New for 2017! Please Review the new Adult Criteria, Pediatric Criteria, Multi-Specialty Criteria and OB/GYN Criteria

Blue Quality Physician Program

Incentivizing independent primary care practices to improve quality and lower the cost of care.

An Overview of the Blue Quality Physician Program (BQPP)


The BQPP focuses on Primary Care Management and rewards independent practices committed to providing high-quality outcomes, and low-cost, patient-centered care for BCBSNC members.

What type of Independent primary care practice should apply for the BQPP program?

A primary care practice accountable for meeting each patient's physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.

How are members attributed to a practice?

Attribution to BCBSNC Members is based on the following criteria and is used for cost and quality:

Members are attributed to the primary care practice they have visited the most (based on Evaluate & Manage claims). If there is a tie, then attribution is based on most recent visit. If there is no primary care utilization during the study period, then the attribution is to OB/GYN practice. Members without any (primary care or OB/GYN) utilization during the study period are not included, as there are no relevant claims on which to attribute those members to a provider.

We offer qualifying independent primary care practices (not affiliated with large health care systems and academic health centers) an opportunity to participate in the BQPP program to improve quality of care for BCBSNC members.

What primary care practices can apply?

Program Benefits

Independent primary care practices that meet BQPP criteria are eligible to receive a double-digit fee increase on their Evaluation and Management (E&M) and Preventive E&M codes. Please see Specialty Criteria, links below for details on scoring.

Practices that enter the BQPP will receive:

  • Quarterly Practice Cost Efficiency reports showing performance relative to peer practices with respect to ER utilization, advanced imaging and specialist's visits
  • Access to online Best Practice Sharing Forums, a collaborative environment for BQPP participants to learn from each other and to share lessons learned in their journey to health care transformation

Important Application Information & Dates

New & Renewing BQPP Practices:

Practices can apply twice a year: March 1 - April 30 or August 1 - September 30

Eligibility & Requirements


Criteria to be eligible to apply to the BQPP:

  • Electronic Health Record (EHR) is required by each practice in order to be eligible to apply to BQPP.
  • Practices must have at least 30 BCBSNC members
  • Contracted on the Standard Fee Schedule (if you're not sure, contact the BQPP program manager at: bqpp@bcbsnc.com)
  • All providers and mid-level practitioners must be credentialed through BCBSNC
  • Electronic Funds Transfer (EFT) is a requirement of the BQPP program

Learn more about applying for credentialing or email your questions about credentialing, provider numbers, contracts and sample fee schedules to network management at: NMSpecialist@bcbsnc.com.

Mandatory Elements of the BQPP program

  • Recognitions through NCQA, JCAHO, URAC or ACOG accrediting bodies
  • The Provider Quality Report must be accessed and viewed monthly from Blue e to close care gaps and raise HEDIS percentiles (see criteria below)
  • Complete the BQPP practice quality scorecard (see criteria below)
  • ACA Risk Adjustment Webinars
  • Patient portal

Mandatory - Practices must have earned one of these types of recognition (All locations must be recognized):

  • NCQA PCMH
  • NCQA PCSP (OB/GYN only)
  • URAC PCMH
  • JCAHO PCMH
  • ACOG SCOPE (OB/GYN only)

Program Recognitions

All recognitions are valued at 225 points (we no longer have different points for levels)

Patient Centered Medical Home

Primary Care and OB/GYN practices can apply for URAC PCMH.

URAC's PCMH (Primary Care Medical Home) certification is made up of standards that align with the "Joint Principles of the Patient Centered Medical Home" issued jointly by the four leading national primary care medical societies. URAC's Achievement program delivers on the promises of health care reform by:

  • Increasing access to services
  • Supporting care coordination across the continuum
  • Improving patient accountability through information and active decision-making
  • Driving efficiency and effectiveness

URAC's PCMH program uses a unique approach with an unprecedented level of flexibility and customizable elements in a stepwise approach not available in other medical home programs. On-site review allows for an interactive and consultative approach to the review process. The program provides both strong educational support and cost advantages.

