2016 Specialist Value-Based Reimbursement Allergy Fact Sheet€¦ · population of patients . 2016...

Allergy Value-Based Reimbursement

The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”

Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 74 allergists are receiving VBR.

Allergy Value-Based Reimbursement Metrics

Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical

cost of care + pharmacy cost (actual cost) Population

level 20%

Cost Difference Change in cost of care PMPM from prior year Population level

10%

Global Quality Index

A single composite score comprised of 49 quality metrics from across many PGIP initiatives

Population level

10%

Cave Weighted average episode cost relative to peer group Population level

10%

Many Allergy Tests

Proportion of allergy-tested members with >65 tests/year Practice level

10%

Proportion Intradermal

Tests

Proportion of subcutaneous and intredermal tests that are intradermal

Practice level

10%

Immunotherapy Cost PUMPM

Immunotherapy cost per utilizing member per month Practice level

10%

Allergy and Asthma IP/ED

Rate

Number of allergy or asthma inpatient/ED encounters per 10,000 members per year

Population level

10%

Asthma Medication

Ratio

Proportion of members meeting the HEDIS persistent asthma case definition whose asthma medication ratio >0.5

Population level

5%

Asthma: Regular

Spirometry

Proportion of asthmatic members receiving >1 spirometry measurement in 2 years

Population level

5%

Immunotherapy: Routine Care

Proportion of members receiving immunotherapy who also received an E&M claim by an allergist during the year

Practice level

None

Allergy IP/ED Follow-Up

Proportion of allergy inpatient/ED encounters followed by an office visit <30 days post-discharge

Population level

None

. Why Does Blue Cross Use Population-Level Metrics?

Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level

Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a

population of patients

2016 Specialist Value-Based Reimbursement Allergy Fact Sheet

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

o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the

primary care physicians with whom specialists collaborate

How Population-Level Metrics Are Calculated

This example shows the measurement approach with only one metric; the metrics used for allergy are listed

above A maximum of three SubPO relationships are included for each practice; to be included:

o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in

the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used

Value-Based Reimbursement Selection Process

Allergist must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of allergy practices based on the allergy weighted composite score are reimbursed in accordance with the VBR Fee Schedule

Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked

Value-Based Reimbursement Percentages and Codes

Practices in the top third are reimbursed at 110% of the Standard Fee Schedules Practices in the second third are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for

ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.

The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims

This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP Physician Organization or your Provider Consultant.



Anesthesiology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 442 anesthesiologists are receiving VBR.

Anesthesiology Value-Based Reimbursement Metrics



level 50%

Cost Difference

Change in cost of care PMPM from prior year Population level

10%



Population level

40%

*Pediatric anesthesiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.

Why Does Blue Cross Use Population-Level Metrics?



population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the



2016 Specialist Value-Based Reimbursement

Anesthesiology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for anesthesiology arelisted above

A maximum of three SubPO relationships are included for each practice; to be included:o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared memberso At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in

the SubPOo If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used


Anesthesiologists must be nominated by their member physician organization The top two-thirds of non-pediatric anesthesiology practices based on the anesthesiology weighted composite

score are reimbursed in accordance with the VBR Fee Schedule All fully nominated pediatric anesthesiology practices based on the Pediatrics weighted composite score are

reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information) Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked


Anesthesiology practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee

Schedules

Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules

Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules

Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for

ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine visionservices, lab, dental and most injections) and the time and base codes.


This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information

on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP

Physician Organization or your Provider Consultant.

Cardiology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 470 cardiologists are receiving VBR.

Cardiology Value-Based Reimbursement Metrics



level 15%

Cost Difference


10%



Population level

30%


30%

Diagnostic Procedure

PMPM

Standard cost PMPM for cardiac diagnostic procedures Population level

15%

*Pediatric cardiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics. Why Does Blue Cross Use Population-Level Metrics?





2016 Specialist Value-Based Reimbursement Cardiology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for cardiology are listed





Cardiologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric cardiology practices based on the cardiology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric cardiology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)



Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for



This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP Physician Organization or your Provider Consultant.



Cardiothoracic Surgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 92 cardiothoracic surgeons are receiving VBR.

Cardiothoracic Surgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric cardiothoracic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.


Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess

performance at the practice level Population-level metrics:

o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients





Cardiothoracic Surgery Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for cardiothoracic surgeryare listed above

A maximum of three SubPO relationships are included for each practice; to be included:o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared memberso At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in

the SubPOo If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used


Cardiothoracic surgeons must be nominated by their member physician organization (and possibly one other PO)and must have been in PGIP for one year

The top two-thirds of non-pediatric cardiothoracic surgery practices based on the cardiothoracic surgery weightedcomposite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric cardiothoracic surgery practices based on the Pediatrics weighted composite score are reimbursed inaccordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)



Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules




ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine visionservices, lab, dental and most injections) and the time and base codes.






