2014 erformance Recognition rogram Blue Care Network erformance Recognition rogram Commercial HMO Incentive Materials 2014
2014 Commercial HMO R Materials December 2013 Dear BCN Affiliated rimary Care hysician or Group Administrator: Blue Care Network is pleased to provide you with details of our 2014 physician incentive materials for the commercial population. Enclosed you will find information about the erformance Recognition rogram including Base R, Improvement on Base R and R Bonus incentives for 2014. Our program strives to align provider incentives with the ever changing, stringent quality benchmarks for HEDIS and STARS. BCN s philosophy towards our provider incentive programs also continues to make meaningful payments that encourage appropriate clinical outcomes. The 2014 program is geared toward accomplishing these objectives. Below, please find the highlights of our 2014 program: 2014 Base R highlights Breast cancer screening Cervical cancer screening Childhood immunizations combo 2 Cholesterol management for patients with cardiovascular conditions LDL C testing Cholesterol management for patients with cardiovascular conditions LDL C control <100mg/dL Colorectal cancer screening Comprehensive diabetes care A1C control 9% Comprehensive diabetes care A1C testing Comprehensive diabetes care LDL C control <100 mg/dl Comprehensive diabetes care LDL C testing Comprehensive diabetes care retinal eye exam Well child visits 15 months 2014 R Bonus highlights Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Avoidance of antibiotic treatment in adults with acute bronchitis Chlamydia screening Follow up care for children prescribed ADHD medication initiation phase Weight assessment and counseling for nutrition and physical activity for children/adolescents lease remember that all data entry into Health e Blue SM must be for services rendered, not just ordered or reminders sent. lease visit the Health e Blue home page for all 2014 physician incentive information. If you have any questions, please contact your medical care group leadership or your BCN provider representative. We appreciate your continued support of our physician incentive programs. Sincerely, Karen Kopytek Manager, rovider Affairs age 2 of 11
2014 Commercial HMO R Materials TABLE OF CONTENTS BCN R Summary..... age 4 2014 Base R.... age 4 8 Base R provider eligibility requirements Base R and Improvement on Base R payment determination Base R performance measurement guidelines Tools to help maximize quality scores Data Submission 2014 R Bonus... age 9 10 Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Avoidance of antibiotic treatment in adults with acute bronchitis Chlamydia screening Follow up care for children prescribed ADHD medication initiation phase Weight assessment and counseling for nutrition and physical activity for children/adolescents Distribution of R ayment Reports and ayments.. age 10 Reconsideration...... age 10 R Questions..... age 11 Listing of Exhibits Exhibit A 2014 R performance measures and scoring methodology Exhibit B 2014 R incentive schedule age 3 of 11
2014 Commercial HMO R Materials BCN R Summary The 2014 recognition program is focused on outcome based scores that will directly align with HEDIS results. Based on industry wide research conducted on plans across the country that performed well on HEDIS metrics, Blue Care Network has kept the same design for the 2014 Commercial R program. The program is summarized below. Definition: The term provider is referenced throughout the booklet. It refers to either the practice group or the individual provider. If a provider does not belong to a practice group, the individual provider s score will be used. R program highlights: An Improvement On Base R component o roviders who do not meet the BCN plan goal rate for a measure are eligible for a payment if they have improved their quality score by five percent or more from their 2013 final Base R score. Base R will be scored and paid on each individual quality measure instead of an overall threshold score o Each measure s score will fall into one of the following categories: 1) Met Base R achieved the BCN plan goal rate will be paid on all eligible services 2) Met Improvement On Base R provider did not meet plan goal rate but improved by the appropriate percentage needed 3) Not met did not meet plan goal rate or improvement on Base R percentage needed BCN plan goal rate will need to be met in order to earn the Base R per service dollar amount (see age 6 description of BCN plan goal rates) roviders that don t meet plan goal rate may qualify for the improvement on Base R component All Base R and improvement on Base R components will be scored and paid at a practice group level o ractice group is identified from ortico based on the Network row associated with the C affiliation o roviders who do not submit claims under a practice group will be scored and paid at their individual practitioner level Base R rovider Eligibility Requirements In order to qualify for any component of the R program, the following conditions must exist: A. rovider/medical care group must have signed the BCN 2014 Medical Services Agreement. age 4 of 11
