UPDATE ON PHYSICIAN PAY-FOR-VALUE (P4V) MEASURE … · metrics in the existing Quality Blue...
12
Camp Hill, PA 17089 Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks and Quality Blue is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. NaviNet is a registered trademark of NaviNet, Inc., which is an independent company that provides a secure, web-based portal between providers and health care insurance companies. HEDIS is a registered trademark of the National Committee for Quality Assurance. UPDATE ON PHYSICIAN PAY-FOR-VALUE (P4V) MEASURE CHANGES This Bulletin is a follow-up to the Special Bulletin, dated Sept. 12, 2013, announcing the evolution of the existing Quality Blue Physician program. Here, we communicate more details on the changes in measurement for the Quality Blue Physician P4V. As noted in the prior communication, the scaled-back Quality Blue Physician P4V program will take effect on April 1, 2014. As of April 1, 2014, providers currently in Quality Blue Physician Pay-for-Performance who do not transition to the Patient-Centered Medical Home (PCMH) or Accountable Care Alliance (ACA) programs will be automatically enrolled in the scaled-back Quality Blue Physician P4V program. While many aspects of the new scaled-back program will be familiar, please remember — this will be a new program and a building block for our expanding Pay-for-Value programs. We are committed to providing you with timely information to support your transition from the existing Quality Blue Physician program toward alignment with our overall pay-for- value strategy. In addition to the measurement changes described here, another key change in the Quality Blue Physician P4V program is the potential incentive reimbursement being set at a uniform $3 per eligible E&M code. Quality measurement for the Physician P4V program will align with the 27 scored metrics used in our P4V Accountable Care Alliance and Patient-Centered Medical Home programs. The two efficiency measures for the Physician P4V program will be for Generic Brand Prescribing and Emergency Department utilization. Practice- specific quality and efficiency performance simulations for Quality Blue Physician P4V will be posted on NaviNet® in early November. Providers can access the files by clicking the link for Quality Blue Reports. The two files will provide preliminary data on your eligibility to earn the $3 incentive. Navigation to the reports will be highlighted via a blue banner reading: “Scroll down to review your Performance Simulation Reports for the new Quality Blue Physician Pay-for-Value program. The new performance measures, scoring and incentive changes are coming April 1, 2014.” (Over, please) OCT. 30, 2013
Transcript of UPDATE ON PHYSICIAN PAY-FOR-VALUE (P4V) MEASURE … · metrics in the existing Quality Blue...
Camp Hill, PA 17089
Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks and Quality Blue is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. NaviNet is a registered trademark of NaviNet, Inc., which is an independent company that provides a secure, web-based portal between providers and health care insurance companies. HEDIS is a registered trademark of the National Committee for Quality Assurance.
UPDATE ON PHYSICIAN PAY-FOR-VALUE (P4V) MEASURE CHANGES This Bulletin is a follow-up to the Special Bulletin, dated Sept. 12, 2013, announcing the evolution of the existing Quality Blue Physician program. Here, we communicate more details on the changes in measurement for the Quality Blue Physician P4V. As noted in the prior communication, the scaled-back Quality Blue Physician P4V program will take effect on April 1, 2014. As of April 1, 2014, providers currently in Quality Blue Physician Pay-for-Performance who do not transition to the Patient-Centered Medical Home (PCMH) or Accountable Care Alliance (ACA) programs will be automatically enrolled in the scaled-back Quality Blue Physician P4V program. While many aspects of the new scaled-back program will be familiar, please remember — this will be a new program and a building block for our expanding Pay-for-Value programs. We are committed to providing you with timely information to support your transition from the existing Quality Blue Physician program toward alignment with our overall pay-for-value strategy. In addition to the measurement changes described here, another key change in