BCBSM PGIP Specialty Fee Uplifts in 2015 > Michigan State Medical Society


BCBSM PGIP Specialty Fee Uplifts in 2015

Blue Cross Blue Shield of Michigan's (BCBSM) Physician Group Incentive Program (PGIP) continues to grow and to evolve. PGIP initially focused predominantly on building primary care infrastructure; however, over the past few years, there has been increased emphasis on bringing specialists into the PGIP mix. The Michigan State Medical Society (MSMS) has dedicated a tremendous amount of time and effort successfully advocating that BCBSM expand the number of specialty physicians eligible to receive increased professional fees (a.k.a, fee uplifts) and include specialty societies in the identification of appropriate quality metrics used for selection by BCBSM.

In 2014, the number of eligible specialties eligible for fee uplifts increased from 7 to 24. BCBSM reports that in 2015 all specialties except for anesthesiology* will be eligible for fee uplifts in PGIP. The inclusion of specialists in BCBSM PGIP specialty fee uplifts is intended to help promote the evolution of the Patient-Centered Medical Home (PCMH) to the PCMH "neighborhood" (PCMH-N) in which specialists are actively engaged in transformation efforts including enhanced interaction and coordination with their respective PCMH partners.

To be considered for a fee uplift, a specialty practice must be nominated by their Physician Organization (PO) or by a PO in which the majority of their patients are attributed. Nomination does not guarantee that a practice will receive an uplift. Determinations are made annually based on one or more metrics of quality, utilization, efficiency, and cost performance. Most measures look at population-level performance versus practice-level performance. Fee uplifts are effective beginning in February of each year and are applied to PPO traditional commercial claims.

In this current year, approximately two-thirds of the nominated practices in eligible specialties received an uplift (10% for the top third and 5% for the second third). This designation will change in 2015, with only the top half of ranked, fully nominated practices receiving either a 10 percent fee uplift (top quartile) or a 5 percent uplift (second quartile). The decision adjust the threshold is largely budget driven. While more total dollars will be dedicated for uplift financing, they will be distributed amongst a larger pool of specialists. Instead of "watering down" the amount of the increase, BCBSM chose to keep the tiered uplift amounts the same and increase the selection threshold. BCBSM predicts that the number of specialists receiving uplifts will increase from more than 5,000 in 2014 to more than 6,000 in 2015.

It is important that specialty practices communicate with their affiliated POs to determination the status of their nominations.

If you have additional questions regarding PGIP, please contact your BCBSM Provider Consultant or Stacey Hettiger, MSMS Director of Medical and Regulatory Policy, at (517) 336-5766 or shettiger@msms.org.

*BCBSM has indicated that anesthesiologists will not be included at this time due to the manner in which they are reimbursed.

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