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Allergy Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 74 allergists are receiving VBR.
Allergy Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 20%
Cost Difference Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10%
Cave Weighted average episode cost relative to peer group Population level
10%
Many Allergy Tests
Proportion of allergy-tested members with >65 tests/year Practice level
10%
Proportion Intradermal
Tests
Proportion of subcutaneous and intredermal tests that are intradermal
Practice level
10%
Immunotherapy Cost PUMPM
Immunotherapy cost per utilizing member per month Practice level
10%
Allergy and Asthma IP/ED
Rate
Number of allergy or asthma inpatient/ED encounters per 10,000 members per year
Population level
10%
Asthma Medication
Ratio
Proportion of members meeting the HEDIS persistent asthma case definition whose asthma medication ratio >0.5
Population level
5%
Asthma: Regular
Spirometry
Proportion of asthmatic members receiving >1 spirometry measurement in 2 years
Population level
5%
Immunotherapy: Routine Care
Proportion of members receiving immunotherapy who also received an E&M claim by an allergist during the year
Practice level
None
Allergy IP/ED Follow-Up
Proportion of allergy inpatient/ED encounters followed by an office visit <30 days post-discharge
Population level
None
. Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients
2016 Specialist Value-Based Reimbursement Allergy Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for allergy are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Allergist must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of allergy practices based on the allergy weighted composite score are reimbursed in accordance with the VBR Fee Schedule
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third are reimbursed at 110% of the Standard Fee Schedules Practices in the second third are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Anesthesiology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 442 anesthesiologists are receiving VBR.
Anesthesiology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric anesthesiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Anesthesiology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for anesthesiology arelisted above
A maximum of three SubPO relationships are included for each practice; to be included:o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared memberso At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPOo If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Anesthesiologists must be nominated by their member physician organization The top two-thirds of non-pediatric anesthesiology practices based on the anesthesiology weighted composite
score are reimbursed in accordance with the VBR Fee Schedule All fully nominated pediatric anesthesiology practices based on the Pediatrics weighted composite score are
reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information) Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Anesthesiology practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee
Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine visionservices, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Cardiology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 470 cardiologists are receiving VBR.
Cardiology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 15%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
30%
Cave Weighted average episode cost relative to peer group Population level
30%
Diagnostic Procedure
PMPM
Standard cost PMPM for cardiac diagnostic procedures Population level
15%
*Pediatric cardiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics. Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement Cardiology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for cardiology are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Cardiologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric cardiology practices based on the cardiology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric cardiology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Cardiothoracic Surgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 92 cardiothoracic surgeons are receiving VBR.
Cardiothoracic Surgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric cardiothoracic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Cardiothoracic Surgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for cardiothoracic surgeryare listed above
A maximum of three SubPO relationships are included for each practice; to be included:o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared memberso At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPOo If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Cardiothoracic surgeons must be nominated by their member physician organization (and possibly one other PO)and must have been in PGIP for one year
The top two-thirds of non-pediatric cardiothoracic surgery practices based on the cardiothoracic surgery weightedcomposite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric cardiothoracic surgery practices based on the Pediatrics weighted composite score are reimbursed inaccordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine visionservices, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Chiropractor Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 103 chiropractors are receiving VBR.
Chiropractor Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric chiropractors are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assessperformance at the practice level
Population level metrics:o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patientso Encourage communication and collaboration between primary care and specialty practitionerso Encourage a focus on system performance, accountability and improvemento Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Chiropractor Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for chiropractors are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Chiropractors must be nominated by their member physician organization and must have been in PGIP for one year
The top four-fifths of non-pediatric chiropractor practices based on the chiropractor weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric chiropractor practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Chiropractor practices in the top two-fifths of non-pediatric practices are reimbursed at 110% of the Standard Fee
Schedules
Practices in the second two-fifths of non-pediatric practices are reimbursed at 105% of the Standard Fee
Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Colon/Rectal Surgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 27 colon/rectal surgeons are receiving VBR.