the Quality Blue Physician P4V program is the potential incentive reimbursement being set at a uniform $3 per eligible E&M code. Quality measurement for the Physician P4V program will align with the 27 scored metrics used in our P4V Accountable Care Alliance and Patient-Centered Medical Home programs. The two efficiency measures for the Physician P4V program will be for Generic Brand Prescribing and Emergency Department utilization. Practice-specific quality and efficiency performance simulations for Quality Blue Physician P4V will be posted on NaviNet® in early November. Providers can access the files by clicking the link for Quality Blue Reports. The two files will provide preliminary data on your eligibility to earn the $3 incentive. Navigation to the reports will be highlighted via a blue banner reading: “Scroll down to review your Performance Simulation Reports for the new Quality Blue Physician Pay-for-Value program. The new performance measures, scoring and incentive changes are coming April 1, 2014.” (Over, please)
OCT. 30, 2013
Please see the attached supplement for a guide to the simulation reports for the quality measures and efficiency measures. Also included in the supplement is a full list of the measure changes for each quality measure. For the simulations you will see in November and December, there will be 27 scored and four profiled quality measures. When the program goes live in April, there will be additional profiled quality measures. Sixteen of the 27 scored quality measures in the new Quality Blue Physician P4V program will overlap the metrics in the existing Quality Blue Physician P4P program. Although they are similar, the coding of the measures in the Quality Blue Physician P4V program will differ from the existing Quality Blue Physician P4P measures. In addition, participants now may have access to mastheads with the detailed measure specifications via the Provider Resource Center via NaviNet. Simply click on Quality Blue Physician Program. INTERPRETING YOUR SIMULATION REPORTS The Provider Relations Representatives who have been working with you will be available to guide you through interpreting your P4V simulation reports, planning for the coming transition and preparing physicians, nurses, practice managers and office staff. They are also available to discuss new P4V programs and provide detailed information. Even if you have not participated previously in the Quality Blue Physician Pay-for-Performance program, you may be able to participate in the new Quality Blue Physician P4V program. If you have questions, please contact your Provider Relations Representative. Also, remember to watch for additional program information in our usual communication channels, including Special Bulletins, NaviNet Plan Central, the online Provider Resource Center and our publications Behind the Shield and Clinical Views.
SUPPLEMENT TO SPECIAL BULLETIN DATED OCT. 30, 2013
SIMULATION REPORT EXAMPLES AND QUALITY PERFORMANCE MEASURE CHANGES
FOR 2013 PERFORMANCE SIMULATIONS
QUALITY PERFORMANCE MEASURES In the new Quality Blue Physician P4V program, Quality is worth 50 points. A minimum total score of 40 points, with a minimum quality score of 15 points and a minimum efficiency score of 10 points, is needed to be eligible for the $3 per eligible E&M incentive. On Page 3 is an example of a Quality report. Practices have the potential to be scored on 27 metrics. Measures that have no members in the denominator will not be scored, and are denoted with an “NS” in the “Met/Exceeded Benchmark?” and “Pass” columns. To pass a measure, the practice’s compliance must meet or exceed the benchmark or be greater than 90 percent. Compliance rates greater than 90 percent or equal to or above the benchmark are highlighted in green; compliance rates below the benchmark are highlighted in red. For composite measures, i.e., measures that have multiple components (QN02, QN06, QN16 and QN17), the practice must meet or exceed the benchmark on all components to pass the measure. Benchmarks for the simulation reports are based on the higher of the Highmark Health Services 50th percentile rate or the national NCQA HEDIS® 50th percentile. Benchmarks are updated on an annual basis. In the example on Page 3, the practice was scored on 19 measures. They met or exceeded the benchmark on 11 of 19 measures to earn a quality score of 29.
