Blue Care Network Performance Recognition Program. Performance Recognition Program Commercial HMO Incentive Materials 2014

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Blue

Care

Network

Performance

Recognition

Program

Commercial

HMO

Incentive

Materials

2014

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Page 2 of 11

December 2013

Dear BCN‐Affiliated Primary Care Physician or Group Administrator:

Blue Care Network is pleased to provide you with details of our 2014 physician incentive materials for the

commercial population. Enclosed you will find information about the Performance Recognition Program including

Base PRP, Improvement on Base PRP and PRP Bonus incentives for 2014.

Our program strives to align provider incentives with the ever changing, stringent quality benchmarks for HEDIS

and STARS. BCN’s philosophy towards our provider incentive programs also continues to make meaningful

payments that encourage appropriate clinical outcomes. The 2014 program is geared toward accomplishing these

objectives.

Below, please find the highlights of our 2014 program:

2014 Base PRP highlights  Breast cancer screening  Cervical cancer screening

 Childhood immunizations combo 2

 Cholesterol management for patients with cardiovascular conditions ‐ LDL‐C testing

 Cholesterol management for patients with cardiovascular conditions ‐ LDL‐C control <100mg/dL  Colorectal cancer screening

 Comprehensive diabetes care ‐ A1C control ≤9%  Comprehensive diabetes care ‐ A1C testing

 Comprehensive diabetes care ‐ LDL‐C control <100 mg/dL  Comprehensive diabetes care ‐ LDL‐C testing

 Comprehensive diabetes care ‐ retinal eye exam  Well‐child visits 15 months

2014 PRP Bonus highlights

 Appropriate testing for children with pharyngitis

 Appropriate treatment for children with upper respiratory infection  Avoidance of antibiotic treatment in adults with acute bronchitis  Chlamydia screening

 Follow‐up care for children prescribed ADHD medication initiation phase

 Weight assessment and counseling for nutrition and physical activity for children/adolescents

Please remember that all data entry into Health e‐BlueSM must be for services rendered, not just ordered or

reminders sent.

Please visit the Health e‐Blue home page for all 2014 physician incentive information. If you have any questions,

please contact your medical care group leadership or your BCN provider representative. We appreciate your

continued support of our physician incentive programs.

Sincerely,

Karen Kopytek

Manager, Provider Affairs

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Distribution of PRP Payment Reports and Payments ………..……… Page 10

Reconsideration ………..………..……….. Page 10

PRP Questions ………..….... Page 11

Listing of Exhibits

 Exhibit A – 2014 PRP performance measures and scoring methodology

 Exhibit B – 2014 PRP incentive schedule

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BCN

PRP

Summary

The 2014 recognition program is focused on outcome‐based scores that will directly align with

HEDIS results. Based on industry‐wide research conducted on plans across the country that

performed well on HEDIS metrics, Blue Care Network has kept the same design for the 2014

Commercial PRP program. The program is summarized below.

Definition: The term “provider” is referenced throughout the booklet. It refers to either the

practice group or the individual provider. If a provider does not belong to a practice group, the

individual provider’s score will be used.

PRP program highlights:

 An Improvement On Base PRP component

o Providers who do not meet the BCN plan goal rate for a measure are eligible for

a payment if they have improved their quality score by five percent or more

from their 2013 final Base PRP score.

 Base PRP will be scored and paid on each individual quality measure instead of an

overall threshold score

o Each measure’s score will fall into one of the following categories:

1) Met Base PRP ‐ achieved the BCN plan goal rate will be paid on all

eligible services

2) Met Improvement On Base PRP ‐ provider did not meet plan goal rate but

improved by the appropriate percentage needed

3) Not met – did not meet plan goal rate or improvement on Base PRP

percentage needed

 BCN plan goal rate will need to be met in order to earn the Base PRP per service dollar

amount (see Page 6 description of BCN plan goal rates)

 Providers that don’t meet plan goal rate may qualify for the improvement on Base PRP

component

 All Base PRP and improvement on Base PRP components will be scored and paid at a

practice group level

o Practice group is identified from Portico based on the Network row associated

with the PCP affiliation

o Providers who do not submit claims under a practice group will be scored and

paid at their individual practitioner level

Base

PRP

Provider

Eligibility

Requirements

In order to qualify for any component of the PRP program, the following conditions

must exist:

A. Provider/medical care group must have signed the BCN 2014 Medical Services

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B. Provider/MCG must be in full compliance with all terms and conditions of BCN’s

Medical Services Agreement, including:

(1) BCN standards for timely and accurate provision of encounter, referral

and claims data.

