Updated 1/19/2017

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Launch of PGIP based onChronic Care Model

Launch PCMH Program

Organized Systems of Care (OSCs)

• Physician Organizations have the structure and technical expertise to create highly functioning systems of care

• Design and execute programs in acustomized and collaborativemanner

• Measure performance at the population level and rewardimprovement as well as absoluteperformance: initial focus on GDRand building patient registries

• Support building of PCMH infrastructure

• Launch quality/use Initiatives

• Measure PO performance across quality and use metrics such as preventive and evidence-based care, preventable ED use, high and low-tech imaging, IP use

• Include specialists involved in chronic care

• Building the PCMH-Neighborhood: expand PGIP to include all specialists (including VBR)

• Catalyze building of Organized Systems of Care: enable OSCs to assume responsibility and accountability for managing the PCP-attributed population of patients across all locations of care

• OSC initiatives support integration of PCMH capabilities at OSC level

Timeline developed from information presented by Dr. David Share at the PGIP quarterly meetings.

Risk-based Reimbursement

• Provider Delivered Care Management: expansion of practice care team to include care managers

• Mutual accountability: clinical integration, comprehensive & proactive management of individuals and populations, & interdependence among providers.

• Creations of Value Indices: capture full picture of value through a mix of total cost, cost of care measures, and overall quality to define “high value”

• Total cost of care: on path to full risk for cost, quality and patient experience

A BCBSM program started in 2004 to transform the delivery of care

BCBSM partners with Physician Organizations (POs) to achieve a high performing health care networks in Michigan

PGIP is moving to a fee-for-value approach

PGIP offers rewards to:

◦ POs to assist with infrastructure support and practice transformation

◦ Physicians through fee-for-value-based reimbursement

PCPs: through Patient Centered Medical Home (PCMH) designation and it’s expansion and advancements

Specialists: through implementation of PCMH-neighborhood capabilities, collaboration with their community of caregivers to optimize use, efficiency and quality in their shared patient populations

Physician Organizations (POs) are the “building blocks” of the program

Each primary care and specialty practitioner belongs to one PO for PGIP enrollment

Patients are attributed to a primary care physician that aggregates up to a PO level for performance measurement

The practice is defined by the PO and by the specialty types of the practitioners represented within the practice

Population-based metrics are calculated for practices based on sub-PO member populations

BCBSM is directing an increasing proportion of professional payment to PCMH designated primary care practices and specialists who obtain the Specialty Valued Based Reimbursement recognition based on population-based metrics (cost, quality and patient experience).

PRIMARY CARE PHYSICIANS

Should work towards obtaining the BCBSM PCMH designation within one year of enrollment in PGIP.

PCMH designation earns practices an additional valued based reimbursement (VBR) of 10% – 40% on E & M billing.

New Advanced Care Practice recognition for additional 5% VBR beginning in 2018.

Other health plans recognize PCMH designation and PCPs may receive additional incentive dollars from these plans.

Processes for PCMH can assist practices to improve their cost and quality which will help them be preferred providers in all networks.

Being PCMH will make it more likely for the practice to earn pay-for-performance incentive dollars across all plans.

SPECIALIST PHYSICIANS

Received an additional 5% - 10% Specialty VBR on RVU billing if criteria is met for the BCBSM Specialist VBR program.

Achieving Specialist VBR meets the criteria for inclusion in The Physician Alliance Organized System of Care and access to the BCBSM Personal Choice PPO product.

Specialist who have improved Patient Centered Medical Home Neighborhood capabilities will support PCPs and be preferred referral specialist.

Achieving The Physician Alliance Specialist Service Excellence Award in Care Coordination and Quality through embracing population health processes and are marketed as good partners in narrow networks and preferred specialist.

Contact your assigned practice resource person

or

Call The Physician Alliance office at 586-498-3555