Colon/Rectal Surgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric colon/rectal surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Colon/Rectal Surgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for colon/rectal surgery are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Colon/rectal surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric colon/rectal surgery practices based on the colon/rectal surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric colon/rectal surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Critical Care Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 57 critical care physicians are receiving VBR.
Critical Care Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric critical care physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Critical Care Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for critical care are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Critical care physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric critical care practices based on the critical care weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric critical care practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Dermatology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 111 dermatologists are receiving VBR.
Dermatology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric dermatologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Dermatology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for dermatology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Dermatologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric dermatology practices based on the dermatology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric dermatology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Emergency Medicine Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 716 emergency medicine physicians are receiving VBR.
Emergency Medicine Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric emergency medicine physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Emergency Medicine Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for emergency medicine are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Emergency medicine physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric emergency medicine practices based on the emergency medicine weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric emergency medicine practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Endocrinology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 83 endocrinologists are receiving VBR.
Endocrinology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 20%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10%
Cave Weighted average episode cost relative to peer group Population level
15%
ACS IP and ED Visits
Rate of ambulatory care sensitive IP and ED visits for patients with diabetes
Population level
20%
HbA1c Poor Control
HbA1c poor control for patients with diabetes Population level
10%
HbA1c Screening
HbA1c testing for patients with diabetes Population level
5%
Nephropathy Screening
Nephropathy screening for patients with diabetes Population level
5%
Vitamin D Screening
and Control
Composite of vitamin D screening and control measures for patients with osteoporosis
Population level
5%
*Pediatric endocrinologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Endocrinology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for endocrinology are
listed above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Endocrinologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric endocrinology practices based on the endocrinology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric endocrinology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Gastroenterology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 297 gastroenterologists are receiving VBR.
Gastroenterology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 30%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10%
Cave Weighted average episode cost relative to peer group Population level
30%
Colonoscopy Proportion of members with a history of adenomatous polyps with a colonoscopy follow-up interval less than three
years
Population level
20%
*Pediatric gastroenterologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Gastroenterology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for gastroenterology are
listed above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Gastroenterologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric gastroenterology practices based on the gastroenterology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric gastroenterology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
General Surgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 383 general surgeons are receiving VBR.
General Surgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric general surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics? Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for general surgery are
listed above
2016 Specialist Value-Based Reimbursement
General Surgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
General surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric general surgery practices based on the general surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric general surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Hospitalist Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 687 hospitalists are receiving VBR.
Hospitalist Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric hospitalists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Hospitalist Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for hospitalists are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Hospitalists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric hospitalist practices based on the hospitalist weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric hospitalist practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Infectious Disease Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 119 infectious disease physicians are receiving VBR.
Infectious Disease Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric infectious disease physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Infectious Disease Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for infectious disease are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Infectious disease physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric infectious disease practices based on the weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric infectious diease practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Nephrology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 178 nephrologists are receiving VBR.
Nephrology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
20%
Nephropathy Screening
Screening for nephropathy among patients with diabetes (HEDIS measure)
Population level
20%
*Pediatric nephrologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Nephrology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for nephrology are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Nephrologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric nephrology practices based on the nephrology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric nephrology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Neurology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 216 neurologists are receiving VBR.
Neurology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 40%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
15%
Cave Weighted average episode cost relative to peer group Population level
20%
Imaging for Headache
Proportion of index headache diagnoses that received EEG, CT or MRI of the head on or within 30 days
Population level
15%
*Pediatric neurologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics? Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Neurology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for neurology are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Neurologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric neurology practices based on the neurology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric neurology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Neurosurgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 74 neurosurgeons are receiving VBR.
Neurosurgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric neurosurgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Neurosurgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for neurosurgery are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Neurosurgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric neurosurgery practices based on the neurosurgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric neurosurgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Obstetrics/Gynecology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 673 Ob/Gyns are receiving VBR.