2014 Commercial HMO R Materials B. rovider/mcg must be in full compliance with all terms and conditions of BCN s Medical Services Agreement, including: (1) BCN standards for timely and accurate provision of encounter, referral and claims data. (2) Remittance of any funds due to BCN for prior contract years. C. rovider must be affiliated with the HMO product at the time of payment in 2015 to be eligible for any R payments, unless the provider is recently retired. D. rovider/provider office must have a Health e Blue sign on and actively use the program. E. BCN retains the right to modify the R for any reason and at any time. Modifications may include, but are not limited to: (1) Exclusion or removal of measures from the R. (2) Changes to the R s calculation methodologies. F. All provider data returns are auditable. Blue Care Network does periodic random audits. If you are randomly selected to be audited for HEB data entry or EMR you must pass the audit in order to be eligible for payment. Base R or Improvement On Base R ayment Determination Base R payments for each eligible provider will be calculated using the following methodology, regardless of membership level. 1) Calculate quality score: A quality score for each Base R measure is calculated as follows on either a practice group or individual basis: Sum the denominators (eligible services) for all eligible Cs in the practice group. Sum the numerators (members who had the service) for all Cs in the practice group. Calculate the practice group or individual provider s quality score for each Base R measure: (numerator sum)/(denominator sum) 2) Compare the practice group or individual provider s quality score to the BCN plan goal rate for quality (column 2). a) If the plan goal rate is met, the payment for services will be calculated (columns 3 and 3A). b) If the plan goal rate is not met, the provider improvement on Base R percentage will be calculated. If the improvement on Base R percentage is achieved (column 4), the payment for services will be calculated (columns 5 and 5A). age 5 of 11
2014 Commercial HMO R Materials c) If neither the plan goal rate nor improvement on Base R is met, then no quality incentive payment will be earned. BCN plan goal rate, improvement on Base R and payment amounts are noted below. (1) Base R Incentive Measures Base R or Improvement On Base R ayment Table Base R (2) 2014 lan Goal Rate (3) $Amount er Service (3A) ractice group or individual provider achieved the plan goal rate, the payment is: Breast cancer screening 80% $40 ($Amount er Service) x (All Eligible Services) Cardiovascular LDL C control <100 mg/dl 71% $100 ($Amount er Service) x (All Eligible Services) Cardiovascular LDL C testing 92% $40 ($Amount er Service) x (All Eligible Services) Cervical cancer screening 82% $40 ($Amount er Service) x (All Eligible Services) Childhood immunization combo 2 89% $225 ($Amount er Service) x (All Eligible Services) Colorectal cancer screening 70% $40 ($Amount er Service) x (All Eligible Services) Diabetes care A1C control 9% 81% $75 ($Amount er Service) x (All Eligible Services) Diabetes care A1C testing 93% $40 ($Amount er Service) x (All Eligible Services) Diabetes care LDL C control <100 mg/dl 55% $100 ($Amount er Service) x (All Eligible Services) Diabetes care LDL C testing 89% $40 ($Amount er Service) x (All Eligible Services) Diabetes care retinal eye exam 74% $100 ($Amount er Service) x (All Eligible Services) Well child visits 15 months 84% $125 ($Amount er Service) x (All Eligible Services) OR (1) Base R Incentive Measures Improvement on Base R (4) ercentage Improved (5) $Amount er Service (5A) ractice group or individual provider did not meet plan goal rate, but improved from prior year by the appropriate percentage needed, the payment is: Breast cancer screening 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Cardiovascular LDL C control <100 mg/dl 5% $40 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Cardiovascular LDL C testing 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Cervical