Blue Care Network of Michigan

2012

Physician Recognition Program

2012 PRP Design – Incentive Categories

Funding is split between Base PRP measures, PRP Bonus Incentives and Pay As You Go (PAYG) Incentives:

- Base PRP Measures

- HEDIS®*-oriented measures

- Analyzed and paid annually

*HEDIS is a registered trademark of the National Committee for Quality Assurance.

- PRP Bonus Incentives

- Incentives with specific time frames, measures and payments

- Analyzed and paid annually

- Pay As You Go Incentives- Payments made throughout the year for services that have been

completed during the year

BCN HMOSM Commercial

Performance Recognition Program 20122012 Base PRP Measures:Quality – Preventive Screening

Well Child – 15 months

Well Child 3-6 years

Childhood Immunizations – Combo 3

Adolescent Immunizations – Combo 1

Cervical Cancer Screening

Breast Cancer Screening

Colorectal Cancer Screening

Quality – Disease Management

Diabetes Retinal Eye Exam

Diabetes HbA1C Testing

Diabetes HbA1C level < 8

Diabetes Monitoring for Nephropathy

Diabetes LDL-C Testing

Diabetes LDL-C level < 100

Cardiovascular Disease LDL-C Testing

Cardiovascular Disease LDL-C level < 100

Quality Payout -

Quality Composite Score 70%-74%: $.75 PMPM

Quality Composite Score 75%-79%: $1.25 PMPM

Quality Composite Score >=80%: $2.25 PMPM

2012 Bonus IncentivesCommercial HMO

Appropriate testing for children with pharyngitis

Appropriate treatment for children with upper respiratory infection

Avoidance of antibiotic treatment in adults w/acute bronchitis

Follow up after Hospitalization – Mental Illness

Follow up care for children with ADHD – Initiation Phase

BMI Child

2012 Pay As You Go Incentives:Commercial HMO

13 of 15 Base PRP measures:

excluded is Breast Cancer Screening & Colorectal Cancer Screening

Chlamydia screening

Scoring and Payout - Fall 2012 and Spring 2013

First Payment PAYG $5

Second payment based on tiered scale

Composite score 0%-69% $5 per service

Composite score 70%-79% $10 per service

Composite score 80% or greater $15 per service

Base PRP and PAYG - Commercial

• Base PRP is made up of seven preventive screenings and

eight disease management measures which are combined

and determine the Quality Summary Report.

• PAYG measures pay twice a year on 13 of the Base PRP

measures.

– First PAYG payment will be $5 for each service completed.

– Second PAYG payment will be paid at the appropriate

amount according to the provider’s Base PRP score.

Base PRP and PAYG - Commercial

• Payment will be based on a primary care physician’s overall

composite score:

Tiered base PRP

$PMPM

Tiered PAYG $ per

measure

70-74% $0.75 0-69% $5.00

75-79% $1.25 70-79% $10.00

≥80% $2.25 ≥80% $15.00

PAYG Incentives - Commercial

• PAYG includes all but the following Base PRP measures:

– Breast cancer and colorectal cancer screening

– Payment: tiered payout by completed service, based on year-end Base PRP Quality Composite Score

Bonus Incentives - Commercial• Chlamydia screening

– Ages: females 16-24 years of age identified as sexually active via pharmacy or claims encounter data

– Measurement period: Jan. 1, 2012 – Dec. 31, 2012

– Payment: flat fee of $25 paid to the eligible provider who completes the qualifying test according to the specifications

Bonus Incentives - Commercial

• Appropriate testing for children with pharyngitis– Ages: 2 yrs. old as of Jan. 1, 2012, to age 18 as of Nov. 30, 2012 with

a single diagnosis of acute pharyngitis, acute tonsillitis or streptococcus sore throat, dispensed an antibiotic and received a group A strep test for the episode

– Measurement period: Jan. 1, 2012, to Nov. 30, 2012

– Payment: $40 for every qualified member; paid at the MCG level

– See technical specifications for clarification and additional criteria to meet.

• Avoidance of antibiotic treatment in adults with acute bronchitis– Ages: Adults 18 yrs. old as of January 1 of the prior year to 64 years

old as of Dec. 24, 2012, with a diagnosis of acute bronchitis and NOT dispensed an antibiotic prescription

– Measurement period: Jan. 1, 2012, through Dec. 24, 2012

– Payment: $60 for every qualified member; paid at the MCG level

– See technical specifications for clarification and additional criteria to meet.

Bonus Incentive – Commercial (con’t.)

• Follow-up care for children with ADHD – initiation phase

– Age: Members 6 years of age as of Jan. 1, 2012, and 12 years of age as

of Dec. 31, 2012, newly diagnosed and dispensed ADHD medication with

one follow-up practitioner visit within 30 days of initiating the medication

– Measurement period: Jan. 1, 2012, through Dec. 31, 2012

– Payment a flat fee of $50 paid to the PCP for each member with qualifying

follow-up visit with a practitioner with prescribing authority

– See technical specifications for clarification and additional criteria to meet.