Obstetrics/Gynecology Value-Based Reimbursement Metrics
Metric Description Level Ob/Gyn Weight
Gyn Only Weight
Women’s PMPM
Overall per member per month (PMPM) medical/surgical cost of care + pharmacy cost (actual cost – women only)
Population level
25% 35%
Cost Difference Change in cost of care PMPM from prior year Population level
10% 10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10% 10%
Cave Weighted average episode cost relative to peer group Population level
15% 20%
Primary C-Sections
Primary C-section incidence during deliveries Population level
10% 0%
Hysterectomies Hysterectomy incidence for women ages 15-64 Population level
10% 10%
Obstetrical Care Quality
Prenatal and postpartum diabetes screening rates Population level
5% 0%
Breast Cancer Screening
Mammograms for women ages 50-64 Population level
5% 5%
Cervical Cancer
Screening
Cervical cancer screening for women ages 21-64 Population level
5% 5%
Women’s Evidence
Based Care
Composite of chronic and acute disease treatment measures for women
Population level
5% 5%
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Obstetrics/Gynecology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for Ob/Gyn are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Ob/Gyns must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of Ob/Gyn practices based on the Ob/Gyn weighted composite score are reimbursed in accordance with the VBR Fee Schedule
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third are reimbursed at 105% of the Standard Fee Schedules
The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Oncology/Hematology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 355 oncologists/hematologists are receiving VBR.
Oncology/Hematology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 5%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
15%
Cancer PMPM Overall PMPM medical/surgical cost of care + pharmacy cost of cancer population
Population level
30%
Cancer Sensitive
Severe Events
IP admissions or ED visits for cancer sensitive severe events per 100 members with cancer per year
Population level
40%
*Pediatric oncologists/hematologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess performance at the practice level
Population-level metrics: o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a
population of patients o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Oncology/Hematology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for oncology/hematology
are listed above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Oncologists/hematologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric oncology/hematology practices based on the oncology/hematology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric oncology/hematology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Ophthalmology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 241 ophthalmologists are receiving VBR.
Ophthalmology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric ophthalmologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Ophthalmology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for ophthalmology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Ophthalmologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric ophthalmology practices based on the ophthalmology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric ophthalmology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Orthopedics Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017,415 orthopedic surgeons are receiving VBR.
Orthopedics Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 25%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
15%
Cave Weighted average episode cost relative to peer group Population level
20%
Low Back Pain
Proportion of visits with primary diagnosis of low back pain receiving an imaging study
Population level
15%
High-Tech Imaging
Adult MRI and CT imaging per 1,000 member years Population level
15%
*Pediatric orthopedic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Orthopedics Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for orthopedics are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Orthopedic surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric orthopedics practices based on the orthopedics weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric orthopedics practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Other Specialty Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 136 physicians with a specialty categorized as “other” (that is, not classified elsewhere) are receiving VBR.
Other Specialty Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric physicians classified as “other” are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Other Specialty Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for the other specialty classification are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric other specialty practices based on the other specialty weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric other specialty practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Otolaryngology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 127 otolaryngologists are receiving VBR.
Otolaryngology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 30%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10%
Cave Weighted average episode cost relative to peer group Population level
30%
Pharyngitis Testing
Proportion of children with acute pharyngitis who received a strep test, among those dispensed an antibiotic
Population level
10%
Acute Otitis Externa
Medications
Proportion of members ages 2-64 with acute otitis externa who filled an appropriate topical prescription but did not fill
an oral antibiotic
Population level
10%
*Pediatric otolaryngologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Otolaryngology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for otolaryngology are
listed above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Otolaryngology must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric otolaryngology practices based on the otolaryngology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric otolaryngology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Pain Management Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 53 pain management physicians are receiving VBR.
Pain Management Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric pain management physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Pain Management Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for pain management are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Pain management physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric pain management practices based on the pain management weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric pain management practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Pathology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 227 pathologists are receiving VBR.
Pathology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric pathologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Pathology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for pathology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Pathologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric pathology practices based on the pathology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric pathology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Pediatrics Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules).
