Clinical Quality Value-Based Reimbursement

A primary focus of the quality department is performance in the Blue Cross Blue Shield of Michigan (BCBSM) Clinical Quality Initiative (CLQI) for TPA’s BCBSM commercial and Medicare Advantage members.

Physicians are scored on a series of Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the National Committee for Quality Assurance (NCQA). Performance on CLQI is rewarded to physicians by BCBSM through value-based reimbursement (VBR). Closing gaps in care is essential to prevention and management of chronic disease in patients.

The Blue Cross Blue Shield of Michigan (BCBSM) clinical quality value-based reimbursement (VBR) is designed to reward PGIP Patient-Centered Medical Home designated primary care physician practices that perform well on quality measures, based on select Healthcare Effectiveness Data and Information Set© (HEDIS) metrics and aligned Medicare Stars metrics.

Summary of scoring: The benchmark scores are multiplied by the metric weight and summed to get a practice level score. For commercial and Medicare Advantage (MA) practices, the commercial practice level score is weighted 70% and the MA practice level score is weighted 30%.

Eligibility for clinical quality VBR:

Ranking Overall Practice Performance: Overall practice performance scores were ranked within each practice type and product type (e.g., higher ranking reflects higher score), such that each practice type/product type had their own percentile rankings.

• The top 20% of practices among each practice type and product type were selected to receive the CQ VBR.
• The 80 – 84.99th percentile receive 105% VBR
• The 85 – to 94.99th percentile receive 110% VBR
• Greater than or equal to the 95th percentile receive 115% VBR