Tiered Network Product
BCBSNC Tiered Network utilizes 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 Tier 1 practices, and all other practices were designated as Tier 2. Providers in 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.
- Obstetrics and Gynecology
- Cardiology - broken into 4 Subspecialties:
- Implant Catheterizations
- Catheterizations only
- All Services
- General Surgery
- Orthopedic - broken into 5 Subspecialties:
- Low Back Treatment
- Knee, Arm, and Shoulder
- Spine, Neck, and Back
- Hand and Wrist
- All Services
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:
|Beta blockers and (ACEI or ARBs) 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||Barbiturate, Hydantoin, miscellaneous (Valproic acid) anticonvulsants, and Diabenzazepine annual monitoring.||Proportion of patients 18 years or older with diagnosis of hyperlipidemia and CAD diagnosis and no diabetes, who were prescribed lipid-lowering therapy.|
|Beta-blocker treatment post-MI||Cervical cancer screening||Complications related to knee replacement surgery||Colonoscopy: Potentially avoidable complications||GERD: Potentially avoidable complications||Migraines: active rx for preventive medications, and narcotic analgesics.||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||Childbirth: Potentially avoidable complications||Complications related to hip replacement surgery||Colon Resection: Potentially avoidable complications||Attestation for use of registry (practice based- 75% bonus if participates)||Migraine and CAD: do not have active rx for triptans or ergot derivatives.||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-50% bonus ie NSQIP )||Eye exam (retinal) performed.|
|Lipid-lowering therapy for those with CAD||Chlamydia Screening||Low-density lipoprotein- Cholesterol (LDL-C Screening)|
|Lipid profile for those with CAD||Medical attention for nephropathy|
|Warfarin prescription for those with heart failure and atrial fibrillation|
|Angioplasty: Potentially avoidable complications|
The quest to improve quality while maintaining efficiency in healthcare is a focus that is central to everyone. BCBSNC's methodology for the Tiered Network program 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.
The specific methodology utilized to tier facilities and providers can be obtained from the links below. Methodology can also be emailed to you upon request.
Tiered Network Criteria for 2013
- The following document on Facility-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2013 and is provided for informational purposes only.
- The following document on Specialty-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2013 and is provided for informational purposes only.
Tiered Network Criteria for 2014
- The following document on Facility-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2014 and is provided for informational purposes only.
- The following document on Specialty-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2014 and is provided for informational purposes only.
- Effective 01/01/2014 Tiering will accept the National Committee Quality Assurance Patient- Centered Specialty Practice (NCQA PCSP) Recognition as a pass for the quality measurement for the six tiering specialties. Practices achieving this recognition have demonstrated commitment to access, communication, care coordination and continuous clinical quality improvement. For more information about the NCQA PCSP recognition process: www.ncqa.org.
Tiered Network Criteria for 2015
- The following document on Facility-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2015 and is provided for informational purposes only.
- The following document on Specialty-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2015 and is provided for informational purposes only.
Tiered Network Criteria for 2016
- The following document on Facility-based Tiering Methodology describes the method used by BCBSNC for the Tiered Network product for 2016 and is provided for informational purposes only.
We recognize that that there may be circumstances that warrant review of your current tier 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 tiering assessment. During the reconsideration process, the practice may submit additional information which can contribute to the accuracy of the measurement process as described online.
A copy of the reconsideration form based on specialty may be obtained from the following links depending on your specialty:
- General Surgery
- Obstetrics and Gynecology
Completed reconsideration documents should be sent to Quality Based Networks via one of the following methods:
- fax (919-287-5459)
- email TieredNetwork@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.
For any additional questions about provider practice specialties related to the Tiered Network, please contact Quality Based Networks at (919) 765-7040 or via email at TieredNetwork@bcbsnc.com.
For any additional questions related to the facilities Tiered Network, please contact Network Management via email at TieredRFP@bcbsnc.com
For more information, please check the website at http://www.bcbsnc.com/content/providers/quality-based-networks/tiered-network.htm