2. Today’s Agenda
Introduce Medical Network One
Describe BCBSM PGIP
Explain how collaboration might look
Introduce the PCMH, PCMH-N and OSC
Open discussion
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4. Who Are We?
Health solutions organization with a 30 year legacy
Primary care providers in five counties
Multi-specialty
Strong relationship with behavioral health
Addition of psychologist
Engaged in transformative activities including PCMH,
PCMH-N and OSC
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5. Timeline
2004 BCBS launched PGIP
Initially PGIP was only open to primary care physicians
2011 PGIP is opened to a number of specialties
2012 psychologists invited to join PGIP
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6. Want to Join?
Individual physicians and psychologists need to join a
participating Physician's Organization
Psychologists were eligible to join and participate in
PGIP beginning in 2012
Physician Organizations could add psychologists in
their Summer 2012 Self Reported Database
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7. Collaborating with a New Partner
Create a mission statement by answering the
question: What do we hope to accomplish by
working collaboratively
Examine initiative and identify who will be
responsible (MNO or Both)
Consider issues and develop an action plan
Record decisions to form a shared vision of
initiative responsibilities
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8. Steps to Successful Collaboration
Translate beliefs into a shared vision
Establish regular cycles
Attain an Advance Plan
Make time to Communicate and Evaluate
Repeat
Regularly
Stick to the Plan
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10. Catalyzing Health System Transformation in Partnership with Communities
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
PGIP
PCMH
OSC
Chronic
Care Model
Primary care
transformation
Organized
Systems of Care
• Transform care processes to effectively
manage chronic conditions
• Build registry and reporting capabilities to
manage populations of patients
• Achieve savings in specified areas
• Reward physicians for improved performance
and efficiency
• Share savings
• Build PCMH infrastructure
• Strengthen doctor-patient
relationship
• Support PCPs and their team’s
ability to effectively manage care
• Coordinate care across the
continuum for a defined patient
population
• Support establishment of
systems of care that
assume responsibility and
accountability for
managing a defined
population of patients
across all locations of care
in a community
• Establish linkages with
community services
Expand PGIP
to include
specialists
involved in
chronic care
Implement
PCMH and
quality/use
initiatives
Continue to
increase
number of
initiatives
Continue to
add new
specialties to
PGIP
Extend providerdelivered care
management with
links to BCBSM for
customer reporting
statewide
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11. 2007 Principles of the PCMH
Personal physician
Physician-directed team
Whole person orientation
Quality and safety
Coordinated, integrated care
Enhanced access
Appropriate payment structure
*March 2007 Statement Issued by:
American Academy of Family Physicians (AAFP); American Academy of Pediatrics (AAP)
American College of Physicians (ACP); American Osteopathic Association (AOA)
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12. 10
Trained and
Engaged
Leadership
Building Blocks of a
High Performing PCMH
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Template of the
Future
5
Population
Management
1
Shared Vision
and Goals
2
Data-driven
Improvement
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Coordination
of care
6
Continuity of care
7
Prompt access to
care
3
Empanelment
and panel size
management
4
Team-based
care
13. Key Element: Care Registry
This population-based application stores age
appropriate surveillance, disease-condition
specific individual and population-based
information to support care management,
outreach, quality improvement, and outcomes
This tool helps identify gaps in care, run reports,
and perform a practice, clinician, physician
organization, and payer level assessment
Join the Conversation:
13
14. Key Element: Evidence Based Guidelines
EBGs are embedded in the care registry or EMR
PCP utilizes and refers to evidence-based guidelines
The United States Preventive Services Task Force
(USPSTF) Guidelines, National Quality Forum (NQF) or
other evidence-based guidelines helps identify care
needs of the patient population not the payer
population
HEDIS measures are selected by NCQA committee but
based on EBGs
Join the Conversation:
14
15. Key Element : eTools Enhance Practice
Transformation
Focus on the patient-physician relationship;
physician-led practice team; enhanced access to
care; coordinated and integrated care; which is
comprehensive, continuous care
Join the Conversation:
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16. Key Elements of New Care Models
Planned care and planned care visits
Shared medical visits
Team building activities including huddles
Self management training
Care management/coordination
Motivational Interviewing
Transitions in care
Join the Conversation:
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20. What’s a PCMH-N: OSC
Accountable to improve performance measures for a
defined population
Legal governance structure
Formal network of providers
Ensure inclusion of the safety-net
Ensure networks are comprehensive and include
acute, preventive, chronic disease, behavioral,
developmental, oral health, and social services
Join the Conversation:
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21. What’s a PCMH-N: OSC
OSCs are accountable for patients enrolled or attributed to
primary care providers within their network
• They must improve care, improve health, contain costs
• Engage patients in program design and quality
improvement
Establish relationships and protocols across the OSC network
• Promote technology adoption, including workflows and
models for using telemedicine and mobile devices
Join the Conversation:
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22. What’s a PCMH-N: OSC
Enhance resources of all OSC network providers
• Support practice-embedded Care Managers and define a
shared patient-centered care plan
Develop common data solutions across the network
•
• Provide training and education
Join the Conversation:
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24. What Is HEDIS
Originally titled the "HMO Employer Data and
Information Set" (Version 1.0: 1991)
"Health Plan Employer Data and Information Set”
(Version 2.0: 1993)
“Healthcare Effectiveness Data and Information Set”
(Version 3.0: 1997)
HEDIS 2009 (year)
Join the Conversation:
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25. NCQA
A private, independent, non-profit health care, quality
oversight organization committed to measurement,
transparency, accountability and uniting diverse
groups around a common goal: improving health care
quality.
