Year: 2012
Resolution Number: 65
Action Taken: Referred to the Board
Status:
Author(s): E. J. Raj, MD
Sponsor: Cathy Blight, MD
On behalf of: Genesee County Delegation
Committee: A (Medical Care Delivery)
Resolved Section(s):
Resolutions 56-12 and 65-12 were considered together. The Committee drafted the following substitute resolution:Title: BCBSM PGIP Transparency and ParticipationWhereas, Blue Cross Blue Shield of Michigan’s (BCBSM) Physician Group Incentive Program (PGIP) was created in 2004, and Whereas, as of December 2011, PGIP includes 40 Physician Organizations (POs) from across the state of Michigan, representing nearly 15,000 primary care and specialty physicians who are members of the BCBSM Trust PPO and/or Traditional networks, and Whereas, there is consternation on the part of specialists, over withholds and quality payments relating to BCBSM quality programs, and Whereas, clarification of funding, eligibility, and program criteria would lead to better outcomes for patients, primary care physicians, specialist physicians, and BCBSM; therefore be itRESOLVED: That MSMS work with Blue Cross Blue Shield of Michigan (BCBSM) to evolve the PGIP program to increase transparency, understanding, and eligibility for participation across specialties. Issues to be addressed include:1. Source of funding – is it added money withhold?2. Transparency of the evaluation and funding distribution model.3. Accelerating eligibility for all specialties.4. The current model of requiring physician organization (PO) memberships and endorsement for full PGIP participation.5. Working with MSMS to document the outcomes of the PGIP program: effects on clinical quality, safety, efficiency, appropriateness, and service.RATIONALE: The Committee heard a healthy debate on the pros and cons of the PGIP model, past and present. Many issues surfaced including the following:Source of funding – Claims payment vouchers currently show a physician organization component amount of 4.2 percent for PGIP incentives (4.7 percent as of July 1, 2012.) Some consider this a withhold, while others consider it dedicated funds for practice transformation that BCBSM processes through the individual claims process to create a pool for POs over and above the fee schedule reimbursement.Value of PGIP – Many physicians and POs believe the PGIP program has funded valuable practice transformation benefitting physicians and their patients. However, some testifiers questioned the lack of outcomes data over the past seven years. There was discussion that better data may help. BCBSM did provide a background document on PGIP that was made available to Committee members and those attending the Reference Committee meeting.Transparency – While many PGIP results are disclosed to POs and their physicians, other features of the model are not, including formulas for distribution of rewards, total funds accrued and their distributions. MSMS’ Principles for Pay-for-Performance Programs calls for complete transparency in such models. Eligible specialties – While primary care and selected other specialties have been included, most specialties are not eligible for full PGIP participation. BCBSM plans to add five more specialties in 2013.PO participation – Currently, participation in PGIP requires membership and cooperation with a PO, as the driver of practice transformation. Some physicians have concerns regarding this requirement. POs vary in structure, governance, and transparency.
Resolutions 56-12 and 65-12 were considered together. The Committee drafted the following substitute resolution:Title: BCBSM PGIP Transparency and ParticipationWhereas, Blue Cross Blue Shield of Michigan’s (BCBSM) Physician Group Incentive Program (PGIP) was created in 2004, and Whereas, as of December 2011, PGIP includes 40 Physician Organizations (POs) from across the state of Michigan, representing nearly 15,000 primary care and specialty physicians who are members of the BCBSM Trust PPO and/or Traditional networks, and Whereas, there is consternation on the part of specialists, over withholds and quality payments relating to BCBSM quality programs, and Whereas, clarification of funding, eligibility, and program criteria would lead to better outcomes for patients, primary care physicians, specialist physicians, and BCBSM; therefore be itRESOLVED: That MSMS work with Blue Cross Blue Shield of Michigan (BCBSM) to evolve the PGIP program to increase transparency, understanding, and eligibility for participation across specialties. Issues to be addressed include:1. Source of funding – is it added money withhold?2. Transparency of the evaluation and funding distribution model.3. Accelerating eligibility for all specialties.4. The current model of requiring physician organization (PO) memberships and endorsement for full PGIP participation.5. Working with MSMS to document the outcomes of the PGIP program: effects on clinical quality, safety, efficiency, appropriateness, and service.RATIONALE: The Committee heard a healthy debate on the pros and cons of the PGIP model, past and present. Many issues surfaced including the following:Source of funding – Claims payment vouchers currently show a physician organization component amount of 4.2 percent for PGIP incentives (4.7 percent as of July 1, 2012.) Some consider this a withhold, while others consider it dedicated funds for practice transformation that BCBSM processes through the individual claims process to create a pool for POs over and above the fee schedule reimbursement.Value of PGIP – Many physicians and POs believe the PGIP program has funded valuable practice transformation benefitting physicians and their patients. However, some testifiers questioned the lack of outcomes data over the past seven years. There was discussion that better data may help. BCBSM did provide a background document on PGIP that was made available to Committee members and those attending the Reference Committee meeting.Transparency – While many PGIP results are disclosed to POs and their physicians, other features of the model are not, including formulas for distribution of rewards, total funds accrued and their distributions. MSMS’ Principles for Pay-for-Performance Programs calls for complete transparency in such models. Eligible specialties – While primary care and selected other specialties have been included, most specialties are not eligible for full PGIP participation. BCBSM plans to add five more specialties in 2013.PO participation – Currently, participation in PGIP requires membership and cooperation with a PO, as the driver of practice transformation. Some physicians have concerns regarding this requirement. POs vary in structure, governance, and transparency.
Fiscal Note: NULL