Blue Cross Blue Shield of Michigan Physician Group Incentive by nhz10206

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									Blue Cross Blue Shield of Michigan

Physician Group Incentive Program


          Margaret Mason, MHSA
Health Care Manager, Provider Partnerships




   Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
BCBSM’s “Value Partnerships” Model


                 Physicians            CQIs: Collaborative
                                                                  Hospitals
2006 BCBSA
                                        Quality Initiatives
“Best of Blue”
                                        Michigan Surgical
Award Winner                           Quality Collaborative
                                                                            Hospital
                                   Michigan Bariatric Surgery
                                                                           Incentive
       PGIP:                             Collaborative
                                                                           Program
  Physician Group          BMC2: BCBSM Cardiovascular Consortium               (in
 Incentive Program         Angioplasty Collaborative Quality Initiative   Participating
                                                                            Hospital
                             Michigan Society of Thoracic Surgeons
                                                                          Agreement)
  Prof-CQI: Michigan                   Cardiac Surgery
 Anticoagulation Quality         Collaborative Quality Initiative
 Improvement Initiative
                                   Michigan Breast Oncology
                                        Quality Initiative
     Prof-CQI: Lean Thinking
      Clinic Re-engineering                          Advanced Cardiac
            Consortium                              Imaging Consortium
                                                                                          2
                                                                                              2
A Shared Vision: Transformed Roles



Patients - poorly served     Active Partners Benefiting
  by health care non-          from Organized Systems
  system                       of Care
 Payer - functions as        Change Facilitator and
   controller and              Catalyst
   adversary

 Individual Providers -      Change Agents in
    respond to prescribed
    controls in fragmented     Collaborative Communities
    system                     of Team-Based Caregivers

                                                      3
   The Physician Group Incentive
   Program (PGIP)

               2005    2006           2007              2008             2009            Future

              Launch           Restructure PGIP      Add PCMH        Add PCMH        Provider-based
              PGIP             Add pmt for pt-self   initiatives     designation     care mgmt
                               mgmt educ/training    Transparency                    Organized
                                                                                     Systems of
                                                                                     Care
Physician        10       31             33                35              36
Orgs                           (including 50 sub-    (including 50   (including 50
                                      POs)             sub-POs)        sub-POs)

Physicians    2,903    4,798         5,980              6,657          7,618          70% of PPO
                                                                       (1.7M            network
(2/3 PCPs;
                                                                      members)
25% solo)
Specialties                       Cardiology          Radiology       Hospitalists
Included                         Immunology                          Nephrologists
                               Medical Oncology                        Ob/Gyn
                                 Hematology
                                Pulmonology

                                                                                                      4
PGIP Participants (July 2009)
                                                                                Marquette County: Upper Peninsula Health Plan (236)
•   36 groups
•   7,618 physicians (as of July 2009)                                                                             Genesee County: Genesys Integrated
•   1,800,000 members (as of July 2009)                                                                            Group Physicians (91), PMC ( 107),
                      Ontonagon                                                                                    McLaren Medical Management (113)
                                        Baraga
                                                 Marquette                              Luce
                  Gogebic                                                                                  Chippewa                           Oakland County: Medical Network One (328),
                                                              Alger
                                                                      Schoolcraft                                                              Oakland Physician Network Services (176),
                                       Iron                                              Mackinac
                                              Dickinson                                                                                       Oakland Southfield Physicians (205), Oncology
                                                             Delta
                                                                                                                                               Physician Resource (67), Quality Partners of
                                                                                                                                              MI (33), St. John Medical Group (66), United
              Saginaw County: Primary                                                                                                                        Physicians (689)
              Healthcare Partners (57)                                                                                 Emmet
                                                                                                                                Presque
                                                                                                                    Cheboygan
                                                                                                                                Isle                        St. Clair County: Mercy~ Physician
                                                                                                     Charlevoix                                             Community PHO (44), Physician
    Kent County: Advantage Health
                                                                                                                                          Alpena            Healthcare Network (36)
    Physicians (160), Michigan Medical, PC                                                                          Otsego
                                                                                                     Antrim
    (MMPC) (126), Regional Delivery                                                Leelanau
    Network of West MI (209), West                                                     Grand Kalkaska                                                                     Macomb County: DMC
                                                                                                              Oscoda
    Michigan Physicians Network (310)                                           Benzie Traverse
                                                                                                      Crawford
                                                                                                                                          Alcona                          Primary Care Physicians
                                                                                                                                                                          (102), St. John
                                                                                                       Missaukee
              Ottawa County: Principal                                                   Wexford                Roscommon
                                                                                                                         Ogemaw                                           HealthPartners (419)
                                                                            Manistee
                                                                                                                                          Iosco
                  Health PHO (52)
                                                                                                                                   Arenac
                                                                          Mason Lake            Osceola Clare                                                             Wayne County: Henry Ford
                            Midwest Medical                                                                            Gladwin
                                                                                                                                                                          Medical Group (257),
                            Center (24)                                                                                                               Huron
                                                                                                Mecosta                                                                   Olympia Medical Services
                                                                        Oceana                              Isabella               Bay                                    (160), UOP, LLC (238)
                Livingston Physician                                                                                                                        Sanilac
                                                                                                                                               Tuscola
                Organization (28)                                                                 Montcalm                       Saginaw                                       Washtenaw County:
                                                                                                                    Gratiot                                                  Huron Valley Physicians
      Ingham County: Consortium of                                                                                                     Genesee Lapeer
                                                                                                                                                              St. Clair         Association (257),
    Independent Physician Associations                                          Ottawa        Kent                  Clinton
                                                                                                           Ionia                 Shiawassee                                     Integrated Health
      (1,640), MSU Health Team (84),
                                                                                                                                                                              Associates (147), U-M
        Sparrow Medical Group (66)                                                                                       Ingham                   Oakland
                                                                                                              Eaton                                                           Health System Faculty
                                                                                 Allegan          Barry                              Livingston
                                                                                                                                                                              Group Practice (442)
         Calhoun County: Integrated Health Partners (72)
                                                                                                                                                   Wayne
                                                                            Van Buren            Calhoun Jackson
                                                                                         Kalamazoo               Washtenaw
                        Kalamazoo County: Bronson                                                                                                               Jackson County: Jackson Physician
                          Medical Group (77) and                                                                                               Monroe                     Alliance (69)
                                                                                 Cass         St. Joseph            Hillsdale
                         ProMed Healthcare (100)                      Berrien                              Branch                Lenawee