2
ACME Practice
Composite
*NCQA Measures Quality Score = 29
3
PERFORMANCE MEASURES: MASTHEAD COMPARISONS Of the 27 scored quality measures in the new Quality Blue Physician P4V program, 16 overlap the metrics in the existing Quality Blue Physician program. Although they overlap, the measures in the Quality Blue Physician P4V program will differ from the existing Quality Blue Physician measures. The following tables highlight the measure differences between the two programs. Comparisons are illustrated by showing the HEDIS-based specifications that will be used in the simulations and the future Quality Blue Physician P4V program quality scoring alongside the existing Quality Blue Physician P4P measure specifications. QN02: Comprehensive Diabetes Care — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Applies to QN02.1 through QN02.4
Includes members without drug coverage Excludes members without drug coverage
Includes members with history of skilled nursing facility claims Excludes members with history of skilled nursing facility claims
12-month continuous enrollment with no more than a 45-day gap in coverage
24-month continuous enrollment with no more than a 20-day gap in coverage
Excludes patients who cannot receive a test for medical reasons
New Quality Blue Physician P4V Existing Quality Blue Physician
QN02.1 HbA1c
Utilizes LOINC codes for HbA1c testing Utilizes G codes for HbA1c testing
QN02.2 LDL-C
Utilizes LOINC codes for LDL-C testing Utilizes G and CPT II codes for LDL-C testing
QN02.3 Nephropathy
Utilizes LOINC codes for nephropathy testing Utilizes DRG and other non-HEDIS codes for numerator compliance
QN02.4 Eye Exam
Utilizes CPT II codes for measure exclusion
4
QN03: Acute Pharyngitis Testing — Source: HEDIS New Quality Blue Physician P4V Existing Quality Blue Physician
Continuous enrollment 30 days prior to episode Continuous enrollment 90 days prior to episode
Children age 2-18 No age range
Includes ED and Outpatient visits Outpatient visits only
Includes LOINC codes for strep tests Includes non-HEDIS antibiotics
QN05: Adolescent Well Care — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Continuous enrollment (the measurement year) and allowable gap in coverage (45 days) is the same for all members
Continuous enrollment and allowable gap in coverage is different for those age 12-18 (continuous enrollment in the measurement year with an allowable gap of 45 days) and age 19-21 (continuous enrollment in the measurement year and year prior with an allowable gap of 20 days)
Compliance is the same for all members (one well-care visit in the measurement year)
Compliance differs for those age 12-18 (one well-care visit in the measurement year) and age 19-21 (one well-care visit in the measurement year or year prior)
QN08: Breast Cancer Screening — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Non-HEDIS codes used for numerator compliance and denominator exclusion
5
QN10: Cervical Cancer Screening — Source: HEDIS New Quality Blue Physician P4V Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Non-HEDIS codes used for numerator inclusion and denominator exclusion
QN12: Well-Child Visits in the First 15 Months of Life — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
No Exclusions Excludes members with initial hospital discharge date of ≥60 days from date of birth
Requires ≥6 well-child visits Requires ≥5 well-child visits
QN13: Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Non-HEDIS codes used for numerator compliance
QN18: Appropriate Medications for People with Asthma — Source: HEDIS
New Quality Blue Physician P4V Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Non-HEDIS codes and medications to identify asthmatics
6
QN19: Cholesterol Screening for Patients with Cardiovascular Conditions — Source: HEDIS New Quality Blue PCMH/ACA Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Non-HEDIS codes used for numerator compliance and denominator exclusion
QN20: MMR Vaccination Status — Source: HEDIS
New Quality Blue PCMH/ACA Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Continuous enrollment needed 12 months preceding the second birthday
Continuous enrollment needed in the measurement year and three years prior
Evaluation of members who turn 2 years who received vaccine by age 2
Evaluation of members who turn 7 years who received vaccine between ages 4 and 7
QN21: Varicella Vaccination Status — Source: HEDIS New Quality Blue PCMH/ACA Existing Quality Blue Physician
Allowable gap in coverage of 45 days Allowable gap in coverage of 20 days
Continuous enrollment needed 12 months preceding the second birthday
Continuous enrollment needed from 31 days of life to 18 months
