A Healthy Bonus

Blue Cross Program Rewards Doctors for Quality Patient Care

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Cover Story – October 2011

Tex Med. 2011;107(10):16-21.

By Ken Ortolon
Senior Editor   

Texas physicians have an opportunity to improve the quality of care delivered to patients while at the same time increasing revenues for their practices. 

Blue Cross and Blue Shield of Texas (BCBSTX) helps physicians meet certain evidence-based standards for quality care – and pays annual bonuses – as part of two physician recognition programs launched in conjunction with Bridges to Excellence.  

The BCBSTX Bridges to Excellence recognition programs in diabetes and cardiac care pay qualifying physicians $100 per patient per year for giving their patients high-quality care. Some physicians in the program say they earned the bonuses simply by documenting the care they were already providing. 

Eduardo Sanchez, MD, vice president and chief medical officer for BCBSTX, says the program allows the carrier to reward good physicians, improve the care its beneficiaries receive, and lower costs for the company and for employers who pay for coverage. 

He says it also helps physicians deal with a health care delivery system that is evolving from fee-for-service to fee-for-value payments. 

"We feel that on a noble front this is offering doctors opportunities to be recognized for doing good work; two, to be rewarded for doing that good work; and, three, to begin organizing themselves in a way that will make them viable practitioners in this evolved medical care delivery system that we're moving into." 

Texas Medical Association officials see tremendous opportunities in the increased revenue and improved quality that the BCBSTX Bridges to Excellence programs present. 

Plano family physician Christopher Crow, MD, chair of TMA's Council on Socioeconomics, participates in the diabetes program. He sees no downside to participation, other than the staff time it takes to pull the data. 

"It's not ridiculous money, but they're paying you for work you're already doing or should be doing in terms of good quality care," Dr. Crow said. "And the data they're collecting is on things that you should be doing every time you see that patient." 

Dr. Crow says his practice looked at clinical quality for years through their electronic medical record (EMR) system before signing up for Bridges to Excellence. Participation in Bridges to Excellence didn't really improve their care because they had already made changes to ensure they were meeting nationally recognized standards. 

"If that had been the first time we looked at it, then most definitely it would have helped." 

Houston internist Lisa Ehrlich, MD, and her three partners completed the Bridges to Excellence recognition programs for both diabetes and cardiac care this spring and says the process was fairly easy. She had her billing staff pull the necessary data from their EMR system and upload it through the IPRO portal. (See "Taking the Right Path.") 

Dr. Ehrlich says it took her staff 12 to 16 hours to gather the data necessary to gain recognition and get approval for the incentive payments under the cardiac program, a little longer for the diabetes programs because more data were requested. They have already received payment for the cardiac patients but were still awaiting payment for the diabetes patients as of early August. 

She says it definitely was worth the time and effort to participate in the program. Between just herself and one of her partners, they had roughly 50 qualified patients, which means $5,000 per year in incentive payments, she says. 

"We'll submit data again in six months and probably have even more patients who qualify," she added. 

During the original pilot of the diabetes program, BCBSTX limited the number of patients for whom a physician could gain incentive payments to 150. The limit has since been lifted

Bridging the Quality Chasm

BCBSTX began its diabetes recognition program as a pilot in June 2009 and added cardiac care in 2010. Dr. Sanchez says the carrier decided to partner with Bridges to Excellence because of the potential for higher quality care and lower cost. 

"What Bridges to Excellence [BTE] brought to us was a very, very compelling story about how, when doctors were identified as being BTE adherent and, therefore, getting BTE recognition, they were delivering better quality care in terms of nationally recognized, agreed-upon metrics," he said. "These are national standards that clinicians use to practice medicine all across the country, whether it's rural Texas, urban Texas, or a state outside of Texas."  

The Bridges to Excellence standards for diabetes include measures of hemoglobin A1c, blood pressure, and low-density lipoprotein (LDL) cholesterol control. For example, physicians earn maximum points if 60 percent or more of their patients have a blood pressure of less than 140/90 or an LDL cholesterol level of less than 130 milligrams per deciliter. 

Additional process measures record whether patients are getting routine ophthalmology, nephropathy, and podiatry examinations. 

For cardiac care, the measures included blood pressure and LDL cholesterol control, as well as whether the physician did a complete lipid profile, used aspirin or another antithrombotic, and carried out smoking status evaluation and cessation advice and treatment. 

Bridges to Excellence was founded in 2002 to improve the quality of care.

"It was a program that really involved recognizing and rewarding providers who met evidence-based performance measures and quality standards," said Chad J. Brown, MPH, MBA, program implementation leader for the Health Care Incentives Improvement Institute (HCI3), a not-for-profit organization that runs Bridges to Excellence, along with another program called Prometheus Payment that focuses on paying physicians for episodes of care. 

A board of directors that includes physicians, employers, health plans, and others runs HCI3. Bridges to Excellence is the only program of its kind in the country.  

