an OSC instead of a PO if the PO is actively engaged with an OSC that has signed the agreement. A standard employment agreement between an employer and a practitioner does not constitute an acceptable Primary Care-Specialist agreement. In 2014, to reduce the burden associated with obtaining signed agreements with principal partners, the member PO/OSC may facilitate the process of obtaining a signed agreement. A member PO/OSC may obtain a signed agreement with the practice that includes a provision stating that the member PO/OSC has the authority to sign an agreement with the practice s principal partner PO on the practice s behalf. The PO/OSC may act on behalf of the practice only if and when the member PO/OSC has taken steps in conjunction with principal partner POs to assure that the specialists with principal partner POs have been informed about the relationships and the attendant responsibilities in the context of those relationships. Can POs use the Organized System of Care (OSC) agreement as the Primary Care-Specialist agreement required for nomination? No. The OSC agreement is a legal agreement between BCBSM and the OSC related to establishment of the Organized System of Care Program. The Primary Care-Specialist agreement required for specialist fee uplift nomination - is an agreement between an individual specialist (or a group of specialist practitioners) and a Physician Organization (or OSC). Because the parties to the agreements are different, and because the agreements serve very different purposes, the OSC agreement cannot be used as the Primary Care-Specialist agreement. What criteria do POs use to nominate specialists for fee uplifts? Nominated practice units (PUs) must be actively engaged with the nominating PO. Active engagement is demonstrated by progress toward: Involvement in managing the use of services and optimizing quality of care Collaboration with primary care physicians in their PO to develop and improve shared processes of care Collaboration on efforts to coordinate care across settings and over time. The approach used by the PO to nominate specialist PUs must be fair, equitable and transparent. While each PO has the flexibility to develop their own process, which may focus on different attributes and capabilities for member and

6 partner specialists, all specialists regardless of their member status must have an equal opportunity to be considered for nomination. Each PO must document their nomination process in writing and disclose the process on the PGIP Collaboration site. When do POs nominate specialist practices? The POs must submit nominations to BCBSM in the fall of each year. In the fall of 2013 and 2014, the POs will submit their nominations through the PGIP Collaboration site. The process for submitting nominations may change in Information is shared with the POs through the PGIP Collaboration site and webinars, prior to the nomination process. Do all specialists nominated by a PO receive a fee uplift? No. Nomination is a necessary, but not sufficient, factor for receipt of the fee uplift. BCBSM uses population-based, specialty-specific measures of quality, utilization and/or efficiency to rank and select the nominated specialist practice units to receive the fee uplifts. For 10 specialties cardiology, emergency medicine, endocrinology, gastroenterology, nephrology, obstetrics/gynecology, oncology, orthopedics, otolaryngology, pulmonology the metrics used to determine receipt of the specialist fee uplift vary by practitioner specialty and include both practice-based and population-based metrics. For the fee uplifts effective February 1, 2014, the top two thirds of fully nominated non-pediatric practices will be selected to receive a fee uplift. In addition, all fully nominated pediatric practices will be selected for a fee uplift.neonatologists and OB/GYNs are an exception to this approach for pediatric practitioners.. How are metrics chosen for the specialty fee uplifts? Comprehensive, specialty-specific metrics for the specialist fee uplifts are selected based on the following process: 1. Comprehensive literature review to identify relevant industry standard metrics and clinical guidelines. 2. Consultation with BCBSM clinical leadership and external specialty-specific subject matter experts (the relevant Michigan specialty societies provide recommendations for subject matter experts). 3. Determining the feasibility of calculating the metrics through claims data or other available data resources. 4. Assessing whether the metric has sufficient sample size to be measured and whether there is adequate variation between practices. What is the difference between a practice-based metric and a population-based metric? Why does BCBSM use population-based metrics? A practice-based metric is based on the performance of the practitioner or practitioners within the practice. A population-based metric is based on the performance of communities of caregivers who share responsibility for a population of patients. Population-based metrics reflect the foundational PGIP principle that communities of caregivers share responsibility for patient populations. Measuring at a population level focuses on system performance and encourages communication and collaboration between specialists as well as between primary care and specialty practitioners.