(2) Remittance of any funds due to BCN for prior contract years.

C. Provider must be affiliated with the HMO product at the time of payment in

2015 to be eligible for any PRP payments, unless the provider is recently retired.

D. Provider/provider office must have a Health e‐Blue sign‐on and actively use the

program.

E. BCN retains the right to modify the PRP for any reason and at any time.

Modifications may include, but are not limited to:

(1) Exclusion or removal of measures from the PRP.

(2) Changes to the PRP’s calculation methodologies.

F. All provider data returns are auditable. Blue Care Network does periodic random

audits. If you are randomly selected to be audited for HEB data entry or EMR you

must pass the audit in order to be eligible for payment.

Base

PRP

or

Improvement

On

Base

PRP

Payment

Determination

Base PRP payments for each eligible provider will be calculated using the following

methodology, regardless of membership level.

1) Calculate quality score: A quality score for each Base PRP measure is calculated as follows

on either a practice group or individual basis:

 Sum the denominators (eligible services) for all eligible PCPs in the practice

group.

 Sum the numerators (members who had the service) for all PCPs in the practice

group.

 Calculate the practice group or individual provider’s quality score for each Base

PRP measure: (numerator sum)/(denominator sum)

2) Compare the practice group or individual provider’s quality score to the BCN plan goal

rate for quality (column 2).

a) If the plan goal rate is met, the payment for services will be calculated (columns 3 and

3A).

b) If the plan goal rate is not met, the provider improvement on Base PRP percentage will

be calculated. If the improvement on Base PRP percentage is achieved (column 4), the

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c) If neither the plan goal rate nor improvement on Base PRP is met, then no quality

incentive payment will be earned.

BCN plan goal rate, improvement on Base PRP and payment amounts are noted below.

Base PRP or Improvement On Base PRP Payment Table

Base PRP (1) Base PRP Incentive Measures (2) 2014 Plan Goal Rate (3) $Amount Per Service (3A) Practice group or individual provider achieved the plan goal rate, the payment is:

Breast cancer screening 80% $40 ($Amount Per Service) x (All Eligible Services)

Cardiovascular LDL‐C control <100

mg/dL 71% $100 ($Amount Per Service) x (All Eligible Services)

Cardiovascular LDL‐C testing 92% $40 ($Amount Per Service) x (All Eligible Services)

Cervical cancer screening 82% $40 ($Amount Per Service) x (All Eligible Services)

Childhood immunization ‐ combo 2 89% $225 ($Amount Per Service) x (All Eligible Services)

Colorectal cancer screening 70% $40 ($Amount Per Service) x (All Eligible Services)

Diabetes care ‐ A1C control ≤9% 81% $75 ($Amount Per Service) x (All Eligible Services)

Diabetes care ‐ A1C testing 93% $40 ($Amount Per Service) x (All Eligible Services)

Diabetes care ‐ LDL‐C control <100

mg/dL 55% $100 ($Amount Per Service) x (All Eligible Services)

Diabetes care ‐ LDL‐C testing 89% $40 ($Amount Per Service) x (All Eligible Services)

Diabetes care ‐ retinal eye exam 74% $100 ($Amount Per Service) x (All Eligible Services)

Well‐child visits 15 months 84% $125 ($Amount Per Service) x (All Eligible Services)

OR Improvement on Base PRP (1) Base PRP Incentive Measures (4) Percentage Improved (5) $Amount Per Service (5A) Practice group or individual provider did not meet plan goal rate, but improved from prior year by the appropriate percentage needed, the payment is: Breast cancer screening 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Cardiovascular LDL‐C control <100 mg/dL 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Cardiovascular LDL‐C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Cervical cancer screening 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Childhood immunization ‐ combo 2 5% $125 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Colorectal cancer screening 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Diabetes care ‐ A1C control ≤9% 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Diabetes care ‐ A1C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Diabetes care ‐ LDL‐C control <100 mg/dL 5% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Diabetes care ‐ LDL‐C testing 5% $25 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Diabetes care ‐ retinal eye exam 5% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria) Well‐child visits 15 months 5% $75 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)

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Base

PRP

Performance

Measurement

Guidelines

 Exhibit A (2014 Performance Measures and Scoring Methodology) outlines definitions for all

of the component measures that constitute the Base PRP measures.

 If a provider does not meet the Base PRP plan goal rate of a measure they are still eligible

for the improvement on Base PRP component. Please reference the above section titled

Base PRP and Improvement On Base PRP Payment Determination for specific criteria that

outline the improvement on Base PRP percentage needed to be eligible for a payment.

