Tiered Network Product

Overview:

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 a cost rating if the practice met the quality criteria. 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. 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
  • Cardiology - broken into 5 Subspecialties:
    • Noninterventionist
    • Implant Catheterizations
    • Catheterizations only
    • Implant Only
    • General Cardiology
  • General Surgery- broken into 7 subspecialties:
    • Gastroenterology
    • Bariatric
    • Oncology
    • Plastic Surgery/Dermatology
    • Cardiovascular
    • General Surgery
    • Other
  • Neurology
  • Orthopedic - broken into 7 Subspecialties:
    • Orthopedic
    • General (medical practices)
    • Trauma
    • Knee and Shoulder
    • Spine
    • Hand
    • Low Procedure Rate

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
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.
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.
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 Migraine and CAD: do not have active rx for triptans or ergot derivatives.
Measurement of LV function for those with heart failure Hysterectomy: Potentially avoidable complications Knee Arthroscopy: Potentially avoidable complications Attestation for use of registry    
Lipid-lowering therapy for those with CAD Chlamydia Screening        
Lipid profile for those with CAD          
Warfarin prescription for those with heart failure and atrial fibrillation          
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 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 following link. Methodology can also be mailed 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.

Reconsideration

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:

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.

Contact Information:

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 Tiered.rfp@bcbsnc.com

For more information, please check the website at http://www.bcbsnc.com/content/providers/quality-based-networks/tiered-network.htm