The meeting was focused on the issue of integrating specialty care services into the primary care models that BCBSM and Medicare are supporting through the concepts and implementation of Patient Centered Medical Homes and Neighborhoods as well as ACO’s and Organized Systems of Care (OSC), the BCBSM equivalent of ACO’s. There were 2 speakers, Thomas L. Simmer, MD. Senior Vice President and Chief Medical Officer.of BCBSM and Michael Williams, MD, CEO of the United Physicians Group (UPG) of Southeastern Michigan.
Dr. Simmer presented the usual information of the high health care costs, the unsustainable growth rate, and BCBSM efforts in implementing physician pay for performance programs over the last several years. The Physician Group Incentive Program (PGIP) has been present for several years initially focused on primary care with more recent step wise expansion into specialty care. The program is funded through withholding 5% the E&M codes paid to physicians including recently proposed increases. Based on performance criteria, monies are then paid to physician organizations around the state who are then free to pay out whatever percentage they feel appropriate to individual physicians based on group financial needs (IT investments), program development (salaries), and individual physician performance. Most specialty physicians will be eligible to participate as of July 1, 2014 who are members of a group. Sleep Medicine was not specifically listed and may be added in 2015 but Neurology, Otolaryngology, Psychiatry, and Pulmonary were added this year. In addition, In 2015 BCBSM will tier E&M coded hospital/office visits according to criteria they have developed internally and according to a ranking of the practice within the state. Most specialty types (except anesthesiology) will be eligible for a fee uplift. Fee uplifts would be 0%, 5%, and 10%. To be considered for a 2015 fee uplift, a practitioner must be a member of a physician organization (PO) that participates in the PGIP. The PO must ensure that the practitioner is enrolled in PGIP by July 1, 2014. Dr. Simmer noted that only 10,000 of the 28,000 practicing physicians in the state are members of one of the 32 PO’s that work with BCBSM. Dr. Simmer’s major message to specialists was; in order to succeed in the new health care environment, the specialist has to be a member of a PO and has to be actively engaged in the PO in individual physician and population health quality improvement initiatives.
Dr. Williams presented United Physicians Groups efforts over the last 2 years of integrating specialty physicians into the PCMH and its neighborhood along with UPG group wide specialty focused performance improvement initiatives. UPG is a 2200+ physician owned and run independent group primarily affiliated with the Beaumont Health System and Crittendon Hospital as well as several other southeast Michigan hospitals. They have developed working groups with Cardiology, ENT, Allergy & Immunology and Dermatology to address group as well as individual outlier performance issues while making available to physicians and their practices IT resources as well as office process redesign through the LEAN process.