• Follow-up care after hospitalization – mental illness

– Age: Members 6 years of age and older hospitalized for treatment of

selected mental health disorders; follow-up visit within seven days of

discharge with a mental health practitioner

– Measurement period: Discharges between Jan. 1, 2012, and Oct. 31,

2012

– Payment: Flat fee $100 paid to the first behavioral health specialist for

each qualifying outpatient visit

– See technical specifications for clarification and additional criteria to meet.

Bonus Incentives – Commercial (con’t.)

• Appropriate treatment for children with upper respiratory

infection

– Age: Members 3 months of age as of Jan. 1, 2012, to 18

years of age as of Dec. 28, 2012, who were given a

diagnosis of upper respiratory infection (URI) and were NOT

dispensed an antibiotic prescription

– Measurement period: Jan. 1, 2012, through Dec. 31, 2012

– Payment: $40 for every qualified member; paid at the MCG

level

– See technical specifications for clarification and additional

criteria to meet.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Child BMI Assessment

- Members 7 to 17 years of age who have an active BCN

commercial span through end of 2012, had an office

visit during 2012.

- Measurement period -

August 1, 2012, through December 31, 2012; payment

calculations after January 31, 2013;

- Payment –

flat fee of $50 paid to the eligible provider for each

reported BMI.

Bonus Incentives – Commercial

(con’t.)

11

2012 BCNA Performance Recognition Program

BCNA 2012 Measures

12

MeasureFinal

Measure

Measure

Type

Breast Cancer Screening Yes BASE/PAYG

Cholesterol Screening for Patients with Diabetes Yes BASE/PAYG

Cholesterol Screening for Patients with Heart Disease Yes BASE/PAYG

Colorectal Cancer Screening yes BASE/PAYG

Diabetes Care – Blood Sugar Controlled Yes BASE/PAYG

Diabetes Care – Cholesterol Controlled Yes BASE/PAYG

Diabetes Care – Eye Exam Yes BASE/PAYG

Diabetes Care – Kidney Disease Monitoring Yes BASE/PAYG

Annual Monitoring For Patients on Persistent Medications Yes BONUS

Diabetes Treatment (ACE/ARB for Hypertension) Yes BONUS

Glaucoma Testing Yes BONUS

High Risk Medication Yes BONUS

Adult BMI Assessment Yes BONUS

BCN Advantage HMO-POSSM and BCBSM Medicare Plus

Blue PPOSM

2012 Performance Recognition Program

2012 Base PRP Measures

Quality –Preventive Measures

– Cancer Screening

– Colorectal cancer screening

Quality – Disease Management

– Diabetes retinal eye exam

– Diabetes HbA1C level < 8

– Diabetes monitoring for nephropathy

– Diabetes LDL-C level < 100

– Diabetes LDL-C testing

– Cardiovascular disease LDL-C testing

Quality Payout -

– Quality composite score PMPM

– 70%-74% $2.00

– 75%-79% $3.50

– >= 80% $5.00

2012 Bonus Incentives

- Annual monitoring for patients on

persistent medications

- Diabetes treatment (ACE/ARB for hypertension)

- Glaucoma testing

- High Risk Medications

- Adult BMI

2012 Pay As You Go Incentives- All of the base PRP measures

Scoring and Payout

- Fall 2012 and Spring 2013

- Payment PAYG $10

Score Thresholds

Base PRP Calculation = MA Quality Score x Member Months x PMPM Amount

Tiered PAYG $Per Measure Tiered BASE PRP $PMPM

Score Between: $/Service Score Between: $PMPM

0% 69% $10 0% 69% $0.00

70% 74% $10 70% 74% $2.00

75% 79% $10 75% 79% $3.50

80% 100% $10 80% 100% $5.00

BCNA Physician Assessment

• To complete the BCN Advantage Physician Assessment on Health e-Blue, use the

Physician Assessment form submission tool to submit each Hierarchical Condition Category

(HCC) relating to a substantial existing chronic disease, including coexisting historical

diagnoses that are still relevant for a member. Be sure to support the diagnoses with

medical record documentation, which is subject to validation by the Centers for Medicare &

Medicaid Services.

• Step-by-step instructions for using the form submission tool is located on Health e Blue at

the bottom of the page.

• In order to qualify for reimbursement, you must complete the physician assessments in

2012. The last date for electronic submission on Health e-Blue is Jan. 4, 2013.

• BCN will pay reimbursements twice a year. If submitted on Health e Blue the

reimbursement is $200 per BCNA member. If hardcopy via fax or mail the reimbursement is

$150 per BCNA member.

Health e-BlueSM Access

Sign up for Health e-Blue

To sign up for access to Health e-Blue, follow these steps:

1. Go to MiBCN.com

2. Click on I am a provider.

3. Under the News and Updates heading, click on Sign up for Provider Secured Services.

4. Under the Solutions available through Provider Secured Services subheading, click on Health e-Blue for Blue Care Network patient data and Blue Cross Blue Shield of Michigan Medicare Advantage patient data (Health e-Blue application).

QUESTIONS??

Thank you for attending.Christina Caldwell, Provider Affairs Representative

734-332-2949 ccaldwell@bcbsm.com