Visit URAC online, or email or call Sheila Brunson at 202-326-3964 for more information. There is a discount for BQPP practices applying for URAC PCMH.

Primary Care and OB/GYN practices may apply for The Joint Commission PCMH Certification.

Primary Care Medical Home (PCMH) Certification for Joint Commission Accredited ambulatory care organizations focuses on care coordination, access to care, and how effectively a primary care provider and interdisciplinary team work in partnership with the patient (and where applicable, their family).

The PCMH certification option is consistent with the new federal health care reform efforts to improve health outcomes and the continuity, quality and efficiency of health care services.

To find out more about JCAHO PCMH Certification please visit www.jointcommission.org .

NCQA PCMH is appropriate for the following primary care medical practices:

  • Family Practice
  • Internal Medicine
  • General Practice
  • Pediatrics

Mid-level practitioners may achieve PCMH recognition.

PCMH recognizes clinician practices functioning as medical homes by using systematic, patient-centered and coordinated care management processes.

The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be." Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.

There are three levels of NCQA PCMH recognition:

  • Basic
  • Intermediate
  • Advanced

If your practice has multiple sites, all sites must be PCMH recognized.

NCQA offers a 20% discount to practices that are sponsored when they apply to receive their NCQA Recognitions. BCBSNC is considered your sponsor. Please enter the NCQA code "CNCBCA" on your NCQA application to receive the discount. Visit www.ncqa.org for more information.

Visit www.communitycarenc.org for NCQA PCMH cheat sheets and tools to assist you through the process.

OB/GYN Practices

All locations must be PCSP recognized.

NCQA PCSP recognizes specialty practices that have successfully coordinated care with their primary care colleagues and each other, and meet the goals of providing timely access to care and continuous quality improvement.

Practices that become recognized will demonstrate patient-centered care and clinical quality through: streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management, and continuous clinical quality improvement.

There are three levels of NCQA PCSP recognition:

  • Basic
  • Intermediate
  • Advanced

To participate in the BQPP, your practice must be recognized in PCSP. If your practice has multiple sites, all sites must be PCSP recognized.

NCQA offers a 20% discount to practices that are sponsored by BCBSNC when they apply to receive their NCQA Recognitions. Please enter the NCQA code "CNCBCA" on your NCQA application to receive the discount. Visit www.ncqa.org for more information.

SCOPE helps OB/GYN assess the implementation and use of patient safety concepts and techniques and distinguishes those offices with strong patient-safety practices. Education and assistance is provided when office processes requiring improvement are identified.

SCOPE focuses solely on processes associated with enhancing the safety environment and reducing risk for patients in the office setting. SCOPE does not evaluate the quality of clinical care provided by an OB/GYN office. Visit Scope for Women's Health online to learn more.

Adult Criteria

Please review Adult Points Allocation Summary (2017) (pdf) to see an overview of the elements and points allocation for the BQPP program.

Additional Mandatory Requirement: Improving Health Outcomes

These quality measures align with MACRA and CMS. Practices are scored on how they perform on Quality Measures based on these national benchmarks. Practices at 50th percentile or below need to complete Plan Do Study Act (PDSA).

  • 90th | 40 points
  • 75th | 30 points
  • 50th | 20 points and complete Plan Do Study Act (PDSA) (pdf)
  • 25th | 0 points and action plan

Please use the Provider Quality Pocket Guide to define your quality measures (pdf). Please use the National Quality Forum link to find the NQF number for measures if necessary.

Family Medicine, Internal Medicine and General Practice

Diabetes:

  1. A1C Poor Control
  2. A1C testing
  3. Nephropathy testing

Cancer Screening:

  1. Breast cancer
  2. Colorectal
  3. Cervical

Other:

  1. Controlling high blood pressure
  2. Avoidance of antibiotic treatment in adults with acute bronchitis

Pediatric Criteria and Eligibility

Please review Pediatric Points Allocation Summary (2017) (pdf) to see an overview of the elements and points allocation for the BQPP program.