Join the Conversation:
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26. Why Create HEDIS
Designed to allow consumers to compare health plan
performance to other plans and to national or regional
benchmarks
Designed for employers to compare health plans
Join the Conversation:
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27. Overall Definition of HEDIS
HEDIS measures are related to many significant public
health issues, such as cancer, heart disease, asthma
and diabetes, preventative services
Join the Conversation:
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28. Measures
Currently, the HEDIS measurement set contains 70
measures across 8 measurement domains
Most of the measures in each domain have more than
1 rate associated with it (for example: there is a
measure of comprehensive diabetes care that is
comprised of 9 specific rates)
Join the Conversation:
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29. Measures and Domains of Care
76 (80) HEDIS measures divided into five domains of
care
• Access/Availability of Care
• Experience of Care
• Utilization and Relative Resource Use
• Cost of Care
• Health Plan Descriptive Information
Join the Conversation:
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30. Effectiveness of Care
Prevention and Screening
Respiratory Conditions
Cardiovascular Conditions
Diabetes
Musculoskeletal Condition
Join the Conversation:
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31. Effectiveness of Care
Behavioral Health
Medication Management
Measures Collected Through Medicare Health
Outcomes Survey
Measures Collected Through the CAHPS Health Plan
Survey
Join the Conversation:
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32. Pay For Performance
Payers rely on HEDIS measures to incentivize primary
care physicians
BCBSM is utilizing HEDIS measures
Select target measures to incentivize
Join the Conversation:
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33. Communication and Marketing
NCQA collaborates annually with U.S. News & World
Report to rank HMOs
“Best Health Plans" list is published in the magazine in
October
Join the Conversation:
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34. Advantages
Rigorous selection process
Useful for "evaluating current performance and setting
goals”
Associated with cost-effective practices or with better
health outcomes
Measures focus largely on processes of care: reflect
care that patients actually receive
HEDIS measures are widely known and accepted
Join the Conversation:
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35. Provider Role in HEDIS
Providers play a central role in promoting health
Providers facilitate HEDIS process by:
• Providing appropriate care within designated timeframe
• Accurately documenting all care in the medical record
• Accurately coding all claim submissions
Join the Conversation:
35
36. HEDIS Data Collection
HEDIS data is gathered by
• Administrative (claims) data
• Hybrid Method – claims data and chart reviews
• Survey - CAHPS
Join the Conversation:
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37. What Are We Measuring Today
Blue Cross Blue Shield of Michigan is committed to
improving the quality of mental health treatment
delivered to patients:
• Encouraging doctors and other health care professionals to
follow treatment standards developed by the Michigan
Quality Improvement Consortium and Blue Cross
• Tracking certain aspects of care quality by using measures
within the Healthcare Effectiveness Data and Information Set
(HEDIS®)
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38. Tracking Measures
Follow-up after hospitalization for mental illness
(FUH7): Proportion of patients discharged from a
mental health facility who are seen by a mental health
care provider within seven days of discharge
Antidepressant medication management: Proportion
of newly diagnosed depressed adults who receive an
antidepressant:
• For 12 weeks (acute phase)
• For six additional months (continuation phase)
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39. Tracking Measures
Follow-up care for children prescribed attention
deficit hyperactivity disorder medication: Proportion
of children prescribed medication for ADHD who
receive:
• At least one follow-up visit within 30 days of medication
initiation
• At least two additional visits within the next seven
months
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40. Tracking Measures
Initiation and engagement of alcohol and other drug
dependence treatment: Proportion of patients
diagnosed with alcohol and other drug dependencies
who receive treatment within 14 days, followed by two
additional services within 30 days
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41. PGIP Endorses Two HEDIS Measures
The Blue Cross Physician Group Incentive Program
(PGIP) has endorsed two of the HEDIS based
behavioral health measures related to depression
medication and follow-up for patients with ADHD in its
tracking initiative (Evidence-Based Care Reports)
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