THE QTIP ADVANTAGE. Pay For Performance (P4P) Value Based Contracting in 2014 and Beyond. Most doctors are taking this approach to the coming payment models. QTIP Practices are More Prepared. Commercial Payer VBP Models Physician ‘Profiling’
Pay For Performance (P4P)
Value Based Contracting in 2014 and Beyond
• Score based on payments and utilization
• Penalizes patients for selecting ‘high cost’ physicians and hospitals by imposing higher out-of-pocket costs for co-pays and co- insurance
• Performance measurement programs based on claims data primarily
Ø Patient cost share and physician payment rates are set according to tiering; higher copays for receiving care from providers with lower ‘grades’; less pay for those providers who don’t make the grade (coming soon)
Patient Centered Medical Homes
• Requires significant coordination of patient care and disease management
• Payers paying an additional fee per patient, or by type of diagnosis (e.g. diabetes), or by community profile
• Requires significant practice investment in accreditation, resources, developing protocols, and technology for data capture and reporting
Ø Hybrid payment system of FFS + PMPM + P4P
March 31, 2014
Develop program for contracting Primary Care Physicians (Family Practice, Internal Medicine, General Practice and Pediatric practices).
Combine incentive program for patient-centered medical home with this program to promote one program where all providers may participate.
Move towards rewarding providers for quality and value rather than volume.
Align incentives across providers, members, employers and payers to improve clinical outcomes, patient experience and cost efficiency.
Respond to employer demands for increased transparency by developing and promoting publically available, relevant clinical measures for quality and outcomes.
Align program and metrics with current federal, state and quality reporting requirements to avoid increase in practice administrative burden.
Provide incentives for practice based improvement as well as top performance. Avoid perverse incentives.
Provide free technical assistance, tools and information to practices to share best practices and improve performance.
Rewarding Excellence quality data reporting is composed of 6 measure suites.
To participate, physicians will report on at least one measure suite which is comprised of several measures. All the measures in the suite are to be reported for the suite to be accepted. The practice can earn additional points by reporting up to three measure suites.
Practices can pull and submit the data through MDInsight or a qualified vendor. BCBSSC will provide the format for submission. Practices in the program will update their data twice a year.
This data will be displayed on our national and local websites at the practice level.
Patient-Centered Medical Home Recognition – Practice must be participating with BlueCross BlueShield of South Carolina and BlueChoice HealthPlan of South Carolina’s Patient-Centered Medical Home program and be recognized by one of the following:
1. NCQA Patient-Centered Medical Home (Level I, Level II or Level III)
2. The Joint Commission PCMH Certification program
3. The Utilization Review Accreditation Committee (URAC) PCHCH Practice Achievement Recognition Program
4. The Utilization Review Accreditation Committee (URAC) PCHCH Practice Achievement Recognition Program with EHR.
99201-99205 New patient office or other outpatient services
99211-99215 Established patient office or other outpatient services
99381-99387 New patient preventative medicine
99391-99397 Established patient preventative medicine
1-5 points = E&M increase
6-8 points = Additional E&M increase
9-10 points = Maximum E&M increase
Display nationally recognized performance measures with comparison results on national and local website
An asthmatic has to be between the ages of 5 and 64 years, and have either:
1: At least one ED visit with the principal diagnosis of asthma
2: At least one Acute Inpatient Admission with the principal diagnosis of asthma
3: At least 4 Outpatient Asthma Visits with the diagnosis of asthma and at least 2 Asthma Medication dispensing Events
4: At least 4 Asthma Medication Dispensing Events- with Singulaironly must also have at least one visit for asthma.