Evaluation of members who turn 2 years who received vaccine by age 2
Evaluation of members who turn 18 months who received the vaccine between 12 and 18 months
QN22: Glaucoma Screening for Older Adults — Source: HEDIS
New Quality Blue PCMH/ACA Existing Quality Blue Physician
Evaluates Medicare population age 65 and over Evaluates all members age 65 and over
7
QN25: Urinary Incontinence Assessment for Older Women — Source: AMA-PCPI w/ modifications New Quality Blue PCMH/ACA Existing Quality Blue Physician
A greater number of CPT codes utilized to identify visits Place of service codes included to identify ambulatory setting
QN26: Plan of Care for Urinary Incontinence in Older Women — Source: AMA-PCPI w/ modifications
New Quality Blue Physician P4V Existing Quality Blue Physician
HCPCS codes and a greater number of CPT codes utilized to identify visits
Place of service codes included to identify ambulatory setting
QN27: Fall Risk Assessment for Older Adults — Source: AMA-PCPI w/ modifications
New Quality Blue Physician P4V Existing Quality Blue Physician
A greater number of CPT codes utilized to identify visits Place of service codes included to identify ambulatory setting
If fall risk exists, must also document the assessment was done with code 3288F
Q28: Fall Risk Plan of Care for Older Adults — Source: AMA-PCPI w/ modifications
New Quality Blue Physician P4V Existing Quality Blue Physician
HCPCS codes and a greater number of CPT codes utilized to identify visits
Place of service codes included to identify ambulatory setting
Denominator inclusion is 3288F with 1100F
8
TWO NEW EFFICIENCY MEASURES: GENERIC DRUG PRESCRIBING AND EMERGENCY DEPARTMENT UTILIZATION In the prior Special Bulletin, dated Sept. 12, 2013, we explained that the Generic-Brand measure in the simulations will be similar to the existing Quality Blue Physician P4P program. The measure will be modified to evaluate a six-month measurement period with three months of claims run-out. Rates of generic drug prescriptions will be compared to network specialty averages for Family Practice, Internal Medicine and Pediatrics. In the Quality Blue Physician P4P program, maximum points were awarded for reaching a 75 percent generic prescribing rate. The new program awards between zero and 25 points for ordering more generic prescriptions than the specialty average. In the report example below, the practice’s specialty is Family Practice. Their generic prescribing rate is 86 percent. This is five percent above the Family Practice Specialty rate of 81 percent. The practice here is awarded 25 points for performing five percent above their specialty average. Specialty rates will be updated quarterly based on the measurement time period.
9
The Emergency Department (ED) Utilization measure is included in the program because of its importance in the P4V strategy of utilizing the most cost-effective treatment location. The ED Utilization metric will calculate the rate of ED visits using Milliman MedInsight ® Grouper Logic. The value is weighted to a rate of visits per 1,000 members to allow comparisons between providers’ member populations. To calculate an individual practice’s rate, attributed patient visits will be grouped into adult commercial, pediatrics and seniors to account for variations based on age. Then, the composite ED utilization rate is compared to the regional market averages and scored. In the example below, the practice’s composite rate is 189. Based on the scoring table of the regional rates for the measurement time period, the practice would earn 25 points for ED utilization. Regional rates will be updated quarterly based on the measurement time period.
In order to be eligible to earn the $3 per eligible E&M code incentive, a practice must earn at least 10 points between the two efficiency measures -- Generic Dispensing and ED Utilization -- in addition to 15 Quality points. A total of 40 points among all three elements -- Generic Dispensing, ED Utilization and Quality -- is needed to be eligible for the incentive. In the example above, the practice scored 79 total points for the Quality and Efficiency measures, making them eligible for the $3 incentive. Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks and Quality Blue is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc. NaviNet is a registered trademark of NaviNet, Inc., which is an independent company that provides a secure, web-based portal between providers and health care insurance companies. HEDIS is a registered trademark of the National Committee for Quality Assurance. Milliman MedInsight is a registered mark of Milliman, Inc.
10
