1. science
2. medicine
3. surgery

Moving Forward
Tom Simmer, M.D.
March 2013
Strategy to address the root causes of low health system
performance
Poorly aligned incentives. Fee-for-service drives increased
delivery of services and members lack benefit incentives to
promote better health.
Lack of population focus. Provider delivers services that are
demanded and paid for, instead of focusing on the health of the
overall population.
Fragmented healthcare delivery. Physicians and hospitals
lack information infrastructure and integration of care
processes across the care continuum.
Weak primary care foundation. Missed opportunities for care
coordination and lower cost approaches.
Lack of focus on process excellence. Creates variation and
re-work, not clinical process improvement.
2
A high performing healthcare
system in Michigan…
– Measures and rewards system performance at the
population level
– Acts as a patient-centered system by sharing
information among all participants in the care
process and by managing processes across
settings of care
Foundational Principles
• PCMH: Care relationships extend over time
and across settings of care
• Care model: “A productive interaction
between an informed, activated patient and a
pro-active, prepared healthcare team.”
• Physician Organizations are key facilitators of
practice transformation.
Foundational Capabilities
(That We Need Right Now)
• PCP practices maintain an accurate registry of all
patients with an active care relationship to the
practice team.
• PO’s and OSC’s integrate PCP registries to maintain
an accurate data set of patients with active care
relationships with affiliated practices.
• Health Information Exchanges create access to
clinical and administrative data sets that source
registries and support clinical processes.
2013: Implement Foundational
Capabilities
• All PCMH practices should have an ongoing
process for assuring an accurate registry of
persons with an active care relationship with
the practice.
• All PO’s and OSC’s should integrate PCP
registries to support health information
exchange processes.
Principles for Health Information
Exchange
• Hospitals should be able to communicate the
ADT information once, regardless of the
number of recipients of the information
• Hospitals should be able to send the
information through the qualified organization
of its choice that connects to the clinical
process for managing transitions
Principles for Health Information
Exchange
• Practitioners should receive the information in
the manner that they choose to support their
clinical processes. This includes the ability to
query data sources.
• The ADT information should meet standard
expectations related to common data
definitions, fields etc.
Moving Forward
• My role at BCBSM has changed.
• Leadership for clinical programs belongs to David
Share, M.D., Tom Leyden, and their stalwart teams.
• Darline El Reda and her gallant team provides
epidemiologic, analytic and reporting support.
• I am available to support Physician Organizations in
practice transformation and population
management. These are exciting challenges, and I
look forward to working with you. Let me know how I
can help you get it done.
PGIP Quarterly Meeting
March 8, 2013
David Share, MD, MPH
Senior Vice President, Value Partnerships
10
Competitive Marketplace
• As a result of the Accountable Care Act and the Health Insurance
Exchange-based Marketplace, the rules of engagement have changed
• There is a sense of urgency and a need to address quality and accurately
quantify population-level risk
• Many more individuals will have insurance
• Individuals will be making choices more often, relying on group purchasing
less so – price will guide those decisions, and collectively we will be
competing on price
11
Government Insurance Programs: harbinger of
the future
• Revenue is dependent upon risk adjustment and quality performance
• These expectations will extend to Commercial insurance offered on the
Exchange
• With risk adjustment and quality performance driving revenue, success
depends on:
– Complete diagnosis coding
– Accurate diagnosis coding
– HEDIS performance; complete data on:
• Processes of care
• Documentation of physiologic control (e.g., BP, lipids)
12
Modernization of Incentives
• Physician Incentives need to explicitly reward:
– Supplemental Data Exchange
– Medical “homeness” and clinical integration in OSCs (frame of reference for
contracting and risk sharing)
– Quality performance
– Cost performance
• Under consideration:
– Tiering of uplift %’s based on multiple performance dimensions
– Uplift opportunities for non-Designated PGIP PCP practices
• These same principles may apply to Specialists Fee Uplifts
• Physician Organizations need to more actively engage Practice Units
– Supplemental Data Exchange
– HEDIS performance
13
Specialist Inclusion – Integration in Physician
Organizations and Organized Systems of Care
• It was a steep learning curve but we have “lessons learned” from the
initial Specialists Fee Uplift process
• We realize it is challenging for POs to engage each new specialty type
– Educating about shared responsibility for optimizing systems and population
level performance: paradigm shift
– Identification of opportunities for improvement (patient perspective: e.g., all
cardiac care, not just that provided by the specialists directly)
• Broaden partnerships: (membership or affiliation status), integrate in
systems and share performance responsibility
– Crucial that we broaden non-MD/DO specialists
• Chiropractors
• Psychologists
14
Specialist Nomination Process
• Close PO collaboration is necessary
• “Fair and Equal”
– Employed and non-employed
– PO member and principal partner
• No recruiting of specialists from other POs
15
PCMH Designation Honor Roll
• Increased stability for PCMH Designation status
16
Michigan Primary Care Transformation
• Within four months we are “half way there”
• As a future delivery model we must “own it”
• Urgency to full engagement
– Need to fully engage so that the evaluation demonstrates positive impact
– Actively deploy care managers
• Treating the right patients
• Properly billing “G” codes
17
PO-led Initiatives: vital to judicious use and
adequate revenue to sustain a high performing
system of care
• Health Care Resource Stewardship Council (HRSC)
• PO Common Interest Group on Diagnosis Billing
• Plan to establish PO interest group for EMR/DMR data exchange process in
2Q 2013.
– Gives POs a forum to discuss issues, best practices, and lessons learned from
initial data exchange roll out
Questions contact: Michelle Ilitch at militch@bcbsm.com
18
Value-Based Contracting
• We are in the “birthing pains” phase of the Organized Systems of Care
(OSC) model (“nascent” is accurate, but a euphemism)
• Community of caregivers coming together with aligned incentives
– Shared information systems and care management/coordination processes
– Population performance accountability
– Hospital care efficiency
• Active partnership between Hospitals and Physician Organizations is “key”
– POs play a crucial role in partnership with hospitals/developing plans/joint
leadership
19
Technology
• Increased electronic mobilization of protected health information (PHI)
across providers is essential for timely and optimal care (quality and
efficiency)
– Admissions, Discharges, Transfers (ADTs): hospital-PO-physicians
– Primary Care Provider - Specialist
– Physician - Hospital: bi-directional sharing of clinical information, leading to
common information system when fully evolved
• Demands a higher level of responsibility in knowing the care relationship
between providers and patients
– PO/OSC is the “source of truth”
• 15.0 OSC Integrated Patient Registry Initiative (OSC Information Technology for
Comprehensive Population Management)
– Patient Registry should include a functional source of truth/master patient index that will
perform demographic and clinical reconciliation
20
David C. Miller, MD
University of Michigan
Center for Healthcare Outcomes & Policy
21
Disclosure
• Grant funding: Agency for Healthcare Research & Quality,
Urology Care Foundation
• BCBSM: Director, Michigan Urological Surgery Improvement
Collaborative (MUSIC)
22
Overview of presentation
• Variation in expenditures around episodes of
hospitalization
• Michigan Value Collaborative
• Goals and work plan
• New opportunities for the CQI programs
23
Big picture
• Unsustainable growth in healthcare expenditures
• Care before, during, and after hospitalizations is a
large component
• Wide variation in episode costs across hospitals
• This is everybody’s problem post ACA
24
HSR, December 2010
Health Affairs,
November 2011
1. Episode payments vary a
lot, even after risk- and priceadjustment
26
27
2. Reasons for variation
depend on clinical context
28
29
Variation idiosyncratic across specialties
30
3. Quality is an important
driver of episode payments
31
How complications increase
utilization and payments
Index hospitalization
Readmissions
• DRG “bumping”
• Outlier payments
• Usually unbundled
Physician services
• Unbundled specialist
consultations, imaging, etc.