Additional Mandatory Requirement: Improving Health Outcomes

These quality measures align with MACRA and CMS. Practices are scored on how they perform on Quality Measures based on these national benchmarks. Practices at 50th percentile or below need to complete Plan Do Study Act (PDSA).

Defining Quality Measures

Improving Quality

Practices are scored on how they perform on Quality Measures based on these percentiles:

  • 90th | 50 points
  • 75th | 40 points
  • 50th | 20 points and complete Plan Do Study Act (PDSA) (pdf)
  • 25th | 0 points and action plan

Pediatrics

  1. Appropriate Testing for Children with Pharyngitis
  2. ADHD-1 ADHD Follow Up: INITIATION PHASE
  3. ADHD-2 ADHD Follow Up: CONTINUATION AND MAINTENANCE PHASE
  4. Appropriate treatment for children with Upper Respiratory Infection
  5. Childhood Immunizations CIS Comb 10
  6. WCC1_ BMI percentile

Please use the Provider Quality Pocket Guide to define your quality measures (pdf). Please use the National Quality Forum link to find the NQF number for measures if necessary.

Multi-Specialty Family Practice/Pediatric Criteria and Eligibility

Please review FM Multi-Specialty Peds Points Summary (2017) (pdf) to see an overview of the elements and points allocation for the BQPP program.

Additional Mandatory Requirement: Improving Health Outcomes

These quality measures align with MACRA and CMS. Practices are scored on how they perform on Quality Measures based on these national benchmarks. Practices at 50th percentile or below need to complete Plan Do Study Act (PDSA).

Defining Quality Measures

Improving Quality

Practices are scored on how they perform on Quality Measures based on these percentiles:

  • 90th | 40 points
  • 75th | 30 points
  • 50th | 20 points and complete Plan Do Study Act (PDSA) (pdf)
  • 25th | 0 points and action plan

Family Medicine, Internal Medicine and General Practice

Diabetes:

  1. A1C Poor Control
  2. Nephropathy testing

Cancer Screening:

  1. Breast cancer
  2. Colorectal
  3. Cervical

Pediatrics

  1. ADHD-1 ADHD Follow Up: INITIATION PHASE
  2. ADHD-2 ADHD Follow Up: CONTINUATION AND MAINTENANCE PHASE
  3. Childhood CIS comb 10

Please use the Provider Quality Pocket Guide to define your quality measures (pdf). Please use the National Quality Forum link to find the NQF number for measures if necessary.

OB/GYN Criteria and Eligibility

Please review OB/GYN Points Allocation Summary (2017) (pdf) to see an overview of the elements and points allocation for the BQPP program.

Additional Mandatory Requirement: Improving Health Outcomes

These quality measures align with MACRA and CMS. Practices are scored on how they perform on Quality Measures based on these national benchmarks. Practices at 50th percentile or below need to complete Plan Do Study Act (PDSA).

Improving Quality: Practices are scored on how they perform on Quality Measures based on these percentiles:

  • 90th percentile: 45 points
  • 75th percentile: 35 points
  • 50th percentile: 25 points and Plan Do Study Act (PDSA) (pdf)
  • 25th percentile: 0 points and action plan

Defining Quality Measures

OB/GYN

Cancer Screening:

  1. Breast cancer
  2. Colorectal
  3. Cervical

Other:

  1. Chlamydia screening
  2. Controlling high blood pressure
  3. Prenatal-PPC1
  4. Postpartum-PPC2

GYN:

Cancer Screening:

  1. Breast cancer
  2. Colorectal
  3. Cervical

Other:

  1. Chlamydia screening
  2. Controlling high blood pressure

Please use the Provider Quality Pocket Guide to define your quality measures (pdf). Please use the National Quality Forum link to find the NQF number for measures if necessary.

Additional Mandatory Requirements for All Providers

Provider Quality Report

The PQR report must be pulled monthly from Blue e. We encourage practices to utilize these reports to close care gaps.

These practice-based reports use claims data to give our doctors and provider groups' member-specific care gap information and an analysis of their performance against nationally recognized measures.

