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Value-Based Alternative Payment Programs
Florida Blue is committed to the development of incentive programs that ensure our members receive high quality, efficient health care services. Aligning with the health care industry’s move to “pay for value” not volume, Florida Blue continues to implement value-based programs while working collaboratively with our physicians and hospitals to improve the quality of the patient experience and overall outcome of our members.
Patient Centered Medical Home
The Florida Blue Patient Centered Medical Home (PCMH) program was implemented in October 2011. Our program supports the transformation of a primary care practice to a physician-directed, data driven practice which uses integrated care teams and care coordination to ensure the member receives appropriate care when and where indicated. The PCMH program is a voluntary, by-invitation-only program available to physicians who practice within the specialties of family practice, internal medicine and pediatrics. To be eligible for the PCMH program, a physician or group must:
- Practice medicine in the field of internal medicine, family practice or pediatrics Participate in NetworkBlue.
- Meet membership requirements of 300 unique attributed commercial Florida Blue members, excluding BlueCard® and Alliance members.
- Attest to office hour availability of six hours before or after regular hours weekdays and/or are open on the weekends.
- Use e-prescribing and its decision support tool.
- Complete a PCMH recognition program such as NCQA or URAC with 24 months of enrollment.
- Perform at an equal quality level with their peers in a core set of HEDIS® clinical quality metrics.
Upon enrollment, each participating practice agrees to follow nationally endorsed core principles of a patient centered medical home:
Personal Physician: Each patient has an ongoing relationship with a personal physician trained to provide first contact, and continuous, comprehensive care.
Physician-Directed Medical Practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole Person Orientation: The personal physician is responsible for providing all the patient’s health care needs and takes responsibility for arranging appropriate care with other qualified professionals when applicable. This includes care for all stages of life; acute care, chronic care, preventive services and end of life care.
Care Is Coordinated and/or Integrated: All elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, and nursing homes) and the patient’s community (e.g., family, public and private community-based services) are coordinated. Care is facilitated by registries, information technology, health information exchange and other means to ensure that patients receive care when and where they need it in a culturally and linguistically appropriate manner.
Practices are required to manage their attributed patients at the population level. Each group is measured in two categories - clinical quality and total cost of care for the practice’s population. The clinical quality section is comprised of clearly defined NCQA Healthcare Effectiveness Data and Information Set (HEDIS®) metrics which are measured through Florida Blue administrative claims. The cost and efficiency measures are risk-adjusted, and compare the physician group against their statewide peers. The PCMH team uses Optum Insight Episode Treatment Groups to calculate these results. All practices are provided access to our Quality and Efficiency Reporting Tool which shows the practice how they are performing over time and compared to their peers. They are able to take the scorecard information and drill down at the member level to understand in more detail how their health care dollars are spent.
Awards are based on the practice’s PMPM trends over time compared to the Consumer Price Index (CPI) and peer PMPM comparisons. Awards are paid as a fee schedule multiplier to applicable primary care codes for the program year and range from adding up to 16 percent to the groups contracted fee schedule. In addition, a medical home initial assessment fee will be paid annually when applicable for the management of patients with chronic diseases such as diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), asthma and congestive heart failure (CHF). PCMH physicians will also receive the management fee when applicable for well visits of children newborn to age seven.
The transformation of a practice into one that meets PCMH standards can be difficult for most PCPs. It can be especially challenging for smaller practices with limited financial reserves, staff time, and administrative infrastructure. Florida Blue provides PCMH practices with a designated Practice Transformation Specialist to assist practices in understanding their performance scorecards, identifying opportunities for improvement, and assessing practice infrastructure and alignment to activities that are critical to PCMH success.
Practices must achieve PCMH recognition within 24 months of their program implementation for continuous participation in PCMH. Florida Blue provides clinical support from our staff of specially trained nurses to assist practices understand the recognition requirements, how to write policies and procedures and other support as they complete the recognition process.
For more detailed program descriptions click the links below:
Comprehensive Primary Care Program
The Comprehensive Primary Care Program (CP2), is offered to family practice, internal medicine and pediatric physicians in groups of 15 physicians or less who feel they do not want to obtain PCMH recognition at this time. Similar to the Patient Centered Medical Home (PCMH) program, to be eligible for the Comprehensive Primary Care Program, a physician or physician group must;
- Practice medicine in the field of internal medicine, family practice or pediatrics.
- Participate in NetworkBlue.
- Meet membership requirements of 300 attributed commercial members under the age of 65.
- Attest to patient access for a minimum of six hours weekly after 6 p.m. weekdays and/or weekends.
- Attest to the utilization of an e-prescribing tool with decision support application.
- Attest to the willingness to meet the basic standards of a PCMH, such as member access and communications.
- Perform at an equal quality level with their peers in a core set of HEDIS clinical quality metric.
Blue Physician Recognition Program
The Blue Physician Recognition (BPR) program is designed to highlight certain physicians, groups, and/or practices that demonstrate a commitment to delivering quality, patient-centered care. Florida Blue designated those physicians participating in our PCMH and Comprehensive Primary Care Program programs with a BPR designation. Additional criteria may be considered in the future.
The Blue Cross and Blue Shield Association displays BPR indicators on the Blue National Doctor & Hospital Finder. Florida Blue also displays BPR indicators on its secure web portal.
Accountable Care Organizations
Accountable care organizations (ACOs) are designed to control quality and costs. Provider groups are jointly responsible for the costs and outcomes of care for a defined population of patients. ACOs can include various combinations of providers, but are primarily hospitals and physicians. They may focus on a specific disease component or be multi-specialty focused. Participants are responsible for achieving clinical quality outcomes and avoiding unnecessary and duplicative medical tests and treatments. Florida Blue ACO participants are held accountable for both the quality and total cost of care for our members. Primary care is the foundation of ACOs because of the strong focus on preventive and wellness care to keep patients healthy.
Resources to Assist with Practice Transformation
Florida Blue NCQA Training Presentations (Links)
- PCMH Starting the NCQA Recognition Process
- PCMH NCQA Review for a Multi-Site Practice
- PCMH NCQA Policies and Procedures
- PCMH NCQA Must-Pass Elements
- PCMH NCQA Documentation Review
American Academy of Family Physicians (Links)
American Academy of Pediatrics
American College of Physicians
- Quality and Efficiency Reporting
- The Commonwealth Fund
- National Center of Medical Home Institute
- Patient-Centered Primary Care Collaborative
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