Post-discharge
ancillary care
• Greater need for home
health care, rehab services,
skilled nursing facilities
32
$400-$1,200 drop in payments for each “bump” in
hospital quality
33
Birkmeyer et al. Ann Surg, 2012
Specific Goals
• Patients & Physicians: better care transitions,
avoiding under-use and over-use
• Hospital leaders: connecting quality and cost,
helping them prepare for ACOs, bundled
payments, etc.
• BCBSM:
Supporting improvement work of CQI programs
Supporting its new efforts in OSCs
34
MVC Leadership
John D. Birkmeyer, M.D.
• Director
• Professor of Surgery
• Medical Director, MBSC
• Director, Center for
Health Outcomes & Policy
David C. Miller, MD MPH
• Associate Director
• Assistant Professor in
Urology
• Co-Director, MUSIC
• Health services researcher
with expertise in ACOs vs.
specialty care
Lena Chen, MD MPH
• Associate Director
• Assistant Professor of Internal
Medicine, University of
Michigan
• Expertise in cost-quality
relationships in hospital-based
medical care
35
MVC Work Plan—summary
• Performance feedback
Timely feedback of utilization / episode payment data
that is scientifically rigorous and clinically relevant
• Improvement strategy
“Macro-system”—engaging hospital leaders charged
with system-wide care delivery and improvement
“Micro-system”—CQI programs and clinician leaders
responsible for care in each specialty
36
Episode payment analysis
• Regular claims data transfers
BCBSM claims data to start, later Medicare/Medicaid
• 30-day episode payments
Clinical relevant episode grouping
Price standardization
Risk adjustment
Full transparency on methods
• Reporting by specialty service line,
condition/procedure, and service type
37
cbirkmeyer
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Dashboard | Overall | Inpatient | Professional | Post-Discharge | Detail | Access | Help
Composite | By Service Line | By Hospital
Outcome Measure
Total Payment
Hospital
Total Cost
Acute Care
Hospital ABC All Others P-Value
$22,170
$25,965
0.03
Hospital ABC
Bariatric
Peer Group
All Michigan
Teaching
>500 beds
Any
$26,672
$25,352
0.12
Lap Band
$22,345
$22,678
0.78
RYGB
$29,765
$27,564
0.02
Time Period
All
Last 12 months
Last 24 months
Custom
Sleeve
$27,898
$25,786
0.09
Cardiac
$107,364
$86,997
0.00
Int Cardiology
$38,378
$37,497
0.60
Medical
$7,746
$8,014
0.50
OBGYN
$7,736
$9,931
0.20
Orthopedic
$32,486
$30,503
0.17
Spine
$23,979
$35,318
0.03
Trauma
$28,715
$25,597
0.74
Vascular
$30,888
$32,073
0.72
Hospital ABC
Benchmark
cbirkmeyer
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Overall | Inpatient | Professional | Post-Discharge | Detail | Access | Help
Summary | Ranking | Trends | Distribution
Hospital
Hospital ABC
Service Line
Acute care surgery
Bariatric surgery
Cancer surgery
Cardiac surgery
Inpatient medical care
Interventional cardiology
Major orthopedics
Obstetrics & gynecology
Spine Surgery
Trauma
Vascular surgery
Procedure
Lap band
RYGB
Sleeve gastrectomy
Peer Group
All Michigan
Time Period
Last 12 months
Hospital ABC
Benchmark
cbirkmeyer
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Overall | Inpatient | Professional | Post-Discharge | Detail | Access | Help
Summary | Ranking | Trends | Distribution
Hospital
Hospital ABC
Service Line
Acute care surgery
Bariatric surgery
Cancer surgery
Cardiac surgery
Inpatient medical care
Interventional cardiology
Major orthopedics
Obstetrics & gynecology
Spine Surgery
Trauma
Vascular surgery
Procedure
Lap band
RYGB
Sleeve gastrectomy
Peer Group
All Michigan
Time Period
Last 12 months
Hospital ABC
Benchmark
cbirkmeyer
Feedback | Logout
Home | Analytics | Dashboard | Overall | Inpatient
Inpatient | Professional | Post-Discharge | Detail | Access | Help
Summary | Ranking | Trends | Distribution | Readmissions
Hospital
Hospital ABC
Service Line
Acute care surgery
Bariatric surgery
Cancer surgery
Cardiac surgery
Inpatient medical care
Interventional cardiology
Major orthopedics
Obstetrics & gynecology
Spine Surgery
Trauma
Vascular surgery
Procedure
All
CABG
Valve replacement
Peer Group
All Michigan
Time Period
by Diagnostic Category (%)
Hospital
ABC
All Others P-Value
Other forms of heart disease
1.0%
2.3%
0.01
Ischemic heart disease
0.0%
1.3%
0.00
Complications of surgical and
medical care
1.0%
1.1%
0.07
Pneumonia and Influenza
0.0%
0.5%
0.00
Symptoms
0.0%
0.5%
0.00
Diseases of arteries
0.0%
0.4%
0.00
Diseases of blood and bloodforming organs
2.1%
0.4%
0.01
Other diseases of respiratory
system
1.0%
0.4%
0.01
Diseases of pulmonary
circulation
0.0%
0.2%
0.00
Diseases of veins and lymphatics
0.0%
0.2%
0.00
Nephritis
0.0%
0.2%
0.00
Supplementary classification of
factors
0.0%
0.2%
0.00
Last 12 months
Hospital ABC
Benchmark
Macro-system improvement
• Engaging hospital leaders
Administrative, financial, and clinical
• Collaborative QI meetings
Semi-annual
Analysis of variation
Benchmarking best performers, etc.
• Focus on organizational strategies and processes
that cut across specialties
42
Tentative timeline
• On-boarding of participating hospitals /
leadership (Feb)
• “Focus group” to review methods, reporting, and
priorities (April)
• Begin dissemination of results through CQI
programs (May)
• Official kick-off meeting with hospital leadership,
initial performance feedback (June)
43
Overview of presentation
• Variation in expenditures around episodes of
hospitalization
• Michigan Value Collaborative
• Goals and work plan
• New opportunities for the CQI programs
44
Opportunities—Immediate
Immediate
• Broader dissemination of performance data and
QI work to hospital leaders
• Wider range of outcome measures
• E.g., ED visits, late readmission & reoperation
Downstream
• Population-based procedure rates
• Accelerate QI work vs. “appropriateness”
45
Making the “business case” for
your CQI program
46
MBSC—the QI highlight reel
Overall complication rates declined from
8.7% in 2007 to 6.6% in 2009, a 24%
drop.