Bridges to Excellence offers physicians recognition (or certification) in 13 different programs, including diabetes, cardiac care, hypertension, and spine care. Mr. Brown says 28,924 physicians nationally have gained recognition in one or more of those programs, including 1,407 Texas physicians. 

So far, 360 Texas physicians participate in the BCBSTX diabetes program, earning $968,200 in bonuses, while 95 physicians earned bonuses totaling $21,600 through the cardiac care program. 

An analysis prepared by BCBSTX, however, indicates that nearly 17,000 Texas physicians treating diabetes patients within its network could earn up to $15.7 million in annual bonuses. And more than 11,000 physicians treating cardiac patients could earn as much as $7.2 million in annual bonuses. 

Dr. Sanchez says BCBSTX would like to see a substantial increase in the number of participating physicians. The company carried out major recruitment efforts in March and June to raise awareness of the program and get physicians to "take advantage of what we think is one of the few programs that truly rewards high quality in a relatively simple way," he said. 

In September, BCBSTX approved a $500 bonus for physicians currently recognized in diabetes care or who are recognized by the end of the year. This bonus, intended to encourage them to achieve recognition and follow evidence-based guidelines, will offset application fees and administrative costs.   

Doing the Two-Step 

The BCBSTX Bridges to Excellence programs are voluntary, and Dr. Sanchez says there will be no adverse actions against physicians who choose not to participate or who apply but fail to gain recognition. 

TMA officials say earning the bonuses is a two-step process. First, physicians apply for recognition to Bridges to Excellence. That makes these programs unlike the physician-ranking systems that many of the health plans, including BCBSTX, use to purportedly rate physicians' quality of care based on claims data. Bridges to Excellence is a third-party administrator that independently rates physicians' performance on the evidence-based standards and provides recognition. 

Once recognized by Bridges to Excellence, the physician is automatically included in the program. Then BCBSTX pulls data on all of its beneficiaries with diabetes or cardiac disease who have seen that physician in the past 15 months. Those patients are "attributed" to that physician if he or she provided most of the diabetes or cardiac care during that time period. 

The physician then must collect biometric information on each patient and submit it to BCBSTX for approval. The health plan then makes the incentive payments.

Jill Brooks, RN, medical program specialist with BCBSTX, says the information submitted to get the bonus is essentially the same as what physicians turn in to Bridges to Excellence to gain recognition. The difference is that Bridges to Excellence actually scores quality of care, whereas BCBSTX rewards physicians for providing the correct care in a timely manner.

To be eligible for Bridges to Excellence recognition, a physician must submit data on the clinical measures outlined above on at least 25 patients. Group practices that apply for recognition must have an overall average of 25 patients per physician in the practice, but no individual physician may have fewer than 10. The patients do not have to be BCBSTX beneficiaries for the physician to gain recognition. BTE recognition is separate from the BCBSTX incentive program. You don't have to submit data on BCBSTX patients to get BTE recognition. But once physicians are recognized, data they submit to BCBSTX to get the bonus payment must come from patients who have been attributed to them by BCBSTX.

Finding a Pathway

Physicians may submit their data to Bridges to Excellence through one of four pathways (for more information on these pathways, see "Taking the Right Path" below):   

  1. Directly from their EMR or registry system;  
  2. Uploading data online to the Bridges to Excellence IPRO Direct Submission Portal;  
  3. Completing the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program or Heart/Stroke Recognition Program; or  
  4. Completing the American Board of Internal Medicine maintenance of certification modules in diabetes or cardiac care.  

Ms. Brooks says the IPRO portal is the fastest and easiest way to submit data for recognition. IPRO is a performance assessment organization, based in Long Island, N.Y., formerly known as Island Peer Review Organization. 

To use the IPRO portal, physicians must register and upload biometric data on 25 patients. Forty-eight hours later, IPRO sends them a score, and Bridges to Excellence notifies them whether they have been recognized, Ms. Brooks says. 

The IPRO portal also is one of the least expensive ways to gain recognition. The IPRO fee is $95 per physician, or $295 for groups of three or more physicians. That compares with more than $400 for NCQA recognition. 

Cutting Costs

Dr. Sanchez says BCBSTX is pleased with the early results of its Bridges to Excellence recognition programs. An early return-on-investment analysis found that the programs produced savings of about $37 per member per month. 

"We've done a second ROI, and the numbers are closer to $100 per member per month reduced cost but better quality care with BTE-recognized physicians delivering the care versus non-BTE-recognized physicians doing the care," he added. 

BCBSTX completed an assessment of 12 months of data comparing care delivered by Bridges to Excellence-recognized physicians and nonrecognized physicians. Their findings show that patients cared for by Bridges to Excellence-recognized physicians are receiving care in their physician's office, are getting appropriate testing, and have fewer inpatient admissions and emergency department visits.

BCBSTX may add other Bridges to Excellence programs, Ms. Brooks says, possibly for depression or low back pain. 