                                                                                                                                                                                                    5
Physician Group Incentive Program
Guiding Principles

   1. Use population-based cost and use measures and evidence-
      based recommendations of care

   2. Recognize and reward performance of physician organizations

   3. Reward improvement, not just highest absolute performance

   4. Rely on physician organizations to facilitate all-payor practice
      change, provide performance feedback and work with individual
      physicians to improve quality and efficiency

   5. Design and execute programs in a customized and collaborative
      manner rather than "one size fits all" - physician group
      sophistication varies, from vertically integrated, highly functioning
      systems to cottage industries

                                                                              6
                PGIP Organizational Model
  Leadership Committees
                                              Ideas, priorities,               Initiative Teams
                                                                                   Medical
 Primary Care         Medical Oncology
                                              oversight                           Oncology
                                                                   1     Improvement Capacity Initiatives


             Hospitalists                     Communicate
                                              progress
                                                                           Condition-Focused Initiatives
                                                                   2       -Oncology
                                         Communication
                                         in both directions
Interest Groups
                                                                            Service-Focused Initiatives
                                                                   3
 Self-management                 Project Teams                              -Radiology
                                                                            -Generic Drugs
Systems integration               Phys Org Common Data                      -ED use
                                    Resource (U of M)                       -IP admits for ACSCs
 Advanced medical
 home and planned                   Development of
    care visits                                                    4 Core Clinical Process-Focused Initiatives
                                   wellness and care
                                     management,
  Organizational                    computer-based
    functions                         training and
                                   assessment tools
 Academic detailing
                                                                   5       Clinical IT-Focused Initiatives
   and regional
    pharmacists
                                                                                                                 7
Example of Risk-Adjusted Population-Based
Performance Report



                                        Adult Population Attributed to PCPs




                                                                              Maximum

                                                                              Your Group

                                                                              75th
                                                                              Percentile

                                                                              25th
                                                                              Percentile

                                                                              Minimum

                     Professional Evaluation
                       and Management in
                      the Emergency Room




                                                                                           8
PGIP Performance on Evidence-Based Care Delivery
is Better and Improving Faster than Control
Population
                                                           Table 4: 2005 -2006 PGIP and POGS Improvement in Evidence-Based Measures
                                                          Table 4: 2005-2006 PGIP and POGS Improvement in Evidence Based Measures
                                                                        Evidence-Based Care Care 2005 2005 vs. 2006
                                                                 OverallOverall Evidence BasedScore Score versus 2006



                                                     70



                                                     69
                                                                                                                 68.7%

                                                     68
                                                                                                                 67.8%
             Overall Evidence Based Care Score (%)




                                                     67                                                          67%
                                                                                   PGIP
                                                                                                                                      Control
                                                     66
                                                                       65.7%                                                          POGS
                                                                                                                                      P4V
                                                                       65.2%
                                                     65
                                                                       64.8%                                     64.9%