 Each provider will be credited for HEDIS® identified services provided through Dec. 31,

2014, to commercial HMO members continuously enrolled with the plan for the entire

year and assigned to the provider, regardless of whether the provider was the member’s

provider at the time services were provided.

 Credit will be granted to the provider for each component measure only when the specific

identified service is documented as provided to the member (by the provider, the member’s

previous provider, or a specialist). Members may be excluded from measures under certain

circumstances as identified by HEDIS criteria, such as bilateral mastectomy for breast cancer

screening. Exclusions must be indicated to BCN by the provider offices via the Health e‐Blue

home page through the panel Treatment Opportunities by Condition/Measure screen.

 BCN recognizes that many provider offices employ reminder letters or may not see certain

members in their offices who are identified by BCN as needing certain services.

Occurrences such as these will not count as credit in place of the provision of the service for

the provider toward the component measure.

Tools

to

Help

Maximize

Quality

Scores

 Each provider’s quality performance measurement data is derived directly from BCN’s

Health Management Program reporting database that is accessible through Health e‐Blue.

With regard to the Base PRP, the Health e‐Blue Treatment Opportunities by Condition/Measure will provide member detail on the following:

 Identification of the cohort member population for each component measure that is in

need of a specific health promotion, disease prevention, or health management service

according to evidence‐based medicine

 Intervention opportunity for physicians to supplement BCN’s databases for provision of

service or exclusion data of which BCN had no knowledge

 Quality Summary Report provides the interim progress report that comprises the

monthly quality rates by measure for providers, practice groups and MCGs

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 A monthly report will be produced for each provider. This report will outline how the

provider is performing by measure against 2014 plan goal rate and the final 2013 Base PRP

score. This report will be available through your provider representative.

 BCN’s expectation is that the provider offices and MCGs will jointly support BCN’s efforts to

encourage the population of members identified to ultimately receive the specific service

identified in Health e‐Blue from the provider or specialist if appropriate, such as cervical

cancer screenings from OB‐GYNs.

Data

Submission

Health e‐Blue provides a valuable opportunity for provider offices to assess their current

performance as described above and return data to BCN. BCN will only accept electronic

submission of data to BCN through the Health e‐Blue application. As provider offices report

missing provision of service information due to coordination of benefits or other issues along

with applicable member measure exclusion information, future reporting errors will be

minimized. If your office needs assistance with or has a question about Health e‐Blue, please

call Health e‐Blue technical support at 248‐455‐3623, email them at [email protected],

or contact your BCN provider representative.

Please remember that all data entry into Health e‐Blue must be for services rendered, not just

ordered or reminders sent.

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PRP

Bonus

Details

BCN plans to offer six PRP bonus initiatives during 2014 for commercial members. Technical

specification documents, which detail timeframes, measures and payments, will be available in

December on Health e‐Blue. Please use this summary to make internal assessments of your

clinical performance for each initiative. Our medical directors and provider representatives are

available to assist you in preparation for these initiatives.

Appropriate testing for children with pharyngitis

Measurement timeframe is January 1, 2014 – November 30, 2014

Provider must be with BCN at time of payment to earn the payment

Payment will be made at the MCG level

Potential incentive to be earned = $75 per eligible member per service

Watch for specific details in email communications and on Health e‐Blue

Appropriate treatment for children with upper respiratory infection Measurement timeframe is January 1, 2014 – December 31, 2014

Avoidance of antibiotic treatment in adults with acute bronchitis Measurement timeframe is January 1, 2014 – December 24, 2014



Chlamydia screening

Measurement timeframe is January 1, 2014 – December 31, 2014

Potential incentive to be earned = $40 per eligible member per service Each service will only be paid once per member

Follow‐up care for children prescribed ADHD medication initiation phase

Payment will be for the follow‐up visit with the practitioner

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Weight assessment and counseling for nutrition and physical activity for

children/adolescents

Potential incentive to be earned = $75 per eligible member Each service will only be paid once per member

Distribution

of

PRP

Payment

Reports

and

Payments

BCN will make every reasonable effort to remit the 2014 PRP payment reports and

payments by summer 2015. PRP payments will be made according to BCN’s incentive

payment policy, subject to the requirements outlined in this PRP document. The

providers PRP payment will be associated with the MCG the provider is affiliated with as

of Dec. 31, 2014.

