2012 prp bcn and bcna
TRANSCRIPT
2012 PRP Design – Incentive Categories
Funding is split between Base PRP measures, PRP Bonus Incentives and Pay As You Go (PAYG) Incentives:
- Base PRP Measures
- HEDIS®*-oriented measures
- Analyzed and paid annually
*HEDIS is a registered trademark of the National Committee for Quality Assurance.
- PRP Bonus Incentives
- Incentives with specific time frames, measures and payments
- Analyzed and paid annually
- Pay As You Go Incentives- Payments made throughout the year for services that have been
completed during the year
BCN HMOSM Commercial
Performance Recognition Program 20122012 Base PRP Measures:Quality – Preventive Screening
Well Child – 15 months
Well Child 3-6 years
Childhood Immunizations – Combo 3
Adolescent Immunizations – Combo 1
Cervical Cancer Screening
Breast Cancer Screening
Colorectal Cancer Screening
Quality – Disease Management
Diabetes Retinal Eye Exam
Diabetes HbA1C Testing
Diabetes HbA1C level < 8
Diabetes Monitoring for Nephropathy
Diabetes LDL-C Testing
Diabetes LDL-C level < 100
Cardiovascular Disease LDL-C Testing
Cardiovascular Disease LDL-C level < 100
Quality Payout -
Quality Composite Score 70%-74%: $.75 PMPM
Quality Composite Score 75%-79%: $1.25 PMPM
Quality Composite Score >=80%: $2.25 PMPM
2012 Bonus IncentivesCommercial HMO
Appropriate testing for children with pharyngitis
Appropriate treatment for children with upper respiratory infection
Avoidance of antibiotic treatment in adults w/acute bronchitis
Follow up after Hospitalization – Mental Illness
Follow up care for children with ADHD – Initiation Phase
BMI Child
2012 Pay As You Go Incentives:Commercial HMO
13 of 15 Base PRP measures:
excluded is Breast Cancer Screening & Colorectal Cancer Screening
Chlamydia screening
Scoring and Payout - Fall 2012 and Spring 2013
First Payment PAYG $5
Second payment based on tiered scale
Composite score 0%-69% $5 per service
Composite score 70%-79% $10 per service
Composite score 80% or greater $15 per service
Base PRP and PAYG - Commercial
• Base PRP is made up of seven preventive screenings and
eight disease management measures which are combined
and determine the Quality Summary Report.
• PAYG measures pay twice a year on 13 of the Base PRP
measures.
– First PAYG payment will be $5 for each service completed.
– Second PAYG payment will be paid at the appropriate
amount according to the provider’s Base PRP score.
Base PRP and PAYG - Commercial
• Payment will be based on a primary care physician’s overall
composite score:
Tiered base PRP
$PMPM
Tiered PAYG $ per
measure
70-74% $0.75 0-69% $5.00
75-79% $1.25 70-79% $10.00
≥80% $2.25 ≥80% $15.00
PAYG Incentives - Commercial
• PAYG includes all but the following Base PRP measures:
– Breast cancer and colorectal cancer screening
– Payment: tiered payout by completed service, based on year-end Base PRP Quality Composite Score
Bonus Incentives - Commercial• Chlamydia screening
– Ages: females 16-24 years of age identified as sexually active via pharmacy or claims encounter data
– Measurement period: Jan. 1, 2012 – Dec. 31, 2012
– Payment: flat fee of $25 paid to the eligible provider who completes the qualifying test according to the specifications
Bonus Incentives - Commercial
• Appropriate testing for children with pharyngitis– Ages: 2 yrs. old as of Jan. 1, 2012, to age 18 as of Nov. 30, 2012 with
a single diagnosis of acute pharyngitis, acute tonsillitis or streptococcus sore throat, dispensed an antibiotic and received a group A strep test for the episode
– Measurement period: Jan. 1, 2012, to Nov. 30, 2012
– Payment: $40 for every qualified member; paid at the MCG level
– See technical specifications for clarification and additional criteria to meet.
• Avoidance of antibiotic treatment in adults with acute bronchitis– Ages: Adults 18 yrs. old as of January 1 of the prior year to 64 years
old as of Dec. 24, 2012, with a diagnosis of acute bronchitis and NOT dispensed an antibiotic prescription
– Measurement period: Jan. 1, 2012, through Dec. 24, 2012
– Payment: $60 for every qualified member; paid at the MCG level
– See technical specifications for clarification and additional criteria to meet.
Bonus Incentive – Commercial (con’t.)
• Follow-up care for children with ADHD – initiation phase
– Age: Members 6 years of age as of Jan. 1, 2012, and 12 years of age as
of Dec. 31, 2012, newly diagnosed and dispensed ADHD medication with
one follow-up practitioner visit within 30 days of initiating the medication
– Measurement period: Jan. 1, 2012, through Dec. 31, 2012
– Payment a flat fee of $50 paid to the PCP for each member with qualifying
follow-up visit with a practitioner with prescribing authority
– See technical specifications for clarification and additional criteria to meet.