  1. 12-Month Rolling View. Allows practices to see where they are currently and how they've performed over the most recent 12 months. For example, if the report was run in March 2017, it would contain data from March 2016 through February 2017.

  2. Prospective View. Shows care gaps based on current HEDIS measures for the calendar year, gaps currently open and how the practice is trending on closing that year's care gaps.

All primary care practices that were continuously contracted with BCBSNC during the measurement period will receive these reports, including Internal Medicine, Family Practice, Pediatrics, OB/GYN practices, and any multi-specialty practices that include any of the above specialties.

We encourage practices to use these Provider Quality Reports to close care gaps. For questions concerning PQRs, contact Quality Management by email or call (919) 765-4809.

Measuring and monitoring quality data is an important part of population health management. BCBSNC will provide practices with an Excel spreadsheet to fill out with numerators and denominators for the following measures, by practice type.

Please pull one year look back or as close as your EMR allows. This is for all populations. To complete your submission, fill in the spreadsheet(s) and email to bqpp@bcbsnc.com after submitting your application.

BCBSNC has partnered with Pulse8 to provide educational resources related to risk adjustment factor coding, also known as HCC coding.

All providers are required to watch at least two recorded or live webinars prior to applying for BQPP. To verify, practices will attest on the BQPP application.

Review the 2017 calendar of available webinars in pdf or recorded.

Live Webinars:

  • Step 1: Email Provider Engagement the date and time you would like to attend. Please write "Registration" in the subject line.
  • Step 2: Once Pulse8 receives your request, you'll receive a WebEx invitation with login information for the session you requested.
  • Step 3: When it's time to join the webinar, you won't need to create a WebEx account. Simply sign in as a guest with your name and email address.

Recorded Webinars:

  • Step 1: Access the ACA Risk Adjustment Transaction through the Blue e portal under the Health Management tab at the top.
  • Step 2: Use the education section to guide you to the webinars. Simply click the orange arrow to the left to access the webinars.
  • Step 3: Click the title to the right of the video icon to access the webinar under Archived Webinars.

Earning Additional Points

  • Patient portal (mandatory requirement) - a secure website that gives patients convenient, 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can see health information such as recent doctor visits.

  • Online appointment requests - patients can request an appointment through the secured portal to create ease of scheduling

    • Patients should be able to understand their ability to schedule appointments through the online portal on the practice website
    • If new patients are not allowed to schedule through the online portal, directions on practice website for scheduling appointments should be given
  • Online patient satisfaction survey - read, "Measuring Patient Satisfaction: How to Do It and Why to Bother" from the American Academy of Family Physicians (AAFP.org)
    • Patient surveys can be distributed to patients through online systems such as Survey Monkey, Text, Email, Patient Portal etc.
    • Patient surveys CANNOT be distributed through any type of paper document even if it is scanned into the EMR for BQPP points.

    Classes below are offered at the practice location and on practice website:

  • Centering Group Visits (OBGYN only)
  • Prenatal education classes (OBGYN only)
  • Healthy Weight Management/ Nutrition classes
  • Parenting Classes

  • The following element enhances the patient experience and are optional points:

  • Group Visits: are medical visits in which multiple patients are seen simultaneously by the physician in a supportive group setting. Group visits are meant to complement, not to completely replace, the traditional individual visit. A group visit brings together a group of patients with similar medical needs or conditions for medical care in an extended appointment with a health care provider. In a group visit, patients have the added benefit of learning from one another and building self-management skills. As health care moves toward more integrated models for care delivery, the group visit model can provide a validated means for practices to improve efficiency, access, patient satisfaction, provider satisfaction and possibly health outcomes.

    For BQPP- group visits consist of at least four existing patients from multiple families.

    BCBSNC Group Visit /Shared Medical Appointment Medical Policy
    http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/group_visit_shared_medical_appointment_guidelines.pdf

  • Another Example of Group Visits:
    http://www.diabetesmasterclinician.org/uploads/1/0/2/7/10277276/aim_high_training_manual_for_group_visits.pdf

Practice website and/or co-management agreement with behavioral health provider:

Advanced care team members must be engaged with BCBSNC members to receive points.