7 For methodological reasons, population-based metrics overcome several limitations inherent in specialist practitioner profiling. Sample size and practitioner sub-specialization can lead to significant case mix differences. Will BCBSM share the new fee uplift metrics with the POs and specialists prior to implementing the fee uplifts? Some specialists have asked to review the metrics used for fee uplifts prior to implementation. BCBSM must balance the requests for advance review of the metrics against the calls for expeditious implementation of the specialist fee uplifts. Were BCBSM to offer the broad practitioner community the opportunity to review the new metrics in advance, the fee uplifts for new specialty types would be significantly delayed. BCBSM has consulted with subject matter experts recommended by the relevant specialty societies at the early stages of conceptualizing and developing the metrics and at the later stages when the metrics were nearly final. BCBSM shared the metrics with the POs and specialists with the final fee uplift selections. The fee uplift metrics and methodology will undergo continuous improvement based on BCBSM analyses and practitioner feedback. Has BCBSM made any changes in 2014 to the specialist fee uplifts for existing eligible specialty types? BCBSM is removing the following from the 2014 fee uplift metrics: 1) Cardiology Percentage of members between 18 and 75 years of age with a diagnosis of congestive heart failure who had LDL cholesterol screening during the measurement period. Percentage of members between 18 and 75 years of age with coronary artery disease who received a statin during the measurement period. 2) Orthopedics Percentage of members aged years with fracture of the hip, spine, or distal radius who had a central dual-energy -ray absorptiometry (DA) measurement performed or pharmacologic therapy. 3) Obstetrics & Gynecology Percentage of female members ages 13 to 17 who received at least one shot in the HPV vaccine series. Percentage of female members ages 13 to 17 who received all three shots in the HPV vaccine series out of those who received at least one dose. Adequacy of prenatal care from the obstetrical composite. What can a PO do to increase the chances of its member practitioners receiving the fee uplift? POs can start by actively engaging and collaborating with specialists to achieve better care for their patients. This may involve implementing a more structured and consistent communication and care coordination process between specialists and primary care physicians consistent with PCMH-N principles and the PCMH-N Interpretive Guidelines. Because BCBSM uses a population-based approach, POs should focus conversations with specialists on improving population-level cost, quality and efficiency performance rather than focusing only on performance at the individual practice level. POs can foster a culture of innovation and improvement by convening groups of practitioners to identify a few key opportunities to improve value. POs can also engage with and assist their practices in conversations with principal partners.

8 For example, POs can encourage specialists to: Implement the recommendations of Choosing Wisely ( to encourage practitioners and their patients to discuss services that may be unnecessary Implement the capabilities in the PCMH-N Interpretive Guidelines, particularly those in Domain 14 Provide care consistent with evidence-based clinical guidelines Examine their prescribing patterns to identify if their practice is making optimal use of generic drugs Review the PO-level CAVE reports with specialists to identify areas of possible improvement Identify specific opportunities for quality improvement and optimizing care through conversations with primary care practitioners and other specialists If a primary care physician practices as a specialist, is the practitioner eligible for a specialist fee uplift? What specialty types map to each specialist fee uplift category? Practitioners are eligible for a specialty fee uplift if they function as a specialist. For example, if an internal medicine physician functions as a gastroenterologist, the physician may receive a gastroenterology fee uplift. This physician would not be eligible to be designated as a PCMH. To determine if a practitioner is eligible for a specific specialty fee uplift, BCBSM uses the Practitioner Alignment tool s listed specialty type (which is either the Primary Portico specialty or the practitioner s functioning as specialty, as identified by the PO in the PA tool). The mappings of Portico specialties to the overall specialty category are noted in Appendix II. Will BCBSM publicly recognize the specialists who are receiving the specialist fee uplift? BCBSM does not plan to publicly acknowledge the practices receiving the specialist fee uplifts. In accordance with the principles of PCMH-N, where primary care physicians (PCPs) routinely interact with the specialists treating their attributed patients, practices are selected for specialist fee uplifts based on the care provided to the populations of patients attributed to the PCPs with whom the specialist collaborates, rather than the care provided solely by the practitioners in the practice. Because BCBSM uses a unique, population-based approach to select specialists for fee uplifts, patients or members might not understand that BCBSM is recognizing selected practices for their partnership with communities of caregivers that provide effective and efficient care, rather than for their practice-level performance. POs may choose how they communicate information on the specialist fee uplifts, but we ask that POs share proposed messages with Value Partnerships staff before they make the communications available to patients. (Please submit the communication information for review and approval through the PGIP Collaboration site using the Uplifts category. Value Partnerships staff will respond to the request within 10 business days.) To which product lines do the fee uplifts apply? Specialist fee uplifts apply to: PPO products, e.g., Community Blue, MIChild, Flexible Blue, Blue Preferred Plus

9 BlueCard Host (outside MI Blues plan member sees MI physician) Traditional Blue Choice PPO (formerly Point-of-Service) Federal Employee Program What is the 2014 timetable for the specialist uplifts? Date BCBSM Responsibilities PO Responsibilities Spring 2014 Spring/Summer 2014 July t 1, 2014 Late Summer 2014 Early November 2014 Fall/Winter 2014 January 2015 BCBSM provides each PO with a list of preliminary member specialist PUs and principal partner specialist PUs (and their member POs)* BCBSM takes snapshot of PA tool for purposes of the 2015 specialist fee uplifts BCBSM provides each PO with a final list of principal partners BCBSM solicits specialist PU nominations from the POs BCBSM applies uplift methodology to each specialty type and selects specialist practice units to receive the uplifts BCBSM notifies POs of the specialist PUs selected to receive the uplifts and provides information on the methodology and the data underlying the selection process POs review list and determine which POs and which preliminary principal partner specialist PUs to contact to begin discussions about nomination and obtaining signed Primary Care-Specialist agreements POs reach out to member PUs to assess or begin engagement and obtain signed Primary Care- Specialist agreements POs reach out to anticipated principal partner PUs and their member POs to begin engagement and obtain signed Primary Care-Specialist agreements POs submit updated information on member practitioners POs nominate specialist PUs for the uplifts February 2015 Specialist uplifts take effect *The final member and principal partner lists cannot be created until the practitioner list snapshot in the summer. Should a PO add their principal partner practice units to their PA tool?