Chiropractor Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 103 chiropractors are receiving VBR.

Chiropractor Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric chiropractors are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.


Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assessperformance at the practice level

Population level metrics:o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a

population of patientso Encourage communication and collaboration between primary care and specialty practitionerso Encourage a focus on system performance, accountability and improvemento Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the




Chiropractor Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for chiropractors are listed above

A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in



Chiropractors must be nominated by their member physician organization and must have been in PGIP for one year

The top four-fifths of non-pediatric chiropractor practices based on the chiropractor weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric chiropractor practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)



Chiropractor practices in the top two-fifths of non-pediatric practices are reimbursed at 110% of the Standard Fee

Schedules

Practices in the second two-fifths of non-pediatric practices are reimbursed at 105% of the Standard Fee

Schedules



ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes






Colon/Rectal Surgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 27 colon/rectal surgeons are receiving VBR.

Colon/Rectal Surgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric colon/rectal surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Colon/Rectal Surgery Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for colon/rectal surgery are listed above




Colon/rectal surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric colon/rectal surgery practices based on the colon/rectal surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric colon/rectal surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Critical Care Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 57 critical care physicians are receiving VBR.

Critical Care Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric critical care physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Critical Care Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for critical care are listed above




Critical care physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric critical care practices based on the critical care weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric critical care practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Dermatology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 111 dermatologists are receiving VBR.

Dermatology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric dermatologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Dermatology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for dermatology are listed above




Dermatologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric dermatology practices based on the dermatology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric dermatology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Emergency Medicine Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 716 emergency medicine physicians are receiving VBR.

Emergency Medicine Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric emergency medicine physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Emergency Medicine Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for emergency medicine are listed above




Emergency medicine physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric emergency medicine practices based on the emergency medicine weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric emergency medicine practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Endocrinology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 83 endocrinologists are receiving VBR.

Endocrinology Value-Based Reimbursement Metrics



level 20%

Cost Difference


10%



Population level

10%


15%

ACS IP and ED Visits

Rate of ambulatory care sensitive IP and ED visits for patients with diabetes

Population level

20%

HbA1c Poor Control

HbA1c poor control for patients with diabetes Population level

10%

HbA1c Screening

HbA1c testing for patients with diabetes Population level

5%

Nephropathy Screening

Nephropathy screening for patients with diabetes Population level

5%

Vitamin D Screening

and Control

Composite of vitamin D screening and control measures for patients with osteoporosis

Population level

5%

*Pediatric endocrinologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Endocrinology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for endocrinology are

listed above A maximum of three SubPO relationships are included for each practice; to be included:




Endocrinologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric endocrinology practices based on the endocrinology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric endocrinology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Gastroenterology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 297 gastroenterologists are receiving VBR.

Gastroenterology Value-Based Reimbursement Metrics



level 30%

Cost Difference


10%



Population level

10%


30%

Colonoscopy Proportion of members with a history of adenomatous polyps with a colonoscopy follow-up interval less than three

years

Population level

20%

*Pediatric gastroenterologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Gastroenterology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for gastroenterology are





Gastroenterologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric gastroenterology practices based on the gastroenterology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric gastroenterology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













General Surgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 383 general surgeons are receiving VBR.

General Surgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric general surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.

Why Does Blue Cross Use Population-Level Metrics? Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess






This example shows the measurement approach with only one metric; the metrics used for general surgery are

listed above


General Surgery Fact Sheet





General surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric general surgery practices based on the general surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric general surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Hospitalist Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 687 hospitalists are receiving VBR.

Hospitalist Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric hospitalists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Hospitalist Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for hospitalists are listed above




Hospitalists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric hospitalist practices based on the hospitalist weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric hospitalist practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Infectious Disease Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 119 infectious disease physicians are receiving VBR.

Infectious Disease Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric infectious disease physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Infectious Disease Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for infectious disease are listed above




Infectious disease physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric infectious disease practices based on the weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric infectious diease practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Nephrology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 178 nephrologists are receiving VBR.

Nephrology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

20%

Nephropathy Screening

Screening for nephropathy among patients with diabetes (HEDIS measure)

Population level

20%

*Pediatric nephrologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.







Nephrology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for nephrology are listed





Nephrologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric nephrology practices based on the nephrology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric nephrology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Neurology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 216 neurologists are receiving VBR.

Neurology Value-Based Reimbursement Metrics



level 40%

Cost Difference


10%



Population level

15%


20%

Imaging for Headache

Proportion of index headache diagnoses that received EEG, CT or MRI of the head on or within 30 days

Population level

15%

*Pediatric neurologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.

Why Does Blue Cross Use Population-Level Metrics? Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess






Neurology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for neurology are listed





Neurologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric neurology practices based on the neurology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric neurology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Neurosurgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 74 neurosurgeons are receiving VBR.

Neurosurgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric neurosurgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Neurosurgery Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for neurosurgery are listed above




Neurosurgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric neurosurgery practices based on the neurosurgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric neurosurgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Obstetrics/Gynecology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 673 Ob/Gyns are receiving VBR.

Obstetrics/Gynecology Value-Based Reimbursement Metrics

Metric Description Level Ob/Gyn Weight

Gyn Only Weight

Women’s PMPM

Overall per member per month (PMPM) medical/surgical cost of care + pharmacy cost (actual cost – women only)

Population level

25% 35%


10% 10%



Population level

10% 10%


15% 20%

Primary C-Sections

Primary C-section incidence during deliveries Population level

10% 0%

Hysterectomies Hysterectomy incidence for women ages 15-64 Population level

10% 10%

Obstetrical Care Quality

Prenatal and postpartum diabetes screening rates Population level

5% 0%

Breast Cancer Screening

Mammograms for women ages 50-64 Population level

5% 5%

Cervical Cancer

Screening

Cervical cancer screening for women ages 21-64 Population level

5% 5%

Women’s Evidence

Based Care

Composite of chronic and acute disease treatment measures for women

Population level

5% 5%







Obstetrics/Gynecology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for Ob/Gyn are listed





Ob/Gyns must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of Ob/Gyn practices based on the Ob/Gyn weighted composite score are reimbursed in accordance with the VBR Fee Schedule



Practices in the top third are reimbursed at 110% of the Standard Fee Schedules

Practices in the second third are reimbursed at 105% of the Standard Fee Schedules

The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.






Oncology/Hematology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 355 oncologists/hematologists are receiving VBR.

Oncology/Hematology Value-Based Reimbursement Metrics



level 5%

Cost Difference


10%



Population level

15%

Cancer PMPM Overall PMPM medical/surgical cost of care + pharmacy cost of cancer population

Population level

30%

Cancer Sensitive

Severe Events

IP admissions or ED visits for cancer sensitive severe events per 100 members with cancer per year

Population level

40%

*Pediatric oncologists/hematologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.







Oncology/Hematology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for oncology/hematology

are listed above A maximum of three SubPO relationships are included for each practice; to be included:




Oncologists/hematologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric oncology/hematology practices based on the oncology/hematology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric oncology/hematology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Ophthalmology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 241 ophthalmologists are receiving VBR.

Ophthalmology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric ophthalmologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Ophthalmology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for ophthalmology are listed above




Ophthalmologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric ophthalmology practices based on the ophthalmology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric ophthalmology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Orthopedics Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017,415 orthopedic surgeons are receiving VBR.

Orthopedics Value-Based Reimbursement Metrics



level 25%

Cost Difference


10%



Population level

15%


20%

Low Back Pain

Proportion of visits with primary diagnosis of low back pain receiving an imaging study

Population level

15%

High-Tech Imaging

Adult MRI and CT imaging per 1,000 member years Population level

15%

*Pediatric orthopedic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Orthopedics Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for orthopedics are listed





Orthopedic surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric orthopedics practices based on the orthopedics weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric orthopedics practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Other Specialty Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 136 physicians with a specialty categorized as “other” (that is, not classified elsewhere) are receiving VBR.

Other Specialty Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric physicians classified as “other” are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Other Specialty Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for the other specialty classification are listed above




Physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric other specialty practices based on the other specialty weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric other specialty practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Otolaryngology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 127 otolaryngologists are receiving VBR.

Otolaryngology Value-Based Reimbursement Metrics



level 30%

Cost Difference


10%



Population level

10%


30%

Pharyngitis Testing

Proportion of children with acute pharyngitis who received a strep test, among those dispensed an antibiotic

Population level

10%

Acute Otitis Externa

Medications

Proportion of members ages 2-64 with acute otitis externa who filled an appropriate topical prescription but did not fill

an oral antibiotic

Population level

10%

*Pediatric otolaryngologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Otolaryngology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for otolaryngology are





Otolaryngology must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric otolaryngology practices based on the otolaryngology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric otolaryngology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Pain Management Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 53 pain management physicians are receiving VBR.

Pain Management Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric pain management physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Pain Management Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for pain management are listed above




Pain management physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric pain management practices based on the pain management weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric pain management practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Pathology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 227 pathologists are receiving VBR.

Pathology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric pathologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Pathology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for pathology are listed above




Pathologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric pathology practices based on the pathology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric pathology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Pediatrics Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules).

From March 1, 2016-February 28, 2017, 628 pediatric specialists (pediatric specialists of all specialty types except allergy and Ob/Gyn) are receiving VBR. (Note that the number of specialists receiving VBR listed in each specialty-specific fact sheet includes pediatric specialists. The 628 pediatric specialists are included in the number of specialists on other fact sheets, such as cardiology. However, pediatric specialists are all evaluated and ranked together according to the metrics below.)

