Blue Care Network of Michigan 2013 Physician Recognition Program

1. 2013 Performance
Recognition Program
April 2013

2. Blue Care Network HMOSM
(commercial)
2013 Performance
Recognition Program (PRP)
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3. BCN HMO 2013 PRP:
Overview
• Blue Care Network has redesigned the 2013
commercial PRP program, based on industry-wide
research conducted on plans across the country
that performed well on HEDIS®
* metrics.
• The changes to the 2013 recognition program are
focused on outcome-based scores that will directly
align with HEDIS results.
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* HEDIS®
is a registered trademark of the National Committee for Quality Assurance.

4. BCN HMO 2013 PRP:
Summary of changes
• The budget has been increased.
• The pay-as-you-go component was eliminated.
• An improvement on the Base PRP component is
being introduced:
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 5 percent or
more from their 2012 final Base PRP score.
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5. BCN HMO 2013 PRP:
Summary of changes
(continued)
• The Base PRP will be scored and paid on each
individual quality measure instead of an overall
threshold score.
The score for each measure will fall into one of the
following categories:
– Met Base PRP – Provider achieved the BCN plan goal
rate.
– Met improvement on Base PRP – Provider did not
meet the plan goal rate but improve on the Base PRP
by the percentage needed.
– Not met – Provider did not meet the plan goal rate or
improve on the Base PRP by the percentage needed.
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6. BCN HMO 2013 PRP:
Summary of changes
(continued)
• BCN plan goal rate will need to be met in order to earn
the Base PRP per-service-dollar amount.
• Providers who 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.
Note: Providers who do not submit claims under a
practice group will be scored and paid at their
individual practitioner level.
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7. BCN HMO 2013 PRP:
Base and Bonus
measures
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2013 Base PRP measures:
Quality – Preventive Screening
Well child – 15 months
Childhood immunizations – Combo 2
Cervical cancer screening
Breast cancer screening
Colorectal cancer screening
Quality – Disease Management
Diabetes retinal eye exam
Diabetes A1C testing
Diabetes A1C control ≤9%
Diabetes LDL-C testing
Diabetes LDL-C control <100 mg/dL
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C control <100 mg/dL
Quality Payout – two opportunities:
Payment by measure for meeting plan goal
OR
Payment by measure for improvement of 5% or more
2013 PRP Bonus Incentives
Commercial HMO
• Appropriate testing for children with pharyngitis
Measurement time frame Jan. 1, 2013 – Nov. 30, 2013
$75 per eligible member per service
• Appropriate treatment for children with upper respiratory
infection
Measurement time frame Jan.1, 2013 – Dec.31, 2013
$75 per eligible member per service
• Avoidance of antibiotic treatment in adults with acute
bronchitis
Measurement time frame Jan.1, 2013 – Dec. 24, 2013
$75 per eligible member per service
• Follow up care for children with ADHD – initiation phase
Jan. 1, 2013 – Dec. 31, 2013
$75 per eligible member per service
• Chlamydia screening
Measurement time frame Jan. 1, 2013 - Dec.31, 2013
$40 per eligible member per service
NOTE: Please visit the home page on Health e-BlueSM
for a complete description and
for other information regarding the 2013 Performance Recognition Program.

8. BCN HMO 2013 PRP:
Base PRP payment
chart
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Base PRP
Base PRP Incentive Measures
2013
Plan Goal
Rate
$Amount
Per Service
Practice group or individual provider achieved the plan
goal rate, the payment is:
Breast cancer screening 80% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Cardiovascular LDL-C control <100
mg/dL 70% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Cardiovascular LDL-C testing 92% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Cervical cancer screening 84% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Childhood immunization - combo 2 89% $250 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Colorectal cancer screening 72% $50 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Diabetes care - A1C control ≤9% 81% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Diabetes care - A1C testing 93% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Diabetes care - LDL-C control <100
mg/dL 49% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Diabetes care - LDL-C testing 89% $40 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Diabetes care - retinal eye exam 74% $100 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Well child visits 15 months 84% $150 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)

9. BCN HMO 2013 PRP:
Improvement on Base PRP
payment chart
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Improvement on Base PRP
Base PRP Incentive Measures
Percentage
Improved
$Amount
Per Service
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% $30 ($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% $30 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Childhood immunization - combo 2 5% $150 ($Amount Per Service) x (Elig Mbrs Meeting Criteria)
Colorectal cancer screening 5% $30 ($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)

10. BCN HMO 2013 PRP:
Practice group scorecard
example
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EXAMPLE 2013 Commercial PRP Scorecard
Practice group: Internal medical group
Base PRP Measures
Total
Mbrs Elig
Elig Mbrs
Meeting
Criteria
2013 Base
PRP Score
2013 Plan
Goal Rate
2012 Final
Base PRP
score % improved Payment Type
$/Service
met
Payment
Earned
Well Child visit 0 -15 months 5 4 80% 84% 85% -5.9% Not met $0 $0
Childhood Imms Combo 2 3 2 67% 89% 62% 7.5% Met improvement $150 $300
Cervical Cancer Screening 16 14 88% 84% 80% 9.4% Met Base PRP $50 $700
Breast Cancer Screening 15 10 67% 80% 70% -4.8% Not met $0 $0
Colorectal Cancer Screening 15 10 67% 72% 60% 11.1% Met improvement $30 $300
Diabetes
Eye exam 8 7 88% 74% 60% 45.8% Met Base PRP $100 $700
A1C Testing 8 7 88% 93% 80% 9.4% Met improvement $25 $175
A1C Control ≤ 9% 8 5 63% 81% 55% 13.6% Met improvement $40 $200
LDL-C 8 6 75% 89% 75% 0.0% Not met $0 $0
LDL-C control <100 mg/dl 8 5 63% 49% 50% 25.0% Met Base PRP $100 $500
Cardiovascular disease
LDL-C 10 8 80% 92% 65% 23.1% Met improvement $25 $200
LDL-C control <100 mg/dl 10 7 70% 70% 62% 12.9% Met Base PRP $100 $700
Payment amount $3,775

