1. 2013 Specialist Fee Uplifts What does this mean for oncology? Tom Ruane, MD Medical Director, BCBSM January 18, 2013 1

2. Funding for Oncology CQI / PGIP Programs 2013 Recognition of the work to this point Describe the continuation of commitment, funding and development for oncology program Introduce a new concept – the PGIP Multi- Specialty Uplift Process – and describe how it will impact oncologists in 2013 2

3. Funding for Oncology CQI / PGIP Programs 2013 Funding from the PGIP Incentive pool – Continues to be delivered to PRM and other POs to support Sub-contract with P4 / Cardinal for administrative and clinical support, data and IT services – Continues to be delivered to U of M and other POs for work in the QOPI, breast, urologic oncology and radiation oncology projects – Continues to be applied to the individual practice units as appropriate to defray the cost of QOPI data abstraction 3

4. Funding for Oncology CQI / PGIP Programs 2013 Fee uplift for oncologists – Prior to 2013 either a 10% or 20% uplift for Evaluation and Management Services has been applied to program participants – In 2013 a 10% fee uplift will continue to be applied to all oncologists who either participate in the Pathways Program or become ASCO QOPI Certified – 33% of all PGIP oncologists will be eligible for a 20% uplift under the terms of the new MultiSpecialty Uplift Process Uplift programs are not additive 4

5. In Development 2013 Search for a tool to replace EOB 1 – Enhanced decision support for pathways – Real time data capture for the Pathways Program – Support rapid cycle feedback of performance to physicians Development of Provider Delivered Care Management 5

6. Multi-Specialty Uplift A fundamental advance in PGIP structure and administration Funding has been set aside to provide for a 20% E&M uplift for up to 33% of PGIP specialists in five specialty fields including oncology and its sub-specialties 6

7. Goals for the Specialty Uplift Recognize and reward high quality care Recognize and reward cost effective care Acknowledge physician participation and cooperation in developing organized systems of care Connect the reward to specialists’ performance Connect the reward to the performance of the system of care for patients seeing specialists Engage the PCP PO to which the specialists’ patient is assigned in the uplift process Simple Transparent Deliverable 7

8. “Generic” uplift process (1) Eligible physician / practice unit is enrolled in PGIP Eligible PU is nominated by his or her PGIP leadership Relevant quality and cost metrics are identified A population of BCBSM patients treated by the PU is identified Quality and cost measures are calculated for the population treated A single numeric score is determined 8

9. “Generic” uplift process (2) Each patient treated by the PU is associated with a “primary care” PO A “primary care” PO score is calculated for all specialists’ patients who were attributed to that PO’s PCPs. The specialty score for the PCP PO is attributed back to the specialty PU in proportion to the percent of specialty care provided to the POs patients by the specialty PU A total final score is calculated. Physicians scoring above the 67 th percentile qualify for the 20% uplift for 2013 9

10. Oncology Uplift Process for 2013 (1) Oncology PU must be enrolled in PGIP Nomination Process is waived No quality measure identified Two cost metrics used: – Total Cost of Care PMPM for members with cancer attributed to an oncologist (cost measure) – Rate of Cancer Sensitive Severe events among members with cancer attributed to an oncologist (utilization measure) Each are weighted at 50% 10

11. Oncology Uplift Process for 2013 (2) PCP PO attribution is established A score is calculated for all oncology patients at the PCP PO level and attributed back to the oncology PU according to the percent of participation in that PO’s oncology care. Final Score for each PU calculated Top 33% identified and awarded a 20% uplift effective 2-1-13 11

12. Selected Methodology Notes All cancer patients included Oncology PU attribution by predominance of care Costs related to transplants are excluded Actual costs rather than standard costs are used The numeric score for each PU along with the uplift cut-off is provided to the PO with which the oncologists are affiliated. 12

13. How to Qualify for the Uplift under this Methodology 1. Provide cost-effective oncology care for patients with cancer – Lower the oncology cost of care metric 2. Participate in the overall management of cancer patients – Lower overall cost of care metric 3. Affiliate with and contribute your ideas to POs who provide cost effective care overall – Maximize the benefit of PO substitution 13

14. Funding and Uplift Strategies for 2014 TBD to Improve Alignment with our Program Goals Recognize and reward high quality care Recognize and reward cost effective care Acknowledge physician participation and cooperation on developing organized systems of care Connect the reward to oncology performance Connect the reward to the performance of the system Engage the PO to which the oncology patient is assigned for primary care in the uplift process Simple Transparent Deliverable 14

15. Questions? 15