VTE rates fell by over half, from 0.5% in
2007 to 0.2% in 2009.
Mortality fell from 0.21 percent in 2007
to 0.02% in 2009, a 90% improvement.
30-day ED visit rates declined 35 percent
from 2007 to 2010.
Share et al., Health Affairs, 2011
47
Cumulative effects on 30-day episode payments
for bariatric surgery in Michigan
$1,000/ pt
48
49
Variation in Total Episode Payments Among MBSC Hospitals
Risk and Reliability Adjusted
35,000
34,000
95% CI
Site-Specific Average
33,000
32,000
31,000
30,000
29,000
28,000
27,000
26,000
25,000
24,000
23,000
22,000
21,000
20,000
1 2
3 4 5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
MBSC Hospital
50
Hospital-specific quality improvement vs.
reductions in episode payments (2008 vs. 2011)
51
Discussion
52
Pediatric Case
Presentation MiPCT
PGIP Quarterly Mtg.
March 8, 2013
Insurance (COB’s):
• Primary insurance: BCBS
• Secondary insurance: Medicaid
• Now – CSHCS (Children’s Special Health Care Services)
Introducing….
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•
•
•
•
•
•
•
•
6 yr. old male
Downs Syndrome
Lives with mother and older sister
Youngest of 9 children
Functionally non-verbal, sign language
Wears glasses
Bowel and bladder incontinence
Total assist for ADL’s – bathing, dressing, feedings
Attends a school for children with Developmental deficiencies.
Rides the bus to and from school
Ambulates independently
Psycho-social:
• Parents separated shortly after son’s birth because of son. Dad
now lives out of state.
• Mother quit “good” job to care for son
• Mother sole care provider – early 50’s
• Skilled, knowledgeable
• Hands-on approach
• Protective
• Involved
• Needs information and understanding
• Advocate
• Has great “gut” realizations regarding son and possible
problem
Diagnoses:
• Downs Syndrome
• Upper GI problems: large tongue, difficulty swallowing, food
aversions.
• GERD
• Constipation and Bowel Irregularities
• Urethral Stricture
• Chronic lung changes – multiple aspirations resulting in
repeated pneumonias and URI’s
• Asthma
• Obstructive sleep apnea with desaturations of oxygenation to
76%
• Bowel and bladder incontinence
Diagnoses (cont’d):
•
•
•
•
•
•
Chronic sinusitis
Chronic OM – resolved vastly with tubes, continues to drain
Decreased Hearing
Dysphagia
Eating disorder – refuses most foods
Sensory aversions – being considered currently for ASD
diagnosis (Plan to use M-CHAT and ABC (Autism Behavior
Checklist) as initial screen due to developmental stage)
Surgical / Medical Hx:
• Nissen Fundoplication
• Gastrostomy
 feeding tube removed subsequently d/t numerous
complications
• Bowel Resection
 Experiences ileus’ with illnesses
• Multiple OR’s for Abdominal Adhesions
• Repairs of incisional hernias
• Bil. Myringotomy (with decreased hearing)
• Dental repairs – general anesthesia
Medical hx:
• Bowel Obstruction
• Experiences ileus’s with illnesses
• Repeated episodes Aspiration Pneumonia – inability to handle
oral secretions and fluids
Specialists:
Peds GI Specialist
Peds Urologist
Peds Pulmonologist in GR
Peds Surgeons – GR (abdominal surgeries)
Peds Ophthalmologist
ENT
Peds Dentist (general anesthesia)
Peds Rehab – Speech Therapist
 Feeding Specialist
• OT and ST through school
•
•
•
•
•
•
•
•
CM Involvement begins:
Warned – mother’s trust
• 8/7/12 - Introduction
 2 denial letters from CSHCS
 Reviewed EMR, Qualifying diagnosis
 Coordinated with Peds Pulmonology
 Qualifying diagnosis
• Building of trust through concern and actions
Mother’s concern:
• Abnormal breathing noted
PCP Intervention:
• Sleep study ordered end of August 2012
CM Response:
• Called for report
PT CARE TRANSFORMATION:
Care Coordination problems noted:
• CM unaware of order from PCP
• Reports not automatically received from Specialists in timely
manner
Resolution:
• Msg in EMR
• Request consult reports back to PCP from Specialists
commonly referred to.
Crisis: Severe Obstructive Sleep
Apnea (OSA)
• Called for report 9/28, Friday: “Very Abnormal”
 Severe Obstructive Sleep Apnea
 Severe Hypoxemia (76%)
 Large number of severe apneic episodes
• BiPAP machine already sent to home – nasal mask
• Mom escalated (decompensating), many phone calls
Care Coordination: BiPAP machine
Mom:
• Called, unable to get DME through preferred provider
DME company:
• Required to sign paperwork
• Weight
Barriers:
• Lack of advocacy with insurance company
• Loop back to PCP office not utilized
Consequences:
• + Child received needed BiPAP machine - persevered
• Family finances – negative impact
F/U: Insurance auth as “Out-of-Network” benefit – mom to contact
us when she receives a bill so we can advocate on her behalf
Care Coordination – Home O2
Driving Need:
• Sensory challenges with mask
• Documented severe Hypoxemia
• Poor lung integrity
• Prevent admission or ED visit
Barriers: (many phone calls)
• DME Company - Titration study with demonstrated
hypoxemia
• Stated requirements inconsistent with Insurance company
BCBS:
• Response
Home assessment: ↑ Safety &
Quality of life:
Comprehensive assessment:
• Suction machine
• Catheter
• Crib
Care Coordination:
• Discussion with PCP – brainstorming
o Orders written for Sx. machine, catheters, and hospital bed
Results:
• Child has functional equipment
• Safe bed
MiPCT – CM Impact (pt.):
Immediate:
• Avoidance of possible death
Secondary:
• Avoidance of progression of lung disease
• Avoidance of hypoxemia sequela
o Child’s color improved
o Agitation decreased
• More active during school hours
• Sleeping better at night
• ↑ interaction with others
Long Term:
• Long term diagnoses – Care Management beneficial for years
• Cared for by family
• Stays in home vs. a facility (ROI)
• ↑ Quality of life
MiPCT - CM Impact (Caregiver):
Immediate:
• Built relationship based on concern, trust and action
• Caregiver (mom) has gained strength and is no longer
decompensating
• Sleep is a wonderful thing!
Secondary:
• Mom is sensing she is “not alone” since CM support
• Mom: ↓ stress
o + Impact on her health
o Enrolled in college
o Financial impact for household
o Quality of life
Long Term:
• Long term diagnoses – Care Management beneficial for
years
• Advocacy ability ↑ secondary to + experience
MiPCT – CM Impact (Financial ROI):
Immediate:
• Avoidance of IP Intensive Care Admission
Secondary:
• Decrease in ED and office visits
• Decrease in frequency of appts. with specialists
Long Term:
• Decrease in URI’s and Pneumonias:
o ↓ in antibiotic usage
o ↓ or cessation of continued lung damage
• Decrease in hypoxemic sequela
• Healthier gut – decrease in surgeries
*Early intervention in chronic diseases or conditions = ↑ Outcomes
MiPCT - CM Impact (Office):
Improved referral process
Care coordination follow-up occurs more consistently
Identification of gaps in care – registry
Redefinition of roles for personnel in office
PCP satisfaction ↑ with awareness patients receive more
“rounded” care.