Mr. Brown of HCI3 says Bridges to Excellence works with major health plans across the country on similar recognition programs. "From our perspective it's improved quality overall," he said. "It's recognizing physicians for providing better care, but it also is suggesting that they continue to provide that better care through the offering of incentives." 

He says the BCBSTX study shows that patients seeing Bridges to Excellence-recognized physicians means lower costs for the health plan but better care for patients. For example, the fewer inpatient admissions and lower emergency department utilization of patients of Bridges to Excellence-recognized physicians reduced costs for the carrier.

BCBSTX is the only insurer offering rewards for Bridges to Excellence recognition at this time. Dr. Sanchez says he would welcome other plans here to get involved in the program.

Mr. Brown says Aetna had a similar program in Texas that was limited to the Austin area, but an Aetna spokesperson said the company does not offer the Bridges to Excellence recognition program here. And Dr. Sanchez says employers also should see lower health insurance costs as a result of the program. 

"If we are seeing a $1,200 per year lower cost, a case can be made that employers will see a lower cost if more of their employees went to BTE-recognized physicians rather than non-BTE recognized physicians," he said. "For us, it has been a win-win on multiple fronts." 

TMA is working with both BCBSTX and Bridges to Excellence to raise awareness of the program among TMA members. Among the ideas considered are seminars or webinars to explain the program and checklists on how to gain recognition and share program expectations. 

Dr. Ehrlich says program participation has not necessarily improved the quality of care she and her partners are providing. They scored pretty high on their Bridges to Excellence evaluations, she says. 

"My partners and I were all doing the things that were required for care of our diabetics," she said. "But one of the four of us didn't do as good a job at documentation. So this has provided an impetus to make sure those things are in the chart." 

But she says the incentive payments certainly could be a big incentive for doctors who scored low to improve their care. "This is definitely an incentive And, Dr. Crow says physicians who fail to gain recognition need to take a hard look at what they're doing. "If you don't meet the criteria, then you need to change." 

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email


Taking the Right Path

 Once you've decided you want to participate in Bridges to Excellence, you may follow one of four pathways to achieve recognition. 

Officials from both Blue Cross and Blue Shield of Texas and TMA say the fastest and easiest way is through the IPRO Direct Submission Portal. It costs $95 per physician or $295 per practice for three or more physicians. 

Using the IPRO portal, physicians or their staff would extract data from 25 patients with either diabetes or cardiac disease from patient charts or electronic medical record (EMR) systems, place the data into a standard file format, and upload it via the web portal for assessment. 

Physicians also can submit data directly from their EMR or registry systems. Their EMR or registry vendor would extract patient data and submit it to MN Community Measurement or IPRO on the physician's behalf. 

There is no charge for this service. Currently, only four EMR vendors participate in the Bridges to Excellence program: GE Healthcare, NextGen, AthenaHealth, and CINA. If your vendor is not on the list, you must select the IPRO portal for electronic submission. 

For more information on this pathway, click here.  

Two other pathways to Bridges to Excellence recognition are the National Committee for Quality Assurance (NCQA) and the American Board of Internal Medicine (ABIM). 

 Physicians who gain NCQA recognition in diabetes or cardiac disease are automatically eligible for Bridges to Excellence recognition, but BCBSTX officials say that process is more arduous than using the IPRO portal or EMR submission. 

It also is more expensive. NCQA charges $80 for program materials, plus a $500 data collection fee. BCBSTX physicians, however, can get a 20-percent discount, reducing the data collection fee to $400. The upside of the NCQA path is it gains you Bridges to Excellence recognition for three years, whereas the other pathways are good for only two years of recognition.  

Physicians also can attain Bridges to Excellence recognition in diabetes care by completing the ABIM maintenance-of-certification module in diabetes. For more information on ABIM's maintenance-of-certification offerings, visit the ABIM website.

In addition to fees charged by ABIM for its maintenance-of-certification products, there is an additional $95 charge for IPRO assessment of the ABIM data.  

More information on the Bridges to Excellence pathways is available on the TMA website

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How to Appeal Your Health Plan Ranking

Health insurance plans continue to use rankings of physicians to lower the cost of care. TMA believes physicians should be aware of their health plan rankings and use TMA-backed legislation passed in 2009 to appeal them, if necessary.

Genevieve Davis, director of TMA's Payment Advocacy Department, says physicians should review their ratings, request the patient-specific data used to develop those ratings, review the data, and appeal to the Texas Department of Insurance (TDI) if they disagree with the rating.

Among ranking programs health plans currently use in Texas are the UnitedHealthcare Premium Designation program, Aetna Aexcel, CIGNA's Care Designation program, and Blue Cross and Blue Shield of Texas' Blue Compare program.

TMA staff developed a two-page guideto help you appeal a health plan ranking or tiering. The guide is based on House Bill 1888, passed by the Texas Legislature in 2009, which authorized the TDI appeals process.

If you have any other issues with reimbursement from insurers, email TMA's reimbursement specialists.    

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