From March 1, 2016-February 28, 2017, 628 pediatric specialists (pediatric specialists of all specialty types except allergy and Ob/Gyn) are receiving VBR. (Note that the number of specialists receiving VBR listed in each specialty-specific fact sheet includes pediatric specialists. The 628 pediatric specialists are included in the number of specialists on other fact sheets, such as cardiology. However, pediatric specialists are all evaluated and ranked together according to the metrics below.)
Pediatrics Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Pediatrics Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for pediatrics are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Pediatric specialists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
All pediatric specialty practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Physical Medicine Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 173 physical medicine physicians are receiving VBR.
Physical Medicine Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric physical medicine physicians are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Physical Medicine Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for physical medicine physicians are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Physical medicine physicians must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric physical medicine practices based on the physical medicine weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric physical medicine practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Plastic Surgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 64 plastic surgeons are receiving VBR.
Plastic Surgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric plastic surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Plastic Surgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for plastic surgery are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Plastic surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric plastic surgery practices based on the plastic surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric plastic surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Podiatry Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 175 podiatrists are receiving VBR.
Podiatry Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric podiatrists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Podiatry Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for podiatry are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Podiatrists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric podiatry practices based on the podiatry weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric podiatry practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Psychiatry Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 295 psychiatrists are receiving VBR.
Psychiatry Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric psychiatrists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Psychiatry Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for psychiatry are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Psychiatrists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric psychiatry practices based on the psychiatry weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric psychiatry practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Psychology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 343 psychologists are receiving VBR.
Psychology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric psychologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Psychology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for psychology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Psychologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric psychology practices based on the psychology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric psychology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Pulmonology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 165 pulmonologists are receiving VBR.
Pulmonology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical cost
of care + pharmacy cost (actual cost) Population
level 20%
Cost Difference Change in cost of care PMPM from prior year Population level
10%
Global Quality Index A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
10%
Cave Weighted average episode cost relative to peer group Population level
10%
Asthma Medication Ratio Proportion of members with persistent asthma whose asthma medication ratio >0.5
Population level
10%
Asthma: Regular Spirometry
Proportion of members with asthma receiving >1 spirometry measurement in 2 years
Population level
5%
Asthma: IP/ED Rate Number of IP or ED encounters per member with asthma Population level
5%
COPD: IP/ED Rate Number of IP or ED encounters per member with COPD Population level
10%
Asthma and COPD: Post IP/ED Follow-up
Proportion of IP/ED encounters followed by an office visit <30 days post-discharge
Population level
5%
Asthma and COPD: IP/ED Return Visits
Proportion of IP/ED encounters followed by an IP/ED encounter <30 days post-discharge
Population level
5%
OSA:Sleep Study for New Diagnosis
Proportion of newly diagnosed members with obstructive sleep apnea who received a sleep study
Population level
5%
OSA: Sleep Study Rate for Long-Term Diagnosis
Number of sleep studies per member with a long-term diagnosis of obstructive sleep apnea
Population level
5%
*Pediatric pulmonologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Pulmonology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for pulmonology are listed
above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Pulmonologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric pulmonology practices based on the pulmonology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric pulmonology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Radiation Oncology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 85 radiation oncologists are receiving VBR.
Radiation Oncology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric radiation oncologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Radiation Oncology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for radiation oncology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Radiation oncologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric radiation oncologists practices based on the radiation oncology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric radiation oncology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Radiology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 554 radiologists are receiving VBR.
Radiology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric radiologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Radiology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for radiology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Radiologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric radiology practices based on the radiology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric radiology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Rheumatology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016-February 28, 2017, 59 rheumatologists are receiving VBR.