                                                     64
                                                                       63.7%
                                                                                            Control
                                                     63



                                                     62



                                                     61
                                                                          2005                                2006




                                                                                                                                                9
PGIP provides the essential foundation for
building the Patient-Centered Medical Home




                            The PGIP Foundation:
        - Provider-payor partnership -Practice transformation
        -Chronic Care Model           -Focus on primary care
                                                                10
“Relentless incrementalism”

     BCBSM - two-pronged approach to bridging the
     “PCMH chasm” & building the Patient-Centered
     Medical Home

     PGIP PCMH Initiatives        PGIP PCMH Designation
     Opportunity for PGIP POs     Program
     to participate in 12 PCMH    Higher E&M reimbursement
     Initiatives that support     for PGIP Practice Units that
     implementation of specific   have made the most progress
     PCMH capabilities (started   in implementing PCMH
     in 2008)                     capabilities (July 2009)




                                                                 11
BCBSM PGIP Patient-Centered Medical
Home “Domains of Function”
                                   122 Total PCMH “Capabilities” support incremental progress:

    Patient-Provider Partnership     8    Patient-provider partnership established

    Patient Registry                15    Diabetes registry in use

    Performance Reporting           12    Trend reports at PO, practice, and physician level

    Individual Care Management      15    Group visits offered to all chronic condition patients

    Extended Access                  9    Patients have 24/7 phone access to clinical decision-
                                          maker
    Test Tracking                    9    Ensure patients with abnormal results receive
                                          recommended follow-up care
    Preventive Services              8    Smoking cessation tools and support available

    Linkage to Community             8    Tracking to ensure high-risk patients receive
    Services                              recommended community services

    Self-Management Support          8    Self-management goal established for all patients

    Patient Portal                  12    Patients can schedule appointments online

    Coordination of Care             9    Routine notice of care transitions

    Specialist Referral Process      9    Practice makes specialist appointments for patients

                                                                                               12
     BCBSM PCMH Domains address all
     concepts in NCQA standards
NCQA PCMH Standards                       BCBSM Initiatives
Access and communication                  Extended Access               Patient-Provider
                                                                        Partnership
Patient tracking and registry functions   Patient Registry
Care management                           Individual Care               Care Coordination
                                          Management
Patient self-management support           Individual Care               Self-Management
                                          Management                    Support
E-Rx                                      E-Rx
Test Tracking                             Test Tracking
Referral Tracking                         Specialist Referral Process
Performance Reporting & Improvement       Performance Reporting

Advanced Electronic Communications        Patient Portal
NA                                        Linkage to Community Services

NA                                        Preventive Services
                                                                                            13
Patients in “Participating” Practices are Benefiting from
Practice Transformation Activities

      A patient-provider partnership has been
   implemented for 50% of all the office’s patients

      A patient registry for at least one chronic
    condition is being used to ensure that all their
    patients with that condition are well-managed
     Performance reports at the PO, practice, and
                                                                                           For example: 60% of members
    physician level allow population management
                                                                                              in “Participating Practices”
          for at least one chronic condition
                                                                                             have 24/7 access to care, as
  Basic care management services for at least one                                           compared to 25% of members
       type of chronic condition are provided                                              in “Non-Participating Practices”


  Patients have 24 hour phone access to a clinical
   decision-maker and to after-hours urgent care


            Patients are notified in a timely manner
                     regarding test results


         Practice uses fully certified E-Prescribing
                           system

                                                            0%    10%   20%   30%   40%   50%   60%   70%   80%   90%   100%

                                                                    BCBSM Members Attributed to PGIP PCPs

    Members in Practices Not Participating in PCMH Initiative    Members in Practices Participating in PCMH Initiatives

                                                                                                                         14
PGIP Physician Care Process
Transformation Activities



  • Physician Organization Staffing Increases
     – Clinical pharmacists, care-managers and analytic staff
  • IT Implementation
     – EMR with embedded clinical decision support, E-Rx, Chronic Disease
       Registries, e-Laboratory access and management
  • Lean Workshops, Improving Performance in Practice (IPIP),
    TransforMED, IHI Learning Collaborative
  • Development of chronic care travel teams
     – RNs, Mental Health Specialists, Exercise Physiologists, Registered
       Dieticians, Certified Diabetes Educators available to small offices to expand
       expertise available for engaging patients in self-management and to provide
       care management services