cancer screening 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Childhood immunization combo 2 5% $125 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Colorectal cancer screening 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Diabetes care A1C control 9% 5% $40 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Diabetes care A1C testing 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Diabetes care LDL C control <100 mg/dl 5% $40 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Diabetes care LDL C testing 5% $25 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Diabetes care retinal eye exam 5% $50 ($Amount er Service) x (Elig Mbrs Meeting Criteria) Well child visits 15 months 5% $75 ($Amount er Service) x (Elig Mbrs Meeting Criteria) age 6 of 11
2014 Commercial HMO R Materials Base R erformance Measurement Guidelines Exhibit A (2014 erformance Measures and Scoring Methodology) outlines definitions for all of the component measures that constitute the Base R measures. If a provider does not meet the Base R plan goal rate of a measure they are still eligible for the improvement on Base R component. lease reference the above section titled Base R and Improvement On Base R ayment Determination for specific criteria that outline the improvement on Base R percentage needed to be eligible for a payment. Each provider will be credited for HEDIS identified services provided through Dec. 31, 2014, to commercial HMO members continuously enrolled with the plan for the entire year and assigned to the provider, regardless of whether the provider was the member s provider at the time services were provided. Credit will be granted to the provider for each component measure only when the specific identified service is documented as provided to the member (by the provider, the member s previous provider, or a specialist). Members may be excluded from measures under certain circumstances as identified by HEDIS criteria, such as bilateral mastectomy for breast cancer screening. Exclusions must be indicated to BCN by the provider offices via the Health e Blue home page through the panel Treatment Opportunities by Condition/Measure screen. BCN recognizes that many provider offices employ reminder letters or may not see certain members in their offices who are identified by BCN as needing certain services. Occurrences such as these will not count as credit in place of the provision of the service for the provider toward the component measure. Tools to Help Maximize Quality Scores Each provider s quality performance measurement data is derived directly from BCN s Health Management rogram reporting database that is accessible through Health e Blue. With regard to the Base R, the Health e Blue Treatment Opportunities by Condition/Measure will provide member detail on the following: Identification of the cohort member population for each component measure that is in need of a specific health promotion, disease prevention, or health management service according to evidence based medicine Intervention opportunity for physicians to supplement BCN s databases for provision of service or exclusion data of which BCN had no knowledge Quality Summary Report provides the interim progress report that comprises the monthly quality rates by measure for providers, practice groups and MCGs age 7 of 11
2014 Commercial HMO R Materials A monthly report will be produced for each provider. This report will outline how the provider is performing by measure against 2014 plan goal rate and the final 2013 Base R score. This report will be available through your provider representative. BCN s expectation is that the provider offices and MCGs will jointly support BCN s efforts to encourage the population of members identified to ultimately receive the specific service identified in Health e Blue from the provider or specialist if appropriate, such as cervical cancer screenings from OB GYNs. Data Submission Health e Blue provides a valuable opportunity for provider offices to assess their current performance as described above and return data to BCN. BCN will only accept electronic submission of data to BCN through the Health e Blue application. As provider offices report missing provision of service information due to coordination of benefits or other issues along with applicable member measure exclusion information, future reporting errors will be minimized. If your office needs assistance with or has a question about Health e Blue, please call Health e Blue technical support at 248 455 3623, email them at healtheblue@bcbsm.com, or contact your BCN provider representative. lease remember that all data entry into Health e Blue must be for services rendered, not just ordered or reminders sent. age 8 of 11