11. Blues Medicare Advantage
(BCN AdvantageSM
and
BCBSM Medicare Plus Blue PPOSM
)
2013 Performance
Recognition Program
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12. Blues Medicare Advantage 2013 PRP:
Base and Bonus measures
2013 Base PRP Measures:
Quality – Preventive Screening
Breast cancer screening
Colorectal cancer screening
Quality – Disease Management
Diabetes retinal eye exam
Diabetes HbA1C level ≤9%
Diabetes monitoring for nephropathy
Diabetes LDL-C level <100 mg/dL
Diabetes LDL-C testing
Cardiovascular disease LDL-C testing
Quality Payout -
Quality composite score 70-74%: $2.00 PMPM
Quality composite score 75-79%: $3.50 PMPM
Quality composite score ≥80%: $5.00 PMPM
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2013 Bonus Incentives
BCNA/MAPPO
Annual monitoring for patients on persistent
medications
Diabetes treatment (ACE/ARB for hypertension)
Glaucoma testing
High-risk medications
Adult BMI
2013 Pay As You Go Incentives
BCNA/MAPPO
All 8 base PRP measures
Scoring and Payout
Fall 2013 and spring 2014
Payment PAYG $10

13. Blues Medicare Advantage 2013 PRP:
Bonus opportunities
Adult BMI
• Measurement time frame is Jan. 1, 2012 – Dec. 31, 2013.
• Provider must be with BCN at time of payment to earn the
payment.
• Payment will be made at the practice group level.
• Potential reward to be earned = $200
Annual monitoring for patients on persistent medications
• Measurement timeframe is Jan. 1, 2013 – Dec. 31, 2013.
• Provider must be with BCN at time of payment to earn the
payment.
• Payment will be made at the practice group level.
• Potential reward to be earned = $200
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14. Blues Medicare Advantage 2013 PRP:
Bonus opportunities
(continued)
Diabetes treatment (ACE/ARB for hypertension)
• Measurement time frame is Jan. 1, 2013 – Dec. 31, 2013.
• Provider must be with BCN at time of payment to earn the
payment.
• Payment will be made at the practice group level.
• Potential reward to be earned = $200
Glaucoma testing
• Measurement time frame is Jan. 1, 2012 – Dec. 31, 2013.
• Provider must be with BCN at time of payment to earn the
payment.
• Payment will be made at the practice group level.
• Potential reward to be earned = $125 - $300
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15. Blues Medicare Advantage 2013 PRP:
Bonus opportunities
(continued)
High risk medication
• Measurement time frame is Jan. 1, 2013 – Dec. 31, 2013.
• Provider must be with BCN at time of payment to earn the
payment.
• Payment will be made at the practice group level.
• Potential reward to be earned = $450
NOTE: A complete booklet about the Blues Medicare Advantage 2013 Performance Recognition Program
is located on the home pages of BCN’s and BCBSM’s Health e-Blue website.
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16. Blues Medicare Advantage 2013 PRP:
Diagnosis Closure Incentive
plan
Diagnosis Closure Incentive highlights:
• Measured at the individual physician level.
• Primary care physicians with one or more Blues Medicare
Advantage patients with at least one open diagnosis gap
identified by the Blues will receive $100 per patient for closing
100 percent of the patient’s diagnosis code gaps.
• Suspected or historic conditions not accurately documented
and coded in the current year are diagnosis gaps.
• Diagnosis gaps will be identified in the new Diagnosis
Evaluation report on Health e-Blue.
• Gaps identified by the Blues Jan. 1 through Sep. 30, 2013,
are eligible for payment.
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17. Blues Medicare Advantage 2013 PRP:
Diagnosis Closure Incentive
Plan (continued)
To earn payment for a patient:
• All the patient’s gaps must be closed in 2013 and reported to the
Blues by Jan. 31, 2014.
• The gaps must be closed following a face-to-face visit.
• The diagnosed conditions must be addressed at the face-to-face
visit.
• Coding and documentation must follow CDC and CMS
standards.
• Gaps closed by InovalonTM
(vendor) will not count for the provider.
NOTE: Step-by-step instructions are located in the Resources section at the bottom
of the Health e Blue Homepage – Training Materials
Health e-Blue Phase 10.3 Enhancements March 2013
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18. Blue Cross Complete of
Michigan
2013 Performance
Recognition Program
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19. Blue Cross Complete 2013 PRP:
Quality PAYG measures
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20. Blue Cross Complete 2013 PRP:
Quality PAYG measures
(continued)
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21. Blue Cross Complete 2013 PRP:
Quality PAYG measures
(continued)
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NOTE: Blue Cross Complete of Michigan 2013 Performance Recognition Program
materials are located on Health e-Blue, in the bottom section on the home page.

22. QUESTIONS?
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