Reconsideration

BCN discontinued any type of retrospective reconsideration beginning with the 2004

PRP, changing the focus to a more prospective data capture and reporting scenario. As

such, BCN strongly encourages individual practitioners and MCGs to focus on the

ongoing review and data return using BCN’s Health e‐Blue application during each PRP year. In the event any future reconsideration process is provided based on extenuating

circumstances, BCN will appropriately notify the provider or MCG of the terms,

conditions and limitations of such a process.

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PRP

Questions

If you have questions or concerns regarding the PRP, please direct them to your BCN

provider representative or the BCN contacts for your region, as follows:

Regional Provide Affairs Contacts

BCN – Southeast Region

Dan Martin, Director II, Provider Outreach

Hashim Yar, M.D., Medical Director

Julie Marvin, R.N., Network Performance Improvement

20500 Civic Center Drive

Mail Code: C238

Southfield, MI 48076

1‐866‐299‐4667

BCN – Central (Mid/East) Region

Felicia Williams, M.D., Medical Director

Julie Marvin, R.N., Network Performance Improvement – East

Christine Wojtaszek, R.N., Network Performance Improvement ‐ Mid 232 S. Capitol Ave Mail Code: L02D Lansing, MI 48933 1‐877‐258‐0168 (Lansing) 1‐800‐527‐1906 (Flint) BCN ‐ West Region

Denice Logan, M.D., Medical Director

Christine Wojtaszek, R.N., Network Performance Improvement

611 Cascade West Parkway, S.E.

Mail Code: G810

Grand Rapids, MI 49546

1‐800‐968‐2583

Health Management Program/Health e‐Blue technical support

248‐455‐3623 or email: [email protected]

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Commercial Members Only Performance Measure (Start Year for Measure) G I

Scoring Methodology / Measured Population P M

(Note: Please consult the latest Health e‐Blue/HMP materials for updates

regarding which HEDIS 2014 codes are applicable for each measure) Interim_Data _SourceReporting G_P _PI

P E D

Data

Sources Comments

Quality ‐ Preventive Screening

Breast cancer screening HMP Quality Summary

Report (QSR)

X X Administrative PCP will get credit for tests performed by OB/GYN

Women who are age 52 – 74 as of 12/31/2014 HMP via Health e‐Blue Measure criteria may change if BCN clinical

guidelines are changed

Received one or more mammograms during October 1, 2012 ‐ 2014 JVHL

Exclusion: Women who have had a bilateral mastectomy

Measured against HEDIS® specification (continuously enrolled with BCN

October 1, 2012 ‐ 2014)

EMR/Electronic data

exchange Cervical cancer screening HMP Quality Summary

Report (QSR)

X X Administrative PCP will get credit for tests performed by OB/GYN

Women who are age 24 – 64 as of 12/31/2014 HMP via Health e‐Blue

The number of women who were screened for cervical cancer, as

identified in steps 1 and 2 below:

JVHL 1. Age 24‐64 as of 12/31/2014 who had cervical cytology (pap)

performed in 2014 or the two years prior

EMR/Electronic data

exchange 2. From the women who did not meet step 1 criteria, women ages 35‐64

as of 12/31/2014 who had cervical cytology/HPV co‐testing with service

dates four or less days apart performed during 2014 or the four years

prior and were age 30 or older on the date of both tests.

Exclusion: Women who have had a hysterectomy with no residual cervix Measured against HEDIS specification (continuously enrolled with BCN

2012 ‐ 2014)

Colorectal cancer screening HMP Quality Summary

Report (QSR)

X X Administrative

51 ‐ 75 years old as of 12/31/2014 HMP via Health e‐Blue

Measured for one or more of the following: JVHL

One or more fecal occult blood tests (FOBT) in 2014 EMR/Electronic data

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Performance Measure (Start Year for Measure) G I Scoring Methodology / Measured Population P M

P E D

Data

Sources Comments

One or more colonoscopy in 2004 through 2014

Exclusion: Members who have had colorectal cancer or total colectomy Measured against HEDIS specification (continuously enrolled with BCN

2013 ‐ 2014)

Childhood immunization – combination 2 HMP Quality Summary

Report (QSR)

X X X Administrative Immunization data downloaded from MCIR by BCN

monthly before Health e‐Blue data is run

Children who turn age 2 during 2014 HMP via Health e‐Blue

Meeting the combination 2 criteria: (4) DTaP* vaccinations, (3) IPV*

vaccinations, (1) MMR, (1) VZV, (3) HiB* vaccinations, and (3) hepatitis B

vaccinations on or before the second birthday.

