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Cost & Quality Designations

Overview:

BCBSNC Cost & Quality Designations utilize administrative claims data to identify high quality, low cost providers and to help consumers make more informed choices for their medical care. Transparent methodology provides physicians with access to information on how their performance compares to their peers on nationally accepted quality measures as well as local cost efficiency benchmarks. Comparison is based on geographical region and across like specialty groups. Practices were aligned and segmented by their area of specialty, and were first measured against a quality rating, and then subsequently against cost. Practices that exceed both the quality and cost thresholds set for analysis were designated as "Low Cost & High Quality" practices, practices that exceed the quality threshold but not the cost threshold were designated as "High Quality," and all other practices are not designated. Providers in the specialties outside of those listed as tiered are paid at the Tier 1 benefit. Physician designation ratings are a guide to choosing a physician, practice or medical group. Because ratings have a risk of error, they should not be the sole basis for selecting a doctor. Patients should confer with their physician before making a decision.

Specialties Included:

  • Gastroenterology
  • Obstetrics and Gynecology
  • Endocrinology
  • Cardiology - broken into 4 Subspecialties:
    • Noninterventionist
    • Implant Catheterizations
    • Catheterizations only
    • All Services
  • General Surgery
  • Neurology
  • Orthopedic - broken into 5 Subspecialties:
    • Low Back Treatment
    • Knee, Arm, and Shoulder
    • Spine, Neck, and Back
    • Hand and Wrist
    • All Services

Quality Measurement:

The data used to evaluate physician practices on quality are based on the following aspects of care:

  • Preventative Care- cancer screening and other screening interventions
  • Appropriate Care- appropriate use of medications, diagnostic tests and procedures, treatment and monitoring
  • Appropriate Care Outcomes- presence of potentially avoidable complications
  • Utilization of Registries (GI and General Surgery specialties)

The following table identifies measures evaluated for each specialty:

Quality Measures

Cardiology OB/GYN Orthopedics General Surgery Gastroenterology Neurology Endocrinology

Beta blockers prescribed after most recent MI

Mammography screening

Imaging studies more than 28 days after initial visit for low back pain

Cholecystectomy: Potentially avoidable complications

Colonoscopy: Potentially avoidable complications

Migraines: active rx for preventive medications, and narcotic analgesics.

Proportion of patients 18 years or older with diagnosis of hyperlipidemia and CAD diagnosis and no diabetes, who were prescribed lipid-lowering therapy.

ACEI or ARB therapy for those with heart failure and LVSD

Cervical cancer screening

Complications related to knee replacement surgery

Colonoscopy: Potentially avoidable complications

GERD: Potentially avoidable complications

Migraine and CAD: do not have active rx for triptans or ergot derivatives.

Proportion of patients 18 years or older with a diagnosis of hyperlipidemia and diagnosis of diabetes and No CAD, who were prescribed lipid lowering therapy.

Beta-blocker therapy for those with heart failure and LVSD

Childbirth: Potentially avoidable complications

Complications related to hip replacement surgery

Colon Resection: Potentially avoidable complications

Attestation for use of registry (practice based- 100% bonus if participates)

Frequent or severe migraine: active prescription for migraine preventive medications within the last 3 months of the measurement year.

Hemoglobin A1c testing

Measurement of LV function for those with heart failure

Hysterectomy: Potentially avoidable complications

Knee Arthroscopy: Potentially avoidable complications

Attestation for use of registry (facility based-100% bonus, e.g., NSQIP)

 

Annual monitoring of Barbiturate level

Eye exam (retinal) performed.

Lipid-lowering therapy for those with CAD

Chlamydia Screening

 

 

 

Annual monitoring of miscellaneous anticonvulsants (Valproic acid) level

Low-density lipoprotein- Cholesterol (LDL-C Screening)

Lipid profile for those with CAD

 

 

 

 

Annual monitoring of Hydantion level

Medical attention for nephropathy

Warfarin prescription for those with heart failure and atrial fibrillation

 

 

 

 

 

Annual monitoring of Diabenzazepine level

Angioplasty: Potentially avoidable complications

 

 

 

 

 

 

Methodology:

The quest to improve quality while maintaining efficiency in healthcare is a focus that is central to everyone. BCBSNC's methodology for the cost & quality designations has been selected and applied to provide optimal results to help assist practitioners with understanding how they compare to market standards in providing quality healthcare.

The methodology utilized is based first on specific quality measures, then on efficiency. Quality measures are adopted from those endorsed by the National Quality Forum (NQF), National Committee for Quality Assurance (NCQA), and the Ambulatory Quality Alliance (AQA). Efficiency information is based on claims data.

Cost & Quality Designation Criteria

The following document on Facility-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2015 and is provided for informational purposes only.

The following document on Specialty-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2015 and is provided for informational purposes only.

The following document on Facility-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2016 and is provided for informational purposes only.

The following document on Specialty-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2016 and is provided for informational purposes only.

Tiered Network Criteria for 2017

The following document on Facility-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2017 and is provided for informational purposes only.

The following document on Specialty-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2017 and is provided for informational purposes only.

Tiered Network Criteria for 2018

The following document on Facility-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2018 and is provided for informational purposes only.

The following document on Specialty-based Designation Methodology describes the method used by BCBSNC for the Cost & Quality Designations for 2018 and is provided for informational purposes only.

The following document on Rowdmap Overview describes the method used by BCBSNC for the Tiered Network product for 2018 and is provided for informational purposes only.

The following document on Rowdmap Methodology describes the method used by BCBSNC for the Tiered Network product for 2018 and is provided for informational purposes only.

Reconsideration

We recognize that that there may be circumstances that warrant review of your current designation. For that reason, we have implemented a reconsideration process.

The reconsideration process allows a practice to request a change to the quality or cost data used in their assessment. During the reconsideration process, the practice may submit additional information which can contribute to the accuracy of the measurement process as described online. Since the criteria used in our designation assessment is the same as that used for our tiered network, your reconsideration will impact both your designation and tier.

A copy of the reconsideration form based on specialty may be obtained from the following links depending on your specialty:

Completed reconsideration documents should be sent to Quality Based Networks via one of the following methods:

  • fax (919-287-5491)
  • email designation@bcbsnc.com or
  • mail: Quality Based Networks/Reconsiderations, BCBSNC, P.O. Box 2291, Durham NC 27702-2291

Once all data is received, reconsiderations will be processed in 45 days. We will notify you of your reconsideration results by letter or e-mail, utilizing the notification preference you selected on the reconsideration document. If there is a change to your public designation display, this will also be included in the notification.

Contact Information:

For any additional questions related to the designations, please contact Quality Based Networks at (919) 765-7040 or via email at designation@bcbsnc.com.