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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’

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Presentation Transcript
the qtip advantage

Pay For Performance (P4P)

Value Based Contracting in 2014 and Beyond


Commercial Payer VBP Models

Physician ‘Profiling’

• 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)


Commercial Payer VBP Models

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

rewarding excellence for physicians program goals
Rewarding Excellence for Physicians Program Goals

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 for physicians layout
Rewarding Excellence for Physicians Layout
  • The Physician Rewarding Excellence Program consists of three components:
    • Quality Data Reporting
    • Physician Recognition
    • Practice Patient-Centered Medical Home Recognition
  • Practices have the opportunity to earn points in each of the three parts for an overall score and increase to their reimbursement.
1 quality data reporting
1. Quality Data Reporting

Rewarding Excellence quality data reporting is composed of 6 measure suites.

  • Diabetes
  • Hypertension
  • Coronary Artery Disease
  • Asthma
  • Pediatric Preventive Health
  • Adult Preventive Screening and Pediatric Preventive Screening

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.

3 patient centered medical home recognition
3. Patient-Centered Medical Home Recognition

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.


Rewarding Excellence – Financial Procedures

  • Total points correspond to a reimbursement increase on all the practices’ office based Evaluation & Management (E&M) codes
  • E&M’s Eligible for Increase:

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

  • Points Earned:

1-5 points = E&M increase

6-8 points = Additional E&M increase

9-10 points = Maximum E&M increase

  • Addendum(s) with reimbursement terms will be effective on the first of the following month from execution with a term of one year (i.e. signed 3-14-14 and effective 4-1-14).

Display nationally recognized performance measures with comparison results on national and local website

  • A percentage is calculated for each measure and displayed using ‘Above Average’, ‘Average’ or ‘Below Average’.
  • Ratings are assigned by comparing each reported score to the NCQA most recent South Atlantic Region benchmarks (75th, 50th and 25th percentile).
  • The 50th percentile is used for the comparison percentage.
  • Ratings are shared with the practice with time to approve. Ratings are not displayed on web sites without approval.
  • Ratings are displayed at the practice level. All physicians have the same ratings.
defining persistent asthma

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.