                                                                                  15
Tools for Change: LEAN Process
Mapping


                          June 2008 established Lean
                           Coordinating Center at University
                           of Michigan
                             10 POs actively engaged
                             1 PO has fully trained Lean
                              Coach internally as a result of
                              Lean CQI
                             PGIP funds support participation
                          Topics addressed include: e-
                           prescribing, patient pre-visit
                           preparation, diabetes care, test
                           tracking, patient self
                           management




                                                                 16
“T-Code” reimbursement for care management &
coordination implemented in 2007
                                                                Payable to:
                                                                •Registered Nurses
   • Individualized, goal-driven care                           •Masters of Social
     management/coordination or self-                           Work
     management training/education services                     •Certified Diabetes
                                                                Educators
     provided by allied health personnel                        •Registered
       – Patients with chronic conditions                       Dietician/Master of
       – Incident to physician office visit and within          Science Trained
                                                                Nutritionist
         context of care plan                                   •Clinical
       – Services may be planned or initiated by                Pharmacists
         patient during phone contact with office               •Respiratory
           • Clinic visit encounter – up to $180 for 45         Therapists
             minutes                                            •Certified Nurse
                                                                Practitioners
           • Personal care services (can be phone or home-      •Physician
             based) – up to $60 for 30 minutes                  Assistants




 Administrative barriers to use for some POs until other payors begin reimbursing

                                                                                      17
The PCMH Designation Program


  •   Effective July 1, 2009, BCBSM designated 300 Primary Care
      Practices (1200 Physicians, representing 25% of PGIP PCPs) as
      Patient-Centered Medical Homes
      –   PCMH Designated PCPs have made the most progress in implementing
          PCMH capabilities, resulting in strong quality/use performance

  •   Designated PCMH Practice Units
      receive 10% increase in
      reimbursement for evaluation and
      management services
  •   All practices reassessed annually




                                                                         18
PCMH Designation Lessons Learned…

    • Collaboration is key
       – Interpretation of how to implement PCMH concepts varies
         widely
       – Payer and provider perspectives are essential
    • Practice transformation is a long-term endeavor
       – Hard, slow work – expect many challenges
       – Structured practice transformation assistance is extremely
         helpful
    • Clinical leadership and team approach is essential
       – Physician leadership is a must
       – Everyone participates: RNs, clinical team, front & back office
         staff
       – Information technology & analytics are invaluable resources in
         mapping the path
                                                                          19
           2008 PGIP Inpatient Initiative: Ambulatory Care Sensitive
           Conditions, Risk-Adjusted Standard Cost PMPM for Adult
             Members (18-64) Attributed to a PGIP Practice Unit,
                       Designated vs. Non-Designated.


                                           Total ACSC-    ACSC-Related     ACSC-Related
                                             Related     Discharge Rates   Standard Cost
                                           Discharges       (per 1,000)        PMPM
                                                (n)
   Designated                                      933             5.08              $3.36
   Practice Units
   Non-Designated                                4,052             6.10              $4.13
   Practice Units
                                                              Designated Practice Units
                                                             have a 22.9% lower ACSC-
                                                             Related Inpatient Standard
                                                            Cost PMPM and a 20.2% lower
                                                              Discharge Rate (per 1,000)
                                                                                           20
Department of Medical Informatics, 2009-07-01
Key PGIP Themes: 2010 and beyond



• Organized Systems of Care (“Accountable Care Organizations”)
    – Creating effective “Organized Systems of Care” will be a major PGIP
      priority over the next 5 years


•   Integrated Wellness & Care Management
    – Disease management/care management delivered by primary care
      practices; coordination and data exchange with BCBSM to support
      customer reporting of activity and outcomes
• Opportunities to partner
    – BCBSM eager to partner with other payors
    – Possible state application for CMS demo



                                                                            21
           Website Information



We are continually updating the PGIP and Value Partnerships sections of the
   www.bcbsm.com website with current information about the program. Some links:

•    Main PGIP section of site under Value Partnerships:
     http://www.bcbsm.com/provider/value_partnerships/pgip/index.shtml

•    Presentations from our most recent PGIP quarterly meeting can be found at:
     http://www.bcbsm.com/provider/value_partnerships/pgip/quarterly_meeting_march_2008.shtml

•    2008 PGIP Initiatives, Initiative Fact Sheets, BCBSM Initiative subject matter experts
     email addresses, etc. can be found at:
     http://www.bcbsm.com/provider/value_partnerships/pgip/pgip_initiatives_registration.shtml

If you experience difficulties with the links, you can access the PGIP website as follows:

1)   Go to www.BCBSM.com
2)   Select "I Am a Provider“ (upper right hand corner of page), then click on “Provider area”
3)   Select "Value Partnerships"
4)   Select "Physician Group Incentive Program"
5)   You will then be on the PGIP Home Page (i.e., first bulleted item above)


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