2014 Commercial HMO R Materials R Bonus Details BCN plans to offer six R bonus initiatives during 2014 for commercial members. Technical specification documents, which detail timeframes, measures and payments, will be available in December on Health e Blue. lease use this summary to make internal assessments of your clinical performance for each initiative. Our medical directors and provider representatives are available to assist you in preparation for these initiatives. Appropriate testing for children with pharyngitis Measurement timeframe is January 1, 2014 November 30, 2014 rovider must be with BCN at time of payment to earn the payment ayment will be made at the MCG level otential incentive to be earned = $75 per eligible member per service Watch for specific details in email communications and on Health e Blue Appropriate treatment for children with upper respiratory infection Measurement timeframe is January 1, 2014 December 31, 2014 rovider must be with BCN at time of payment to earn the payment ayment will be made at the MCG level otential incentive to be earned = $75 per eligible member per service Watch for specific details in email communications and on Health e Blue Avoidance of antibiotic treatment in adults with acute bronchitis Measurement timeframe is January 1, 2014 December 24, 2014 rovider must be with BCN at time of payment to earn the payment ayment will be made at the MCG level otential incentive to be earned = $75 per eligible member per service Watch for specific details in email communications and on Health e Blue Chlamydia screening Measurement timeframe is January 1, 2014 December 31, 2014 rovider must be with BCN at time of payment to earn the payment otential incentive to be earned = $40 per eligible member per service Each service will only be paid once per member Watch for specific details in email communications and on Health e Blue Follow up care for children prescribed ADHD medication initiation phase Measurement timeframe is January 1, 2014 December 31, 2014 rovider must be with BCN at time of payment to earn the payment ayment will be for the follow up visit with the practitioner otential incentive to be earned = $75 per eligible member per service Watch for specific details in email communications and on Health e Blue age 9 of 11
2014 Commercial HMO R Materials Weight assessment and counseling for nutrition and physical activity for children/adolescents Measurement timeframe is January 1, 2014 December 31, 2014 rovider must be with BCN at time of payment to earn the payment otential incentive to be earned = $75 per eligible member Each service will only be paid once per member Watch for specific details in email communications and on Health e Blue Distribution of R ayment Reports and ayments BCN will make every reasonable effort to remit the 2014 R payment reports and payments by summer 2015. R payments will be made according to BCN s incentive payment policy, subject to the requirements outlined in this R document. The providers R payment will be associated with the MCG the provider is affiliated with as of Dec. 31, 2014. Reconsideration BCN discontinued any type of retrospective reconsideration beginning with the 2004 R, changing the focus to a more prospective data capture and reporting scenario. As such, BCN strongly encourages individual practitioners and MCGs to focus on the ongoing review and data return using BCN s Health e Blue application during each R year. In the event any future reconsideration process is provided based on extenuating circumstances, BCN will appropriately notify the provider or MCG of the terms, conditions and limitations of such a process. HEDIS is a registered trademark of the National Committee for Quality Assurance age 10 of 11
2014 Commercial HMO R Materials R Questions If you have questions or concerns regarding the R, please direct them to your BCN provider representative or the BCN contacts for your region, as follows: Regional rovide Affairs Contacts BCN Southeast Region Dan Martin, Director II, rovider Outreach Hashim Yar, M.D., Medical Director Julie Marvin, R.N., Network erformance Improvement 20500 Civic Center Drive Mail Code: C238 Southfield, MI 48076 1 866 299 4667 BCN Central (Mid/East) Region Dan Martin, Director II, rovider Outreach Felicia Williams, M.D., Medical Director Julie Marvin, R.N., Network erformance Improvement East Christine Wojtaszek, R.N., Network erformance Improvement Mid 232 S. Capitol Ave Mail Code: L02D Lansing, MI 48933 1 877 258 0168 (Lansing) 1 800 527 1906 (Flint) BCN West Region Dan Martin, Director II, rovider Outreach Denice Logan, M.D., Medical Director Christine Wojtaszek, R.N., Network erformance Improvement 611 Cascade West arkway, S.E. Mail Code: G810 Grand Rapids, MI 49546 1 800 968 2583 Health Management rogram/health e Blue technical support 248 455 3623 or email: healtheblue@bcbsm.com age 11 of 11