Pediatrics Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%








Pediatrics Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for pediatrics are listed





Pediatric specialists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

All pediatric specialty practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)











Physical Medicine Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 173 physical medicine physicians are receiving VBR.

Physical Medicine Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric physical medicine physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Physical Medicine Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for physical medicine physicians are listed above




Physical medicine physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric physical medicine practices based on the physical medicine weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric physical medicine practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Plastic Surgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 64 plastic surgeons are receiving VBR.

Plastic Surgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric plastic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Plastic Surgery Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for plastic surgery are listed above




Plastic surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric plastic surgery practices based on the plastic surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric plastic surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Podiatry Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 175 podiatrists are receiving VBR.

Podiatry Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric podiatrists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Podiatry Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for podiatry are listed above




Podiatrists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric podiatry practices based on the podiatry weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric podiatry practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Psychiatry Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 295 psychiatrists are receiving VBR.

Psychiatry Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric psychiatrists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Psychiatry Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for psychiatry are listed above




Psychiatrists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric psychiatry practices based on the psychiatry weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric psychiatry practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Psychology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 343 psychologists are receiving VBR.

Psychology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric psychologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Psychology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for psychology are listed above




Psychologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric psychology practices based on the psychology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric psychology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Pulmonology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 165 pulmonologists are receiving VBR.

Pulmonology Value-Based Reimbursement Metrics

Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical cost

of care + pharmacy cost (actual cost) Population

level 20%


10%

Global Quality Index A single composite score comprised of 49 quality metrics from across many PGIP initiatives

Population level

10%


10%

Asthma Medication Ratio Proportion of members with persistent asthma whose asthma medication ratio >0.5

Population level

10%

Asthma: Regular Spirometry

Proportion of members with asthma receiving >1 spirometry measurement in 2 years

Population level

5%

Asthma: IP/ED Rate Number of IP or ED encounters per member with asthma Population level

5%

COPD: IP/ED Rate Number of IP or ED encounters per member with COPD Population level

10%

Asthma and COPD: Post IP/ED Follow-up

Proportion of IP/ED encounters followed by an office visit <30 days post-discharge

Population level

5%

Asthma and COPD: IP/ED Return Visits

Proportion of IP/ED encounters followed by an IP/ED encounter <30 days post-discharge

Population level

5%

OSA:Sleep Study for New Diagnosis

Proportion of newly diagnosed members with obstructive sleep apnea who received a sleep study

Population level

5%

OSA: Sleep Study Rate for Long-Term Diagnosis

Number of sleep studies per member with a long-term diagnosis of obstructive sleep apnea

Population level

5%

*Pediatric pulmonologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Pulmonology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for pulmonology are listed





Pulmonologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric pulmonology practices based on the pulmonology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric pulmonology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Radiation Oncology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 85 radiation oncologists are receiving VBR.

Radiation Oncology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric radiation oncologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Radiation Oncology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for radiation oncology are listed above




Radiation oncologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric radiation oncologists practices based on the radiation oncology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric radiation oncology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Radiology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 554 radiologists are receiving VBR.

Radiology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric radiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Radiology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for radiology are listed above




Radiologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric radiology practices based on the radiology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric radiology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Rheumatology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 59 rheumatologists are receiving VBR.

Rheumatology Value-Based Reimbursement Metrics



level 30%

Cost Difference


10%



Population level

15%

Rheumatoid Arthritis PMPM

Overall PMPM medical/surgical cost of care + pharmacy cost (actual cost) for patients with rheumatoid arthritis

Population level

25%

DMARD Use Proportion of patients with rheumatoid arthritis having at least one DMARD in each of the past two years (HEDIS)

Population level

20%

*Pediatric rheumatologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.








Rheumatology Fact Sheet



This example shows the measurement approach with only one metric; the metrics used for rheumatology are





Rheumatologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric rheumatology practices based on the rheumatology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric rheumatology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Urology Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 214 urologists are receiving VBR.

Urology Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric urologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Urology Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for urology are listed above




Urologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric urology practices based on the urology weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric urology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)













Vascular Surgery Value-Based Reimbursement


Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 59 vascular surgeons are receiving VBR.

Vascular Surgery Value-Based Reimbursement Metrics



level 50%

Cost Difference


10%



Population level

40%

*Pediatric vascular surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.









Vascular Surgery Fact Sheet


This example shows the measurement approach with only one metric; the metrics used for vascular surgery are listed above




Vascular surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year

The top two-thirds of non-pediatric vascular surgery practices based on the vascular surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule

All pediatric vascular surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)












2016 Specialist Value-Based Reimbursement Allergy Fact Sheet€¦ · population of patients . 2016...

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