Blue Cross Blue Shield of Michigan Physician Group Incentive by nhz10206


									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
2006 BCBSA
                                        Quality Initiatives
“Best of Blue”
                                        Michigan Surgical
Award Winner                           Quality Collaborative
                                   Michigan Bariatric Surgery
       PGIP:                             Collaborative
  Physician Group          BMC2: BCBSM Cardiovascular Consortium               (in
 Incentive Program         Angioplasty Collaborative Quality Initiative   Participating
                             Michigan Society of Thoracic Surgeons
  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
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

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

   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
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;
25% solo)
Specialties                       Cardiology          Radiology       Hospitalists
Included                         Immunology                          Nephrologists
                               Medical Oncology                        Ob/Gyn

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)
                                                 Marquette                              Luce
                  Gogebic                                                                                  Chippewa                           Oakland County: Medical Network One (328),
                                                                      Schoolcraft                                                              Oakland Physician Network Services (176),
                                       Iron                                              Mackinac
                                              Dickinson                                                                                       Oakland Southfield Physicians (205), Oncology
                                                                                                                                               Physician Resource (67), Quality Partners of
                                                                                                                                              MI (33), St. John Medical Group (66), United
              Saginaw County: Primary                                                                                                                        Physicians (689)
              Healthcare Partners (57)                                                                                 Emmet
                                                                                                                                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
    (MMPC) (126), Regional Delivery                                                Leelanau
    Network of West MI (209), West                                                     Grand Kalkaska                                                                     Macomb County: DMC
    Michigan Physicians Network (310)                                           Benzie Traverse
                                                                                                                                          Alcona                          Primary Care Physicians
                                                                                                                                                                          (102), St. John
              Ottawa County: Principal                                                   Wexford                Roscommon
                                                                                                                         Ogemaw                                           HealthPartners (419)
                  Health PHO (52)
                                                                          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
                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)
                                                                            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

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

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

             Hospitalists                     Communicate
                                                                           Condition-Focused Initiatives
                                                                   2       -Oncology
                                         in both directions
Interest Groups
                                                                            Service-Focused Initiatives
 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
  Organizational                    computer-based
    functions                         training and
                                   assessment tools
 Academic detailing
                                                                   5       Clinical IT-Focused Initiatives
   and regional
Example of Risk-Adjusted Population-Based
Performance Report

                                        Adult Population Attributed to PCPs


                                                                              Your Group




                     Professional Evaluation
                       and Management in
                      the Emergency Room

PGIP Performance on Evidence-Based Care Delivery
is Better and Improving Faster than Control
                                                           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



             Overall Evidence Based Care Score (%)

                                                     67                                                          67%
                                                                       65.7%                                                          POGS
                                                                       64.8%                                     64.9%



                                                                          2005                                2006

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
“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)

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-
    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

     BCBSM PCMH Domains address all
     concepts in NCQA standards
NCQA PCMH Standards                       BCBSM Initiatives
Access and communication                  Extended Access               Patient-Provider
Patient tracking and registry functions   Patient Registry
Care management                           Individual Care               Care Coordination
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
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

                                                            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

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

Tools for Change: LEAN Process

                          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

“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
     provided by allied health personnel                        •Registered
       – Patients with chronic conditions                       Dietician/Master of
       – Incident to physician office visit and within          Science Trained
         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
           • 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

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

PCMH Designation Lessons Learned…

    • Collaboration is key
       – Interpretation of how to implement PCMH concepts varies
       – 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
    • Clinical leadership and team approach is essential
       – Physician leadership is a must
       – Everyone participates: RNs, clinical team, front & back office
       – Information technology & analytics are invaluable resources in
         mapping the path
           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
   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)
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

           Website Information

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

•    Main PGIP section of site under Value Partnerships:

•    Presentations from our most recent PGIP quarterly meeting can be found at:

•    2008 PGIP Initiatives, Initiative Fact Sheets, BCBSM Initiative subject matter experts
     email addresses, etc. can be found at:

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

1)   Go to
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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