• Pt. support and education has increased
• Improved pt. satisfaction as noted by physician inquiry
• Evidence-based screening guidelines and tools readily
available for various diagnoses and social situations
•
•
•
•
•
Patient Care Transformation !
Be PROUD of your participation in this demo project…it works!
Dr. Arthur Ronan
Laura Young RN
Patient History
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
Diabetes Mellitus
Coronary Artery Disease
Atrial Fibrillation
Heart Failure
COPD
Elevated Cholesterol
HTN
Ischemic Heart Disease
Aortic Valve Disease
Osteoarthritis
PVD
Compression fractures of lower spine
Hospital admit X 2
 Hospitalization 4/8/12 – 4/13-12
 Symptoms of weakness
 Diagnosis: Atrial Fibrillation
 Within 24 hours post hospital discharge
 voiding blood
 transported to ER via ambulance
 Rehospitalization 4/15/12 – 4/19/12 (different hospital)
 Blood transfusions
 Problem: Coumadin dose
Post Hospitalization
 From 4/12 through the summer 2012
 JW reports weakness and dizziness
 Multiple visits to PCP and Cardiologist
 Patient reports taking his medications “as directed”
Post Hospitalization
 Quality of life declining
 Reports feeling sick and weak
 Not able to do yard work, usual daily chores
 Can only walk in his home
 Not able to do his favorite activity: bowling twice a week
with friends
 Hygiene takes a toll
 Facing challenges caring for himself
Care Manager Referral, Assessment
 Referral to Care Manager from PCP 8/12
 Bradycardia, weakness, dizziness
 Assessment by Care manager
 Review records, bradycardia for several months
 Medication reconciliation

taking Lopressor 25 mg twice a day and Metoprolol 25 mg
twice a day since 4/12.
Care Management Action
 Communication between PCP and CM
 Two different pharmacies = trouble
 Patient has same day PCP appointment
 PCP office visit


Assessment, “work up”
Plan
 Medication adjusted: discontinue Lopressor
 Scheduled follow up PCP appointment 1 week
Care Management Plan
 One week return PCP appointment
 Bradycardia continues
 Next step - Cardiologist appointment

On course, no change in plan
 A few weeks later, follow up appointment with PCP
 Heart Rate 60s, still has dizziness, lethargy
 Metoprolol discontinued
 Result: Heart Rate above 60, dizziness resolved
Care Manager Uncovers
 Minimal understanding of self care for diabetes
 Poor diet


JW does not cook
Spouse is ill, not able to cook
 Medication issue

Taking Metformin at 10pm
 Unexpectedly JW has a new role - “care giver” for his
spouse
 Lack of social support

pride
Care Manager Intervention
 Assessed patient’s understanding of diabetes
 Discussed current diet
 Shared information about Diabetes and diet
 Support rallied


Contacted daughter
Daughter informed, agrees to visit on weekends, cooks meals
 Medication reconciliation

Right medication, right dose, right time - metformin
Care Manager Intervention
 Follow up phone visits
 Support at home
 Medication reconciliation
 PCP vs ED
 Education
 Call PCP office first
 Red Flags, when to call Care Manager
 How to contact PCP office after hours
Outcomes
 Avoided unnecessary ER visit
 Work up bradycardia in PCP office
 Collaboration between PCP and Care Manager results
 Involve the patient
 Involve the family
 Assess need, develop plan, monitor patient’s response to plan
 JW’s Quality of Life is improved
 JW now functioning independently,
 Caring for wife,
 Bowling with friends!
PGIP and Data Exchange
March 8, 2013
Alina Pabin
Manager
85
The Road to Long Term Success
Health Insurance Market Place
Affordable Products
High Quality
High Customer
Satisfaction
Accurate Picture of
Population Health Status
Need to impact all
BCBSM covered lives
NCQA Accreditation and HEDIS® Performance
HEDIS Measures
Data Exchange Capabilities
Member Engagement and
Customer Satisfaction
MA Stars Ratings
Risk Adjustment
Improve Data Exchange
(EMR/DMR) Capabilities
86
Complete and Accurate Coding
Risk-Adjusted Reporting
Why is PGIP Integral to Long Term Success?
• Innovative programs developed in partnership with the provider
community
• Shared commitment to efficient and high quality patient care
• Facilitates the shift from fee for service to fee for value
• Innovative reimbursement models at physician level and incentives at the
PO-level to achieve population level results
• A connected Physician Organization (PO) community that can mobilize
• Leverages existing resources
– Epidemiology , technical, and field teams
– Reporting structures (claims and self reported data)
– Communications (web, email, newsletters, etc)
87
Why is PGIP Integral? (cont.)
• Largest Patient Centered Medical Home (PCMH) program in the country
•
•
•
•
995 designated PCP practices in 66 of 83 Michigan counties
Over 3,000 PCPs (another 2,600 PCPs are actively implementing PCMH capabilities)
Impacts 1.8 million BCBSM commercial members
Statistically improved performance
• Provider-Delivered Care Management (PDCM)
• Largest demonstration project in the country – Eight state CMS pilot with Michigan physicians
representing over 50% of PCMH practices
• Unique opportunity to further evolve the care delivery model, assuming pilot results are
compelling
• 1,630 PCPs and 300 trained care managers (FNPs, PAs, or MSWs)
• ~1 million eligible lives, 44% are BCBSM members
• Organized Systems of Care (OSCs)
• 38 OSCs as of 4Q12
• 4,300 PCPs and 8,754 specialists
• Impacts 1.3 million attributed BCBSM commercial members
88
Leveraging PGIP for Long Term Success
Evaluate
Incentivize
Report
Build
Align
89
2013 PGIP NCQA Alignment
• Evidence Based Care Tracking (EBCT) payments aligned with NQCA HEDIS®
Accreditation Measures
– NCQA benchmarks replaced PO benchmarks, program year 2013
• Aligned measures included in quality scores for PCMH designation
• EBCT better aligned with MA Stars and HEDIS®
• Patient Centered Medical Home (PCMH) capabilities aligned with NCQA
standards for coordination and continuity of care
– E.g., diabetes patient registry, coordination of care, specialist referral
• Provider Delivered Care Management (PDCM) focus on chronic condition
management
90
2013 Infrastructure Building
• Clinical community infrastructure
– PCMH Neighbor (PCMH-N) capability implementation
– Incentives for enrolling non-physician providers
• Functional data exchange
– Health e-Blue (HEB) Web, and/or
– Electronic Medical Record (EMR)/Disease Management Registries (DMR)
Expansion
• Communications and PO Resources
– PO Diagnosis Billing Common Interest Group focused on discussing best
practices in coding
– Tools for successful participation in Medicare Advantage (MA)– Gain Sharing
and Diagnosis Closure incentive programs
91
Engaging in EMR/DMR Activities
• What is EMR/DMR?
– Electronic Medical Record (EMR)/Disease Management Registries (DMR)
– Uses current Blue Care Network (BCN) file layout
– Provides data submission capabilities in batch format for non claims data
• Where’s more information?