EXHIBIT A 2014 BCN erformance Recognition rogram erformance Measures and Scoring Methodology Commercial Members Only erformance Measure (Start Year for Measure) G I Scoring Methodology / Measured opulation M (Note: lease consult the latest Health e Blue/HM materials for updates regarding which HEDIS 2014 codes are applicable for each measure) Quality reventive Screening Breast cancer screening Interim Reporting Data Source HM Quality Summary G I E D Data Sources Comments X X Administrative C will get credit for tests performed by OB/GYN Women who are age 52 74 as of 12/31/2014 HM via Health e Blue Measure criteria may change if BCN clinical guidelines are changed Received one or more mammograms during October 1, 2012 2014 Exclusion: Women who have had a bilateral mastectomy Measured against HEDIS specification (continuously enrolled with BCN October 1, 2012 2014) Cervical cancer screening Women who are age 24 64 as of 12/31/2014 The number of women who were screened for cervical cancer, as identified in steps 1 and 2 below: 1. Age 24 64 as of 12/31/2014 who had cervical cytology (pap) performed in 2014 or the two years prior 2. From the women who did not meet step 1 criteria, women ages 35 64 as of 12/31/2014 who had cervical cytology/hv co testing with service dates four or less days apart performed during 2014 or the four years prior and were age 30 or older on the date of both tests. HM Quality Summary X X Administrative C will get credit for tests performed by OB/GYN HM via Health e Blue Exclusion: Women who have had a hysterectomy with no residual cervix 2012 2014) Colorectal cancer screening HM Quality Summary X X Administrative 51 75 years old as of 12/31/2014 HM via Health e Blue Measured for one or more of the following: One or more fecal occult blood tests (FOBT) in 2014 One or more sigmoidoscopy in 2010 through 2014 age 1 of 4
EXHIBIT A 2014 BCN erformance Recognition rogram erformance Measures and Scoring Methodology Commercial Members Only erformance Measure (Start Year for Measure) G I Scoring Methodology / Measured opulation M (Note: lease consult the latest Health e Blue/HM materials for updates regarding which HEDIS 2014 codes are applicable for each measure) One or more colonoscopy in 2004 through 2014 Exclusion: Members who have had colorectal cancer or total colectomy Interim Reporting Data Source G I E D Data Sources Comments 2013 2014) Childhood immunization combination 2 Children who turn age 2 during 2014 Meeting the combination 2 criteria: (4) DTa* vaccinations, (3) IV* vaccinations, (1) MMR, (1) VZV, (3) HiB* vaccinations, and (3) hepatitis B vaccinations on or before the second birthday. for 12 months prior to 2nd birthday) *Vaccinations administered prior to 42 days after birth should not be counted as a numerator hit. Well child visits 15 months Children turning 15 months old during 2014 Received at least six (6) well child visits with a C during first 15 months of life 31 days after birth through the 15 month birth date) Quality Disease Management HM Quality Summary HM Quality Summary Cholesterol management for patients with cardiovascular disease HM Quality Summary LDL C testing Report Member 18 to 75 years as of 12/31/2014 identified through HEDIS Cholesterol Management for atients with Cardiovascular Condition (CMC) specification An LDL C test performed in 2014 for 2013 and 2014) X X X Administrative Immunization data downloaded from MCIR by BCN monthly before Health e Blue data is run HM via Health e Blue MCIR X X X Administrative HM via Health e Blue X X Administrative HM via Health e Blue Measure is "all or none" no partial credit given for individual vaccinations age 2 of 4