25 points

If the practice does not employ one of the provider types listed below, 25 points will be allocated. If the practice partners with a behavioral health provider through a co-management agreement to provide mental health/substance abuse treatment and care coordination for the patients of the practice, practices will attest to having a behavioral health provider co-management agreement on the BQPP application.

50-75 points

The BQPP values practices that utilize an advanced care team model. The program will assign points if your practice employs one (50 points) or more (75 points) of the following types of providers on a part-time or full-time basis:

  • Health Coach (RN, LPN, or MA)
  • PharmD or Pharm Tech
  • Social Worker (LCSW or LPC)
  • Psychologist/Psychiatrist
  • Nutritionist/Dietician
  • RN-Triage
  • Case Manager/Care Coordinator (MA, RN, LPN or CNA)

After hours and all below have to be listed on Practice website in order to receive points.

  • After hours/weekdays (50 points)- after 5 pm or before 8 am on weekdays (total of 7 after hours weekdays)
  • Weekdays and Weekend hours (both = 150 points) Total of 7 afterhours each
  • Or 4 hours on weekends – 50 points
  • and/or Co-management agreement with urgent care facility (must be 3 providers or less)- 50 points

  • Other options to improve Access in your practice: 50 points max

  • Telehealth (50 points) - may provide increased access to health care for patients and reduce the cost of patient care Learn More (pdf)

  • - OR -

  • Direct provider access afterhours (50 points) – offer a direct phone number to provider-on-call for urgent issues.
    • patient access after business hours for contacting the primary care provider directly
    • Separate business phone number for the on call provider to use after hours
    • Primary Care provider communication in real time
    • Doesn't include nurse triage line (this is very important for your patients and every practice should have a nurse triage line).

The Practice Cost Report (Internal BCBSNC Data) is an evaluation of the cost efficiency and utilization metrics of a practice in comparison to peer-group practices by specialty and region in North Carolina.

Regions:

  • Asheville
  • Charlotte
  • Triad
  • Triangle
  • Eastern
  • Wilmington

The member total cost calculation includes:

  • Primary Care Office Visits
  • Emergency Room Visits
  • Inappropriate ER Visits
  • Specialist Visits
  • Urgent Care Visits
  • Inpatient Hospital Admissions
  • Imaging (MRI and CAT Scans)

Practice cost report cost index goal: .93 or below

BCBSNC generates the practice cost report at the time a practice applies to the BQPP program to determine the number of points the practice will be awarded.

The report is shared with the practice after the application is scored. If a practice's cost index is higher than 1.17 it will be placed on a cost improvement plan for one year.

The cost index is the practice data divided by the peer practice data. Points are awarded based on the practice's cost index as follows:

Cost Index             Points
.93 or below 400
.94-1.01 325
1.02-1.09 275
1.10-1.17 125
1.18-1.30 75

Education


BQPP Practice Collaborative:

The BQPP program team will facilitate quarterly online "Best Practice Sharing Forums." The forums will provide an opportunity for BQPP practices to share the lessons they’ve learned and the tools they have used in their journey to healthcare transformation. The goal is to create a collaborative environment for the BQPP practices to learn from one another.


Primary Care Research and Trends:

Throughout the year, BQPP practices will receive articles and research focused on key trends, changes and challenges that primary care providers and their practices currently face, along with resources on how to overcome barriers. We'll also offer select educational webinars from state and national health care organizations.


Continuing Medical Education Courses:

The following courses are optional for practice staff and providers to view (these are not included in the BQPP criteria or points).


Resources

The information (numbers) in the excel practice scorecard below needs to come from the Practice's EHR.


Application and Renewal


Before You Begin the Application

Every practice must have at least 30 BCBSNC members. To complete your application, you'll need the following:

  • The practice group NPI number
  • NPI numbers for all providers and mid-level practitioners
  • Address and phone numbers for all practice locations
  • Knowledge of any practice co-management agreements that are in place

Applications are currently not being accepted. See the Important Dates section information on when they will be accepted.