• Follow-up care after hospitalization – mental illness
– Age: Members 6 years of age and older hospitalized for treatment of
selected mental health disorders; follow-up visit within seven days of
discharge with a mental health practitioner
– Measurement period: Discharges between Jan. 1, 2012, and Oct. 31,
2012
– Payment: Flat fee $100 paid to the first behavioral health specialist for
each qualifying outpatient visit
– See technical specifications for clarification and additional criteria to meet.
Bonus Incentives – Commercial (con’t.)
• Appropriate treatment for children with upper respiratory
infection
– Age: Members 3 months of age as of Jan. 1, 2012, to 18
years of age as of Dec. 28, 2012, who were given a
diagnosis of upper respiratory infection (URI) and were NOT
dispensed an antibiotic prescription
– Measurement period: Jan. 1, 2012, through Dec. 31, 2012
– Payment: $40 for every qualified member; paid at the MCG
level
– See technical specifications for clarification and additional
criteria to meet.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Child BMI Assessment
- Members 7 to 17 years of age who have an active BCN
commercial span through end of 2012, had an office
visit during 2012.
- Measurement period -
August 1, 2012, through December 31, 2012; payment
calculations after January 31, 2013;
- Payment –
flat fee of $50 paid to the eligible provider for each
reported BMI.
Bonus Incentives – Commercial
(con’t.)
BCNA 2012 Measures
12
MeasureFinal
Measure
Measure
Type
Breast Cancer Screening Yes BASE/PAYG
Cholesterol Screening for Patients with Diabetes Yes BASE/PAYG
Cholesterol Screening for Patients with Heart Disease Yes BASE/PAYG
Colorectal Cancer Screening yes BASE/PAYG
Diabetes Care – Blood Sugar Controlled Yes BASE/PAYG
Diabetes Care – Cholesterol Controlled Yes BASE/PAYG
Diabetes Care – Eye Exam Yes BASE/PAYG
Diabetes Care – Kidney Disease Monitoring Yes BASE/PAYG
Annual Monitoring For Patients on Persistent Medications Yes BONUS
Diabetes Treatment (ACE/ARB for Hypertension) Yes BONUS
Glaucoma Testing Yes BONUS
High Risk Medication Yes BONUS
Adult BMI Assessment Yes BONUS
BCN Advantage HMO-POSSM and BCBSM Medicare Plus
Blue PPOSM
2012 Performance Recognition Program
2012 Base PRP Measures
Quality –Preventive Measures
– Cancer Screening
– Colorectal cancer screening
Quality – Disease Management
– Diabetes retinal eye exam
– Diabetes HbA1C level < 8
– Diabetes monitoring for nephropathy
– Diabetes LDL-C level < 100
– Diabetes LDL-C testing
– Cardiovascular disease LDL-C testing
Quality Payout -
– Quality composite score PMPM
– 70%-74% $2.00
– 75%-79% $3.50
– >= 80% $5.00
2012 Bonus Incentives
- Annual monitoring for patients on
persistent medications
- Diabetes treatment (ACE/ARB for hypertension)
- Glaucoma testing
- High Risk Medications
- Adult BMI
2012 Pay As You Go Incentives- All of the base PRP measures
Scoring and Payout
- Fall 2012 and Spring 2013
- Payment PAYG $10
Score Thresholds
Base PRP Calculation = MA Quality Score x Member Months x PMPM Amount
Tiered PAYG $Per Measure Tiered BASE PRP $PMPM
Score Between: $/Service Score Between: $PMPM
0% 69% $10 0% 69% $0.00
70% 74% $10 70% 74% $2.00
75% 79% $10 75% 79% $3.50
80% 100% $10 80% 100% $5.00
BCNA Physician Assessment
• To complete the BCN Advantage Physician Assessment on Health e-Blue, use the
Physician Assessment form submission tool to submit each Hierarchical Condition Category
(HCC) relating to a substantial existing chronic disease, including coexisting historical
diagnoses that are still relevant for a member. Be sure to support the diagnoses with
medical record documentation, which is subject to validation by the Centers for Medicare &
Medicaid Services.
• Step-by-step instructions for using the form submission tool is located on Health e Blue at
the bottom of the page.
• In order to qualify for reimbursement, you must complete the physician assessments in
2012. The last date for electronic submission on Health e-Blue is Jan. 4, 2013.
• BCN will pay reimbursements twice a year. If submitted on Health e Blue the
reimbursement is $200 per BCNA member. If hardcopy via fax or mail the reimbursement is
$150 per BCNA member.
Health e-BlueSM Access
Sign up for Health e-Blue
To sign up for access to Health e-Blue, follow these steps:
1. Go to MiBCN.com
2. Click on I am a provider.
3. Under the News and Updates heading, click on Sign up for Provider Secured Services.
4. Under the Solutions available through Provider Secured Services subheading, click on Health e-Blue for Blue Care Network patient data and Blue Cross Blue Shield of Michigan Medicare Advantage patient data (Health e-Blue application).
QUESTIONS??
Thank you for attending.Christina Caldwell, Provider Affairs Representative
734-332-2949 [email protected]