EXHIBIT A 2014 BCN erformance Recognition rogram erformance Measures and Scoring Methodology Commercial Members Only erformance Measure (Start Year for Measure) G I Scoring Methodology / Measured opulation M (Note: lease consult the latest Health e Blue/HM materials for updates regarding which HEDIS 2014 codes are applicable for each measure) Interim Reporting Data Source Cholesterol management for patients with cardiovascular disease HM Quality Summary LDL C control <100 mg/dl Report Member 18 to 75 years as of 12/31/2014 identified through HEDIS Cholesterol Management for atients with Cardiovascular Condition (CMC) specification Last LDL C test performed in 2014 shows a level <100 mg/dl for 2013 and 2014) Diabetes care A1C testing Members with diabetes as identified through HEDIS specification Age 18 through 75 years old as of 12/31/2014 One (or more) A1c tests conducted during 2014 for 2014) Diabetes care A1C control 9% Members with diabetes as identified through HEDIS specification Age 18 through 75 years old as of 12/31/2014 Last A1C test performed in 2014 shows a level of 9% for 2014) Diabetes care LDL C screening Members with diabetes as identified through HEDIS specification Age 18 through 75 years old as of 12/31/2014 At least one LDL C test done during 2014 for 2014) HM Quality Summary HM Quality Summary HM Quality Summary G I E D Data Sources X X Administrative HM via Health e Blue X X Administrative HM via Health e Blue X X Administrative HM via Health e Blue X X Administrative HM via Health e Blue Comments age 3 of 4
EXHIBIT A 2014 BCN erformance Recognition rogram erformance Measures and Scoring Methodology Commercial Members Only erformance Measure (Start Year for Measure) G I Scoring Methodology / Measured opulation M (Note: lease consult the latest Health e Blue/HM materials for updates regarding which HEDIS 2014 codes are applicable for each measure) Diabetes care LDL C control <100 mg/dl Members with diabetes as identified through HEDIS specification Age 18 through 75 years old as of 12/31/2014 Last LDL C test performed in 2014 shows a level <100 mg/dl for 2014) Diabetes care retinal eye exam Members with diabetes as identified through HEDIS specification Age 18 through 75 years old as of 12/31/2014 One or more retinal exams by an eye care professional (optometrist, ophthalmologist or EyeTel Imaging DigiScope) in 2014 or a negative retinal exam result in 2013 for 2014) Interim Reporting Data Source HM Quality Summary HM Quality Summary G I E D Data Sources X X Administrative HM via Health e Blue X X Administrative HM via Health e Blue Comments age 4 of 4
INCENTIVE EXHIBIT B 2014 COMMERCIAL HMO R INCENTIVE SCHEDULE MEASUREMENT ERIOD AYMENT AYMENT MADE TO 2014 Base R Cervical cancer screening Jan Dec 2014 June 2015 ractice group Childhood immunizations combo 2 Jan Dec 2014 June 2015 ractice group Breast cancer screening Jan Dec 2014 June 2015 ractice group Colorectal cancer screening Jan Dec 2014 June 2015 ractice group Cholesterol mgmt for pts with cardiovascular disease LDL C testing Jan Dec 2014 June 2015 ractice group Cholesterol mgmt for pts with cardiovascular disease LDL C control <100 mg/dl Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care A1C testing Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care A1C control 9% Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care LDL C testing Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care LDL C control <100 mg/dl Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care retinal eye exam Jan Dec 2014 June 2015 ractice group Well child visit 15 months Jan Dec 2014 June 2015 ractice group 2014 Improvement on Base R Cervical cancer screening Jan Dec 2014 June 2015 ractice group Childhood immunizations combo 2 Jan Dec 2014 June 2015 ractice group Breast cancer screening Jan Dec 2014 June 2015 ractice group Colorectal cancer screening Jan Dec 2014 June 2015 ractice group Cholesterol mgmt for pts with cardiovascular disease LDL C testing Jan Dec 2014 June 2015 ractice group Cholesterol mgmt for pts with cardiovascular disease LDL C control <100 mg/dl Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care A1C testing Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care A1C control 9% Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care LDL C testing Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care LDL C control <100 mg/dl Jan Dec 2014 June 2015 ractice group Comprehensive diabetes care retinal eye exam Jan Dec 2014 June 2015 ractice group Well child visit 15 months Jan Dec 2014 June 2015 ractice group 2014 R Bonus Appropriate testing for children with pharyngitis Jan Nov 2014 May 2015 MCG Group Appropriate treatment for children with upper respiratory infection Jan Dec 2014 May 2015 MCG Group Avoidance of antibiotic treatment in adults with acute bronchitis Jan Dec 2014 May 2015 MCG Group Chlamydia screening Jan Dec 2014 May 2015 Individual C or OB/GYN Follow up care for children prescribed ADHD medication initiation phase Jan Dec 2014 May 2015 Individual C Weight assessment, counseling for nutrition and physical activity for children/adolescents Jan Dec 2014 May 2015 Individual C