– December 2012 EBCT webinar slides
– Frequently asked questions (FAQ) document
• Where do I start?
– 1:1 kick-off meeting with PO and BCBSM/BCN
– Value Partnerships field team member
92
2013 Incentives for Engaging in EMR/DMR Activities
• $50K per PO distributed in January 2013
• Total of $750K available for PGIP POs in July 2013
– Payment commensurate with activities
• Additional incentives in January 2014 payment cycle
– Again, payment commensurate with activities
– No action/lack of good faith effort by end of 3Q 2013 will result of take back of
$50K distributed in Jan 2013 payment cycle
– PO inaction in 2013 also will impact PGIP EBCT Initiative incentives for 2014
(estimated at approximately $15 million+).
• Need details?
– Tuned in to April 2013 PGIP Matters
– Set an alert for the announcements on the PGIP Collaboration web site
93
Contacts
Alina Pabin apabin@bcbsm.com
Stephanie Nieman snieman@bcbsm.com
Donna Saxton dsaxton@bcbsm.com
94
Key Changes to Evidence Based Care Tracking
Initiative in 2013
1
2
3
4
95
• Measures strongly aligned with HEDIS® specifications
• Enhance reporting to provide more frequent year-to-date data
• Scoring and reward PO performance in the program year
• Provide mechanism to deliver Supplemental Data
HEDIS® Measures – 2013 Performance
NCQA 90th Percentile
Score for PPO
PGIP Average
Score#
1. Breast Cancer Screening*
80%
76.50%
2. Colorectal Cancer Screening
70%
54.70%
3. Chlamydia Screening
58%
39.20%
4. Childhood Immunization Status
89%
67.30%
5. Appropriate Testing Children With Pharyngitis
91%
74.80%
6. HbA1c Testing
93%
83.40%
7. LDL-C Testing
89%
77.00%
8. Nephropathy Monitoring
88%
72.80%
9. Retinal Eye Exam
74%
32.80%
10. HbA1c Poor Control (>9.0%) (Currently lab data not available)
19%
-
11. Appropriate Medication Use for Asthma
95%
94.10%
12. Cholesterol Management LDL-C Screening
92%
79.60%
13. Persistence of Beta Blocker Treatment After Acute Myocardial Infarction
89%
81.70%
COPD Measures
14. Use of Spirometry Testing in the Assessment and Diagnosis of COPD
53%
45.50%
Low Back Pain
15. Use of Imaging Studies for Low Back Pain
82%
72.50%
16. Appropriate Treatment for Children with Upper Respiratory Infection
93%
78.20%
17. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
37%
20.20%
18. Antidepressant Medication Management--Acute Phase
72%
70.40%
19. Antidepressant Medication Management--Continuation Phase
57%
53.10%
50%
37.00%
57%
28.90%
93%
33.80%
Category
Adult Prevention Measures
Pediatric Prevention Measures
Diabetes Measures
Asthma Measures
Coronary Artery Disease Measures
Antibiotic Use Measures
Medication Management Measures
ADHD Measures
Prenatal/Postpartum Care Measures
96
EBCT HEDIS measure for scoring and payment in 2013
20. Follow-up Care for Children Prescribed ADHD Medication-- Initiation Phase Ages 6 to 12 Years
Old
21. Follow-up Care for Children Prescribed ADHD Medication-- Continuation and Maintenance
Phase Ages 6 to 12 Years Old
22. Prenatal and Postpartum Care Overall
* Modified for a lower age parameter of 50 years of age # Average score for all PGIP POs for the period July 1, 2011 – June 30, 2012
2013 EBCT Performance Measures – Alignment with
NCQA and MA Stars
Category
Adult Prevention Measures
Pediatric Prevention Measures
Diabetes Measures
Asthma Measures
NCQA Accreditation
MA Stars
1. Breast Cancer Screening*
X
X
2. Colorectal Cancer Screening
X
X
3. Chlamydia Screening
X
4. Childhood Immunization Status
X
5. Appropriate Testing Children With Pharyngitis
X
6. HbA1c Testing
X
X
7. LDL-C Testing
X
X
8. Nephropathy Monitoring
X
X
9. Retinal Eye Exam
X
X
10. HbA1c Poor Control (>9.0%) (Currently lab data not available)
X
X
11. Appropriate Medication Use for Asthma
Ret. 2013
12. Cholesterol Management LDL-C Screening
X
13. Persistence of Beta Blocker Treatment After Acute Myocardial Infarction
X
COPD Measures
14. Use of Spirometry Testing in the Assessment and Diagnosis of COPD
X
Low Back Pain
15. Use of Imaging Studies for Low Back Pain
X
16. Appropriate Treatment for Children with Upper Respiratory Infection
X
17. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
X
18. Antidepressant Medication Management--Acute Phase
X
19. Antidepressant Medication Management--Continuation Phase
X
Coronary Artery Disease Measures
Antibiotic Use Measures
Medication Management Measures
ADHD Measures
Prenatal/Postpartum Care Measures
97
EBCT HEDIS measure for scoring and payment in 2013
20. Follow-up Care for Children Prescribed ADHD Medication-- Initiation Phase Ages 6 to 12 Years
Old
21. Follow-up Care for Children Prescribed ADHD Medication-- Continuation and Maintenance
Phase Ages 6 to 12 Years Old
22. Prenatal and Postpartum Care Overall
* Modified for a lower age parameter of 50 years of age
X
X
X
X
2013 EBCT Reporting Measures
Category
Adult Prevention Measures
NCQA 90th Percentile
Score for PPO
PGIP Average
Score#
82%
76.3%
79%
*
3. Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents - BMI Percentile
79%
*
4. Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents - Counseling for Nutrition
74%
*
5. Weight Assessment and Counseling for Nutrition and Physical Activity for
Children/Adolescents - Counseling for Physical Activity
69%
*
87%
*
97%
*
72%
45.5%
72%
*
EBCT HEDIS measure for scoring and payment in 2013
1. Cervical Cancer Screening
2. Adult BMI Assessment
Pediatric Prevention Measures
COPD Measures
6. Pharmacotherapy Management of COPD Exacerbation- Bronchodilator
7. Pharmacotherapy Management of COPD Exacerbation- Systemic Corticosteroid
Mental Illness
Other
8. Follow-Up After Hospitalization for Mental Illness - 7 Day Rate
9. Controlling High Blood Pressure
# Average score for all PGIP POs for the period July 1, 2011 – June 30, 2012
* New measure. Average PGIP Score currently unavailable
98
Components of EBCT Overall Score
50 Points
50 Points
Overall Performance Score = 50% of EBCT score and Overall Improvement Score = 50% of EBCT score
Components of EBCT score
EBCT Performance
∑
(Weight)N
(Performance) N
+
EBCT
Improvement
∑
(NIF)N
(Improvement)N
Overall Performance Score = 50% of EBCT score and Overall Improvement Score = 50% of EBCT score
100
2013 EBCT Performance Score – Weights
Category
Adult Prevention Measures
Pediatric Prevention Measures
Diabetes Measures
Asthma Measures
Coronary Artery Disease Measures
Chronic Obstructive Pulmonary Disease
Measures
Low Back Pain
Antibiotic Use Measures
Medication Management Measures
EBCT HEDIS measure
1. Breast Cancer Screening*
2.3
2. Colorectal Cancer Screening
3.1
3. Chlamydia Screening
1.5
4. Childhood Immunization Status
3.1
5. Appropriate Testing Children With Pharyngitis
2.3
6. HbA1c Testing
3.1
7. LDL-C Testing
3.1
8. Nephropathy Monitoring
3.1
9. Retinal Eye Exam
3.1
10. HbA1c Poor Control (>9.0%) (Currently lab data not available)