10 In connection with the specialist fee uplift process, POs receive a list of principal partner practices and practitioners. This information is made available to the POs to assist with identifying specialist practitioners that the POs may choose to nominate for fee uplifts. This information is not intended to serve as a list of practitioners that POs should add to their POs and POs should not actively recruit practitioners based on this information. As a result of conversations regarding fee uplifts and PCMH-N approaches, principal partner POs and practitioners may jointly determine that the practitioner would prefer to switch to a new PO. In such cases, it is incumbent upon both the practitioner and the new PO to have a conversation with the practitioner s former PO to clarify who will list the practitioner for PGIP purposes. How do employed practitioners receive uplifts? Fee uplifts are applied based on the rendering practitioner on the claim. BCBSM will send reimbursement for a claim to the reimbursement address on record for the rendering practitioner. Reimbursement for an employed practitioner may be sent directly to the employer, such as a health system or medical group. BCBSM plays no role in private employment decisions related to disbursement of claims reimbursements. Will specialists who are newly added to PGIP in the summer be eligible for fee uplifts during the following uplift cycle? Yes. All practitioners in the relevant specialties eligible for fee uplifts who are listed in the PA tool effective July 1, 2014 will be eligible for a fee uplift if their PU has sufficient claims activity to support the metric calculations. Like in the past, the 2015 fee uplift criteria will have peer group substitution limits for PUs to be eligible for the fee uplifts. Practitioners who are added to PGIP after July 1, 2014 will not be eligible for the 2015 fee uplifts, but can be considered for the 2016 fee uplifts.

11 APPENDI I: SPECIALTY MAPPINGS FOR FEE UPLIFTS Specialty Allergy Cardiology Chiropractic Critical Care Emergency Medicine Endocrinology Gastroenterology Infectious Disease Neonatal Care Nephrology Primary Portico or Functioning As Specialty Allergy/Immunology - Internal Medicine Allergy/Immunology Pediatric Allergy/Immunology Cardiology Cardiovascular Disease Clinical Cardiac Electrophysiology Interventional Cardiology Nuclear Cardiology Pediatric Cardiology Chiropractic Medicine Critical Care Medicine - Internal Medicine Critical Care Medicine Pediatric Critical Care Medicine Pediatric Intensive Care Surgical Critical Care Emergency Medical Services Emergency Medicine Pediatric Emergency Medicine Undersea/Hyperbaric Medicine - Emergency Medicine Endocrinology Endocrinology, Diabetes / Metabolism Pediatric Endocrinology Gastroenterology Pediatric Gastroenterology Infectious Disease Pediatric Infectious Disease Neonatal Perinatal Medicine (MD Only) Neonatology Nephrology Pediatric Nephrology

12 Specialty Neurology Obstetrics/Gynecology Oncology Orthopedics Otolaryngology (ENT) Primary Portico or Functioning As Specialty Pediatric Neurology Child/Adolescent Neurology Clinical Neurophysiology Neurodevelopmental Disabilities Neurodevelopmental Disabilities - Pediatrics Neurology Neurology / Psychiatry Neurology with Special Quals in Child Neurology Neuromusculoskeletal Medicine Vascular Neurology Critical Care - Obstetrics/Gyn Gynecology Maternal and Fetal Medicine Obstetrics / Gynecology Obstetrics Reproductive Endocrinology Gynecologic Oncology Hematology Hematology/Oncology Oncology Pediatric Hematology/Oncology Hand Surgery Hand Surgery - Orthopedic Surgery Orthopedic Surgery Sports Medicine - Orthopaedic Surgery Neurotology Otolaryngic Allergy Otorhinolaryngology Plastic Surgery within Head and Neck - Otolaryngology Otolaryngology Otolaryngology/Facial Plastic Surgery Pediatric Otolaryngology

13 Specialty Pain management Podiatry Psychiatry Psychologist Pulmonology Rheumatology Physical Medicine Sports Medicine Urology Primary Portico or Functioning As Specialty Pain Management - Psychiatry / Neurology Pain Management Podiatric Medicine Addiction Medicine - Psychiatry / Neurology Addiction Psychiatry Child/Adolescent Psychiatry Forensic Psychiatry Geriatric Psychiatry Psychiatry Clinical Psychologist-Fully Licensed Pediatric Pulmonogy Pulmonary Disease Pediatric Rheumatology Rheumatology Pediatric Rehabilitation Medicine Physical Medicine / Rehabilitation Sports Medicine - Emergency Medicine Sports Medicine - Family Practice Sports Medicine - Internal Medicine Sports Medicine - Neuromusuloskeletal Medicine Sports Medicine - Physical Medicine / Rehabilitation Sports Medicine Pediatric Pediatric Urology Urological Surgery Urology