Rheumatology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 30%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
15%
Rheumatoid Arthritis PMPM
Overall PMPM medical/surgical cost of care + pharmacy cost (actual cost) for patients with rheumatoid arthritis
Population level
25%
DMARD Use Proportion of patients with rheumatoid arthritis having at least one DMARD in each of the past two years (HEDIS)
Population level
20%
*Pediatric rheumatologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
2016 Specialist Value-Based Reimbursement
Rheumatology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
How Population-Level Metrics Are Calculated
This example shows the measurement approach with only one metric; the metrics used for rheumatology are
listed above A maximum of three SubPO relationships are included for each practice; to be included:
o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Rheumatologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric rheumatology practices based on the rheumatology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric rheumatology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Urology Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 214 urologists are receiving VBR.
Urology Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric urologists are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Urology Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for urology are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Urologists must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric urology practices based on the urology weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric urology practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Vascular Surgery Value-Based Reimbursement
The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement.”
Specialists who participate in the Physician Group Incentive Program and meet specific criteria are eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule (VBR Fee Schedule). The VBR Fee Schedule sets reimbursement rates for particular procedure codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules (the Standard Fee Schedules). From March 1, 2016 through February 28, 2017, 59 vascular surgeons are receiving VBR.
Vascular Surgery Value-Based Reimbursement Metrics
Metric Description Level Weight PMPM Overall per member per month (PMPM) medical/surgical
cost of care + pharmacy cost (actual cost) Population
level 50%
Cost Difference
Change in cost of care PMPM from prior year Population level
10%
Global Quality Index
A single composite score comprised of 49 quality metrics from across many PGIP initiatives
Population level
40%
*Pediatric vascular surgeons are evaluated/ranked with other pediatric specialists; see the Pediatrics Fact Sheet for the relevant metrics.
Why Does Blue Cross Use Population-Level Metrics?
Methodological concerns (sample size, case mix, sub-specialization, etc.) often make it difficult to assess
performance at the practice level Population-level metrics:
o Promote the foundational PGIP principle of a community of caregivers’ shared responsibility for a population of patients
o Encourage communication and collaboration between primary care and specialty practitioners o Encourage a focus on system performance, accountability and improvement o Promote optimal quality, efficiency and health care utilization in the population of patients attributed to the
primary care physicians with whom specialists collaborate
How Population-Level Metrics Are Calculated
2016 Specialist Value-Based Reimbursement
Vascular Surgery Fact Sheet
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
This example shows the measurement approach with only one metric; the metrics used for vascular surgery are listed above
A maximum of three SubPO relationships are included for each practice; to be included: o The SubPO must be among the top 3 SubPOs for the practice based on the number of shared members o At least 10% of all PGIP-attributed members treated by the practice must be attributed to a primary care physician in
the SubPO o If a practice has no SubPOs meeting the 10% threshold, the single top SubPO will be used
Value-Based Reimbursement Selection Process
Vascular surgeons must be nominated by their member physician organization (and possibly one other PO) and must have been in PGIP for one year
The top two-thirds of non-pediatric vascular surgery practices based on the vascular surgery weighted composite score are reimbursed in accordance with the VBR Fee Schedule
All pediatric vascular surgery practices based on the Pediatrics weighted composite score are reimbursed in accordance with the VBR Fee Schedule (see the pediatric fact sheet for more information)
Practices that serve a small number of Blue Cross patients cannot be evaluated/ranked
Value-Based Reimbursement Percentages and Codes
Practices in the top third of non-pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second third of non-pediatric practices are reimbursed at 105% of the Standard Fee Schedules
Practices in the top half of pediatric practices are reimbursed at 110% of the Standard Fee Schedules
Practices in the second half of pediatric practices are reimbursed at 105% of the Standard Fee Schedules The VBR Fee Schedule is applied to the RVU-based procedure codes (most procedure codes, except those for
ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections) and the time and base codes.
The VBR Fee Schedule is applied only to Blue Cross Blue Shield of Michigan Commercial claims
This document summarizes the methods used to select the PGIP practices receiving VBR. For more detailed information
on the methodology, please contact your PGIP Physician Organization. If you have questions, please contact your PGIP
Physician Organization or your Provider Consultant.