2.3
11. Appropriate Medication Use for Asthma
1.5
12. Cholesterol Management LDL-C Screening
3.1
13. Persistence of Beta Blocker Treatment After Acute Myocardial Infarction
14. Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive
Pulmonary Disease
15. Use of Imaging Studies for Low Back Pain
3.1
16. Appropriate Treatment for Children with Upper Respiratory Infection
1.5
17. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
2.3
18. Antidepressant Medication Management--Acute Phase
1.5
19. Antidepressant Medication Management--Continuation Phase
20. Follow-up Care for Children Prescribed ADHD Medication-- Initiation Phase Ages 6
to 12 Years Old
ADHD Measures
21. Follow-up Care for Children Prescribed ADHD Medication-- Continuation and
Maintenance Phase Ages 6 to 12 Years Old
Prenatal/Postpartum Care Measures
22. Prenatal and Postpartum Care Overall
* Modified for a lower age parameter of 50 years of age
101
Weight for Performance
(Overall Performance = 50 points)
1.5
2.3
1.5
1.5
1.5
1.5
2013 EBCT Improvement Score – Weights
Category
EBCT HEDIS measure
Weight for Improvement
(Overall Improvement = 50 points)
1. Breast Cancer Screening*
Adult Prevention Measures
2. Colorectal Cancer Screening
3. Chlamydia Screening
Pediatric Prevention Measures
4. Childhood Immunization Status
5. Appropriate Testing Children With Pharyngitis
6. HbA1c Testing
7. LDL-C Testing
Diabetes Measures
8. Nephropathy Monitoring
Improvement weight for
each measure is specific
to every PO
9. Retinal Eye Exam
10. HbA1c Poor Control (>9.0%) (Currently lab data not available)
Asthma Measures
Coronary Artery Disease Measures
Chronic Obstructive Pulmonary Disease
Measures
Low Back Pain
Antibiotic Use Measures
Medication Management Measures
11. Appropriate Medication Use for Asthma
12. Cholesterol Management LDL-C Screening
13. Persistence of Beta Blocker Treatment After Acute Myocardial Infarction
14. Use of Spirometry Testing in the Assessment and Diagnosis of Chronic Obstructive
Pulmonary Disease
15. Use of Imaging Studies for Low Back Pain
16. Appropriate Treatment for Children with Upper Respiratory Infection
17. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
18. Antidepressant Medication Management--Acute Phase
19. Antidepressant Medication Management--Continuation Phase
20. Follow-up Care for Children Prescribed ADHD Medication-- Initiation Phase Ages 6
to 12 Years Old
ADHD Measures
21. Follow-up Care for Children Prescribed ADHD Medication-- Continuation and
Maintenance Phase Ages 6 to 12 Years Old
Prenatal/Postpartum Care Measures
22. Prenatal and Postpartum Care Overall
* Modified for a lower age parameter of 50 years of age
102
Improvement weight
=
NIF for the measure
2013 EBCT Overall Score – Weights
Weight for Performance
(Assumption:
Overall Performance = 50 points)
Weight for Improvement
(Assumption:
Overall Improvement = 50 points)
Total Weight (100 Points)
1. Breast Cancer Screening*
2.3
0.0 - 6.5
2.3 - 8.8
2. Colorectal Cancer Screening
3.1
11.7 - 29.6
14.8 - 32.7
3. Chlamydia Screening
1.5
0.0 - 7.2
1.5 - 8.7
4. Childhood Immunization Status
3.1
0.0 - 1.8
3.1 - 4.9
5. Appropriate Testing Children With Pharyngitis
2.3
0.0 - 3.4
2.3 - 5.7
6. HbA1c Testing
3.1
0.3 - 2.9
3.4 - 6.0
7. LDL-C Testing
3.1
1.1 - 3.5
4.2 - 6.6
8. Nephropathy Monitoring
3.1
0.7 - 4.0
3.8 - 7.1
9. Retinal Eye Exam
3.1
5.9 - 11.4
9.0 - 14.5
10. HbA1c Poor Control (>9.0%) (Currently lab data not available)
2.3
0.0 - 0.0
2.3 - 2.3
11. Appropriate Medication Use for Asthma
1.5
0.0 - 0.2
1.5 - 1.7
12. Cholesterol Management LDL-C Screening
3.1
0.2 - 0.8
3.3 - 3.9
3.1
0.0 - 0.1
3.1 - 3.2
EBCT HEDIS measure
13. Persistence of Beta Blocker Treatment After Acute Myocardial
Infarction
14. Use of Spirometry Testing in the Assessment and Diagnosis of Chronic
Obstructive Pulmonary Disease
1.5
0.0 - 0.7
1.5 - 2.2
15. Use of Imaging Studies for Low Back Pain
2.3
0.0 - 1.4
2.3 - 3.7
16. Appropriate Treatment for Children with Upper Respiratory Infection
1.5
0.1 - 3.0
1.6 - 4.5
17. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
2.3
0.2 - 3.1
2.5 - 5.4
18. Antidepressant Medication Management--Acute Phase
1.5
0.0 - 0.3
1.5 - 1.8
19. Antidepressant Medication Management--Continuation Phase
1.5
0.0 - 0.3
1.5 - 1.8
0.0 - 0.7
1.5 - 2.2
0.0 - 0.4
1.5 - 1.9
0.9 - 7.3
2.4 - 8.8
20. Follow-up Care for Children Prescribed ADHD Medication-- Initiation
Phase Ages 6 to 12 Years Old
21. Follow-up Care for Children Prescribed ADHD Medication-Continuation and Maintenance Phase Ages 6 to 12 Years Old
22. Prenatal and Postpartum Care Overall
* Modified for a lower age parameter of 50 years of age
103
1.5
1.5
1.5
EBCT Incentives vs. NCQA Accreditation
100%
13%
90%
5%
80%
70%
32%
All EBCT incentives are aligned to impact
NCQA accreditation
6%
7%
8%
60%
4%
8%
8%
50%
28%
12%
40%
Others
Prenatal/Postpartum Care
30%
12%
Coronary Artery Disease
Antibiotic Use
20%
Pediatric Prevention
33%
24%
10%
0%
2013 EBCT Incentives
104
2013 NCQA HEDIS Overall Score
Diabetes
Adult Prevention
EBCT Incentives vs. MA Stars
100%
13%
13%
5%
CAD
6%
5%
CAD
6%
7%
7%
8%
8%
Diabetes
28%
Diabetes
28%
67% of EBCT Incentives Impact MA Stars
90%
80%
70%
Optimizing PO performance on EBCT
should positively affect performance for
MA population
60%
50%
40%
Others
Prenatal/Postpartum Care
30%
CAD
Antibiotic Use
20%
Adult Prevention
33%
Adult Prevention
33%
10%
Diabetes
Adult Prevention
0%
2013 EBCT Incentives
105
Pediatric Prevention
Impact on MA Stars
PGIP Quarterly Meeting
March 8, 2013
Tom Leyden, MBA
Director II, Value Partnerships
106
“Welcome 2013” – PGIP Continues to Grow
• Total number of physicians in PGIP have increased from 16420 to 16960
(55% book of business participate in PGIP)
• Number of Primary Care Physicians: 5631
• Number of Specialists: 11,329
– Need for Continued Psychologist Recruitment: 9% currently in PGIP
– Need for Continued Chiropractor Recruitment: 3% currently in PGIP
– Incentives offered for recruitment
• Total number of practice units in PGIP: 5,848
• Number of practice units nominated for 2013 PCMH Designations: 1,347
• Number of Safety Net practices in PGIP: 97
Based on Winter 2013 Physician List
107
Safety Net Practices
• Effective in 2013, safety net practices will be eligible for
participation in PCMH Designation
– POs had opportunity to note safety net practices during DIVA process
• School-based health centers will be eligible for designation as
part of the 2014 designation cycle
– Details will be provided in Fall 2013
• Additional modifications to this year’s designation cycle will
be announced in spring 2013
108
Chiropractor Enrollment Incentive
• PGIP will offer enrollment incentives to PGIP POs for currently
and newly enrolled chiropractors starting with July 2013
payment cycle .