MCIR

JVHL

Measure is "all or none" ‐ no partial credit given for

individual vaccinations Measured against HEDIS specification (continuously enrolled with BCN

for 12 months prior to 2nd birthday)

EMR/Electronic data

exchange *Vaccinations administered prior to 42 days after birth should not be

counted as a numerator hit.

Well child visits – 15 months HMP Quality Summary

Report (QSR)

X X X Administrative

Children turning 15 months old during 2014 HMP via Health e‐Blue

Received at least six (6) well‐child visits with a PCP during first 15 months

of life

EMR/Electronic data

exchange Measured against HEDIS specification (continuously enrolled with BCN 31

days after birth through the 15 month birth date)

Quality ‐ Disease Management

Cholesterol management for patients with cardiovascular disease ‐

LDL‐C testing

HMP Quality Summary

Report

X X Administrative

Member 18 to 75 years as of 12/31/2014 identified through HEDIS

Cholesterol Management for Patients with Cardiovascular Condition

(CMC) specification

HMP via Health e‐Blue

An LDL‐C test performed in 2014 JVHL

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Commercial Members Only Performance Measure (Start Year for Measure) G I

Scoring Methodology / Measured Population P M

P E D

Data

Cholesterol management for patients with cardiovascular disease ‐

LDL‐C control <100 mg/dL

HMP Quality Summary

Report

X X Administrative

Member 18 to 75 years as of 12/31/2014 identified through HEDIS

Cholesterol Management for Patients with Cardiovascular Condition

(CMC) specification

HMP via Health e‐Blue

Last LDL‐C test performed in 2014 shows a level <100 mg/dL JVHL

Measured against HEDIS specification (continuously enrolled with BCN

for 2013 and 2014)

EMR/Electronic data

exchange Diabetes care ‐ A1C testing HMP Quality Summary

Report (QSR)

X X Administrative

Members with diabetes as identified through HEDIS specification HMP via Health e‐Blue

Age 18 through 75 years old as of 12/31/2014 JVHL

One (or more) A1c tests conducted during 2014

for 2014)

EMR/Electronic data

exchange Diabetes care ‐ A1C control ≤9% HMP Quality Summary

Report (QSR)

X X Administrative

Last A1C test performed in 2014 shows a level of ≤9%

for 2014)

EMR/Electronic data

exchange Diabetes care ‐ LDL‐C screening HMP Quality Summary

Report (QSR)

X X Administrative

At least one LDL‐C test done during 2014

for 2014)

EMR/Electronic data

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Performance Measure (Start Year for Measure) G I Scoring Methodology / Measured Population P M

P E D

Data

Diabetes care ‐ LDL‐C control <100 mg/dL HMP Quality Summary

Report (QSR)

X X Administrative

Last LDL‐C test performed in 2014 shows a level <100 mg/dL

for 2014)

EMR/Electronic data

exchange Diabetes care ‐ retinal eye exam HMP Quality Summary

Report (QSR)

X X Administrative

One or more retinal exams by an eye care professional (optometrist,

ophthalmologist or EyeTel Imaging DigiScope) in 2014 or a negative

retinal exam result in 2013

EMR/Electronic data

exchange Measured against HEDIS specification (continuously enrolled with BCN

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INCENTIVE MEASUREMENT

PERIOD PAYMENT

PAYMENT

MADE TO

2014 Base PRP

Cervical cancer screening Jan ‐ Dec 2014 June 2015 Practice group

Childhood immunizations – combo 2 Jan ‐ Dec 2014 June 2015 Practice group

Breast cancer screening Jan ‐ Dec 2014 June 2015 Practice group

Colorectal cancer screening Jan ‐ Dec 2014 June 2015 Practice group

Cholesterol mgmt for pts with cardiovascular disease ‐ LDL‐C testing Jan ‐ Dec 2014 June 2015 Practice group Cholesterol mgmt for pts with cardiovascular disease ‐ LDL‐C control <100 mg/dL Jan ‐ Dec 2014 June 2015 Practice group

Comprehensive diabetes care – A1C testing Jan ‐ Dec 2014 June 2015 Practice group

Comprehensive diabetes care – A1C control ≤9% Jan ‐ Dec 2014 June 2015 Practice group

Comprehensive diabetes care – LDL‐C testing Jan ‐ Dec 2014 June 2015 Practice group

Comprehensive diabetes care – LDL‐C control <100 mg/dL Jan ‐ Dec 2014 June 2015 Practice group

Comprehensive diabetes care – retinal eye exam Jan ‐ Dec 2014 June 2015 Practice group

Well child visit – 15 months Jan ‐ Dec 2014 June 2015 Practice group

2014 Improvement on Base PRP