provider quality portal. biography emily bagley director, provider analytics and partner solutions...
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Provider Quality Portal
Biography Emily Bagley Director, Provider Analytics and Partner Solutions BlueCross BlueShield of Tennessee Responsibilities
Clinical data exchange with providers Provider Implementation of tools and technology Provider Performance Assessment
o Episode Bundles to Support the State of TN Health Care Innovation Initiative (THCII)
o Provider Directory Validation and NCCTo Hospital Analytics Toolo Clinician and Facility Dashboardso Efficiency Practice Pattern Analysis (PPA)
Provider Measurement Analytics (Provider Incentive Program Overview) Contact Info:
Phone: 423-535-7046Email: [email protected]
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Biography
Jyothi Anantha Business Intelligence Applications Lead
Responsible for building business intelligence and external facing agile applications to meet business demands.
Contact Info:
Phone: 423-535-6346Email: [email protected]
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Chattanooga, Tennessee
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BlueCross BlueShield of Tennessee
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Who We Are
BCBST Provider Quality Incentive Programs PCMH (Enterprise-wide initiative) Moving from a chronic model to a Transitions of Care (TOC) model for
chronic and non chronic populations
Commercial programs Quality Care Partnership Initiative (QCPI)
o Fee schedule re-basement program based upon HEDIS quality scores for a group
o 8 pilot groups for 2015 o Total cost of care criteria to be added in future QCPI phases
Commercial Pay for Gaps (P4G)o 38 groups in 2015 with quality bonus payments for gap closures
Provider Transparency (i.e. Physician Quality Measurement Tool)o Association initiative that measures providers 2 times a year and
publishes those scores in our Provider Directory tool for members
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BCBST Provider Quality Incentive Programs BlueCare Programs (Medicaid) BlueCare and BlueCare Plus Pay for Gaps (P4G)
o 45 groups in 2015 and quality bonus payments for gap closures Community Mental Health Pay for Gaps (P4G)
o Incentivize the mental health facilities to close gaps on members who seek services at mental health facilities versus a PCP
BlueCare Pay for Performance (P4P)o Quality and utilization program to incentivize PCPs to see patients
that are assigned to their practice BlueCare Provider Practice Patterns Assessments (PPAs)
o Quarterly report that measures individual providers across 7 cost/utilization metrics and compares them to their peers
Medicare Advantage Programs (STARs) Medicare Advantage Physician Quality (STARs)
o Fee Schedule re-basement program that measures groups on 18 STARs measures
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Business Need for Provider Quality Portal As the market shift towards value-based contracting and a quality
emphasis, BCBST felt the need to develop tools and technology to support the providers in this transition.
Since the accreditation measures are moving towards outcomes based scoring, BCBST needed to obtain clinical data that is not currently captured on a submitted claim.
BCBST developed a portal for providers to access a member’s health information at the point of care that allows for the following: Review and close gaps in care Complete attestations Complete a Provider Assessment Form (PAF)
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Product Development and Delivery
Developed first phase that was available to providers in 3 months Ability to obtain supplemental data through provider
attestations Developed in an Agile manner (incremental product delivery)
Obtained feedback from providers and further refined product
Leveraged platform development for other lines of business (changed measures and financial incentives model)
Implemented the portal for all major lines of businesses across the enterprise within a year
Utilized the development efforts to also support a Risk/Gain share contracting model to display financial opportunities
Automated the incentive payments generated within the portal to disburse payments to providers
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Project Outcomes-Medicare Advantage Portal Third highest source of gap closures by supplemental data to
support HEDIS (EMR data and biometric screenings were first and second, respectively) Primarily impacted Medicare Advantage Significantly impacted the Adult BMI and Colorectal Cancer
Screening measures Gap closures via attestations by different lines of business (as of
9/11/15): 37, 962 gaps closed for Medicare Advantage between (Jun
2014 – Dec. 2014) and 42,373 gaps closed YTD 2015 4, 970 gaps closed for BlueCare and BlueCare Plus since an
April 2015 portal go live 6, 103 gaps closed for the Commercial line of business since a
mid-July 2015 go live Passed (100%) the HEDIS audit for primary source verification
Supplemental Data Repository
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Clinical Data Exchange• Electronic Medical Records• Lab Feeds
Quality Care Programs• Attestations• PCMH Data• Pay for Quality Data• Transparency Data• Patient Assessment Forms
Immunization Data• Tennessee• North Carolina
Provider Performance Module Overview
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Architecture
Source Systems
Staging
Integration
Data Marts
Empower Business Users
Copy
ETL
ETL
DB2 SQL Sybase
Clinical Data Warehouse
P4P Clinician FCIR SIMS
Teradata
Flat File
Provider Facing AgileSolutions/Applications
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Click icon to add picture
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Software Structure
SOLID Design
Our Software Quality Goals
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Consolidated Portal – Future State Build a single provider module that aggregates information for a
practice/group Aggregates information across the multiple provider incentive
programs Includes metrics across the different lines of business Provides interactive capabilities to close gaps Automates reports that are currently static pdf reports Contains a member roster for the different lines of business Allows for a member/provider search across the differing programs Look at performance as compared to state/regional benchmarks
Centralized the login process for all provider portals
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Future State – Example Landing Page
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