• POs with PGIP chiropractic practice units would be eligible to
receive a one-time enrollment incentive to assist/start the
collaboration between chiropractors and primary care
community and jumpstart work on PCMH-N capabilities.
• The enrollment incentives will be offered for up to 24 months
to encourage POs to start and continue with the enrollment
efforts.
109
Chiropractor Enrollment
PGIP encourages physician organizations to continue the efforts
to enroll chiropractors either via full or associate membership
and develop strategies to:
• Engage chiropractors in implementing PCMH-N capabilities.
• Explore ways to improve chiropractor input for managing patients
with musculoskeletal conditions.
• Improve coordination of care between chiropractors and other
medical providers and keep other providers informed when their
patients are undergoing chiropractic care.
110
Chiropractor Enrollment
• PGIP is actively recruiting subject matter experts from physician
organizations and Michigan Association of Chiropractors to establish
a Chiropractor Engagement Workgroup. If interested, contact Niki
Su via e-mail xsu@bcbsm.com by April 30, 2013.
• The workgroup will focus on the following activities:
– Develop strategies and tools to assist POs in their efforts to recruit
chiropractors
– Share best practices of building effective relationships between primary care
community and chiropractors
– Explore ways to expand PCMH-N capabilities and use of BCBSM’s use
management data
• PGIP plans to complete subject matter experts recruitment and
start first workgroup meeting in spring 2013.
111
Behavioral Health Enrollment Incentive
• PGIP will offer enrollment incentives to PGIP POs for currently
and newly enrolled FLPs (fully licensed psychologists) and
psychiatrists starting with July 2013 payment cycle.
• POs are eligible to receive a one-time enrollment incentive to
assist start the collaboration between behavioral health
providers and primary care community and jumpstart work on
PCMH-N capabilities.
• The enrollment incentives will be offered for up to 24 months
to encourage POs to start and continue with the enrollment
efforts.
7
Behavioral Health and PGIP
• PGIP has assembled a group of subject matter experts from
physician organizations and a wide range of behavioral health
providers.
• The workgroup is focusing on following activities:
– Developing a business case for behavioral health/PCP integrated care
– Developing tools and sharing best practices of building effective relationships
between primary care community and behavioral health professionals
– Explore ways to improve continuity and coordination of care
– Opportunities for behavioral health patient registry
– Discussions about innovative reimbursement strategies
8
2013 Specialists Fee Uplift Results
114
Specialist Uplift Results
Specialty
E&M Uplift Type
(Percent)
Cardiology
Perf. (25%)
57
293
Emergency Medicine
Perf. (15%)
20
306
Gastroenterology
Perf. (20%)
38
105
Nephrology
Perf. (25%)
19
73
5
12
106
285
Onc Par. (10%)*
31
121
Perf. (20%)
47
213
Perf. (20%)
53
181
376
1,589
PUs Uplifted
Onc Par. (10%)*
OBGYN
Perf. (20%)
Oncology
Orthopedic Surgery
Physician Level Totals
*Participation in Oncology Clinical Pathways initiative or QOPI Certification
115
Physicians Uplifted
Eligible E&M Codes for the Specialist Fee Uplift
•
All physicians selected for the specialist fee uplifts will receive uplifts on the same
set of Evaluation and Management (E&M) service codes (in the 99XXX range)
E&M Visit Type
•
•
116
E&M Visit Code
Office
99201-15
Preventive Medicine
99381-97
Emergency Department
99282-84
Inpatient and Observation
99217-39
These E&M codes represent a broader range than those used for PCMH
The codes were selected to recognize the contributions of specialists that practice
in outpatient, inpatient and emergency department settings
Specialist Uplift Results
As of February 1, 2013:
• For those specialties in PGIP:
– 37% (3,931) of PGIP participating specialists were eligible for a
specialist fee uplift
– 40% (1,589) of the eligible specialists are receiving a fee uplift
117
All Specialist Uplifts
376 Practice Units
1,589 Physicians
Red – Cardiology
Purple – Emergency Med
Green – Gastroenterology
Yellow – Nephrology
Pink – OB/GYN
Orange – Oncology
*Markers represent PUs (not individual uplifted physicians)
Cardiology Uplifts
57 Practice Units
293 Physicians
*Markers represent PUs (not individual uplifted physicians)
Emergency Medicine
20 Practice Units
306 Physicians
*Markers represent PUs (not individual uplifted physicians)
Gastroenterology
38 Practice Units
105 Physicians
*Markers represent PUs (not individual uplifted physicians)
Nephrology
19 Practice Units
73 Physicians
*Markers represent PUs (not individual uplifted physicians)
OB/GYN
111 Practice Units (106 Performance; 5 Participation*)
297 Physicians
*Markers represent PUs (not individual uplifted physicians)
Participation refers to QOPI Certification and/or Oncology Pathways Participation
Oncology
78 Practice Units (Performance 47; Participation 31*)
334 Physicians
*Markers represent PUs (not individual uplifted physicians)
Participation refers to QOPI Certification and/or Oncology Pathways Participation
Program Updates
125
Women’s Care Initiative
• Replaces Labor Induction and Hysterectomy Initiatives; focuses on a
variety of topics to improve women’s health care across the lifespan
• Aligns with OB/GYN specialist uplifts, but focus is on POs and PCPs
– Topics included in both Initiative and OB/GYN uplift include obstetrical
care, cesarean section, hysterectomy, breast cancer screening, HPV
vaccinations, women’s cost of care PMPM and women’s GDR
• July ‘13, January ‘14, July ‘14 will be participation-based; will
transition to performance payments in 2015
• The Women’s Care Initiative Plan and Executive Summary are now
posted on the PGIP Collaboration site
• Deadline for selection/de-selection is April 30th
21
Increasing the Use of Generic Drugs Initiative
(GDR)
• 2013 will be the last program year for payment on risk-adjusted GDR
(18-64 yrs)
• New methodologies for a pharmacy initiative are being explored for 2014
program year.
• POs will still be accountable for pharmacy PMPM cost trend
• Contact Michelle Ilitch and/or Mike Strampel for questions
militch@bcbsm.com or mstrampel@bcbsm.com
127
E-Prescribing Initiative
• Starting with July 2013 payment cycle, E-Prescribing
Initiative reward payments (based on implementation of new
e-prescribing capabilities) will be adjusted based on PCP
membership and electronic claims submission rates (derived
from Express Scripts Reports)
• Express Scripts reports are developed quarterly by BCBSM and sent to
PO E-Prescribing Initiative contacts via email
128
Radiology Management Initiative
• Check the PGIP Collaboration Site in mid- March for the
Radiation Safety and Imaging Appropriateness education plan
requirements
• The education plan information will also be shared in the
April edition of PGIP Matters
• At the June Quarterly there will be an RMI Best Practices
break-out session
• Save the date - June 26, 1 to 2 p.m. Webinar regarding the
radiation exposure education plans
129
Organized Systems of Care (OSC)
Timeline for 2013
Date
Mid February Distributed 1st installment of OSC start up payment
March 6 - 18
OSC Data Collection Tool Due
April – May
OSC site visits
May
OSC Initiatives payment for OSC capabilities implemented
June - August New OSC PGIP open enrollment
130
June
Population Insights report
September
OSC Data Collection Tool Due
November
OSC Initiatives payment and 2nd installment of OSC start up
payment
December
Population Insights report
Provider-Delivered Care Management
• PDCM session this afternoon from 1:30 – 3:00 in the main
auditorium.
– New PDCM codes for care manager time coordinating care with
other providers, and physician time spent in team conferences
• PDCM Expansion to include Oncology practices in late 2013
– Collaborative BCBSM-provider oncology workgroup currently
developing criteria for oncology practices to participate in PDCM
• Foundational PCMH capabilities
• POs will need to work closely with oncology practices to
accurately complete SRD regarding PCMH capabilities
implemented
131
Field Team Updates
March 8, 2013
Donna Saxton, MHA, MPH, FACHE, CPHQ
Field Team Manager
132
Field Team Updates
• Welcome to our newest field team representative!
– Andrew Billi
• In the process of realigning PO assignments
– Realigning to provide better regional support
– Current field team representative will schedule meetings to conduct transition
(if applicable)
Site Visits
• OSC Site Visits
– Will begin in Mid-Late April once Data Collection tool is finalized
• Would like volunteers for calibration training
– Suggest moving forward and scheduling OSC visits to occur in May
• PCMH – N Site Visits
–
–
–
–
134
Calibration training will begin mid- April
Site visits will begin late April and continue throughout the year
Target completion September/October
Will be flexible, but will adhere to the no more than 3 reschedule rule
PGIP Quarterly Meeting
Continuity and Coordination of Care
March 8, 2013
Marianne Thomas, R.N.
Manager, NCQA Accreditation
Value Partnerships
135
Continuity and Coordination of Medical Care
Purpose
The organization uses information at its disposal to facilitate continuity and
coordination of medical across the delivery system.
Examples
 Inpatient settings
- Hospital
- Rehabilitation
- Skilled Nursing
- Extended Care Facility
- Hospice
Continuity and Coordination of Medical Care
 Outpatient Setting
- Outpatient Rehab
- Physician office
- Surgery Center
- Home Health
- Emergency Center
The organization annually identifies and acts on opportunities to improve
coordination of care
 Collecting data
 Conducting qualitative and quantitative analysis
 Identifies opportunity for improvement
 Takes action to improve
Continuity and Coordination of Care
Taking Action
 Advise patients to schedule office visit with Primary Medical Provider after
an episode of care from a specialist
 Prompt specialists to send summaries of recommendations to
practitioners who provide primary care services
 Collaboration through PCMH initiative via support of the medical home
initiative through incentives and information system integration
 Notify practitioners about patients with prescriptions from multiple
practitioners
PGIP Quarterly Meeting
Analytic Updates & Communications
March 8, 2013
Michael Paustian, PhD, MS
Dept. of Clinical Epidemiology & Biostatistics
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.
Overview
• PGIP reporting updates
–
–
–
–
Datasets
Cave
Specialist uplift
Future risk score changes
• Program-related analytic updates
– Diagnosis code billing
– Chronic disease tracking
• Analytic sessions
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PGIP reporting
• Files (Datasets) delivered to each PO’s EDDI mailbox on 2/28
• Specialist Uplift
• Sub-PO scores and weights delivered on 2/14
• Webinar on 3/7, to be available on PGIP collaboration site
• CAVE
– PO and practice reports for 21 specialties released on 2/28
– Technical guidance and FAQ documents now on PGIP collaboration site
• Risk score will be transitioning from version 6.5 to version 8.0
– Expect risk scores to fall ~ 10% based on Symmetry’s experience
– Expect re-based reports when it happens
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Cave methods update
Criterion
(evaluated
separately for
each year)
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Old
New
Age
18-64 years
18-64 years
Continuous
Enrollment
Enrolled for ≥11
months during the
year
Had no gaps in
coverage of >45
days during the
year
PO Population
Members attributed
to a Michigan PCP
Members attributed
to a Michigan PCP*
PU Population
Members attributed
to a Michigan PCP
All members,
regardless of PCP
attribution status
*PO reports are still based on episodes for the PO’s PCPattributed members. However, the peer group now also
includes members not attributed to a PCP.
Billing diagnosis codes monitoring
•Negligible variations in diagnosis codes seen throughout the 18
months covered by these two Professional Claims Diagnosis
Coding Reports
•No increase in diagnosis codes per claim was observed for the
PGIP physician panel, as a whole
•At the individual Physician Organization level, only slight
increases or decreases in the average diagnoses per claim
were observed (range: -0.1 to 0.3).
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Total professional claims by number of
billed diagnoses, 2012
16,000,000
Frequency of Submitted Professional Claims
49.4%
14,000,000
12,000,000
10,000,000
8,000,000
23.7%
6,000,000
12.5%
4,000,000
11.0%
2,000,000
1.6%
0.8%
0.3%
0.4%
0.1%
7
8
>8
0
1
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2
3
4
5
6
Number of Diagnosis Codes
Chronic disease dropoff in claims –
Diabetes
100%
100%
90.4%
90%
84.4%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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N = 58,249
N = 52,633
N = 49,147
% met case definition for
diabetes, 2008
% with any mention of
diabetes, 2009
% met case definition for
diabetes in 2009
Chronic disease dropoff in claims –
COPD
100%
100%
90%
80%
70%
60%
50.5%
50%
43.5%
40%
30%
20%
10%
0%
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N = 5,297
N = 2,675
% met case definition for
COPD, 2008
% with any mention of COPD,
2009
N = 2,223
% met case definition for
COPD in 2009
Analytic learning opportunities
• Breakout Session: Data Users Workgroup
– Presenter: Jack Green
– Time: 11:15 – 12:00
• Breakout Session: Interpreting Cave data
– Presenter: Erin Schlemmer, MPH
– Time: 1:30 - 2:15
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