Physician Group Incentive Program (PGIP)

Specialists encouraged to join PGIP

In 2005, PGIP began its health care transformation journey with a focus on primary care. At that time, PGIP participation was restricted to M.D.s or D.O.s who were primary care physicians or who were on a list of select specialties.

The program's long-term goal, however, has always been to create high-functioning, coordinated systems of care that involve all physicians who care for patients. Toward this end, in 2011, BCBSM opened PGIP to all remaining medical/surgical specialists not previously in the program.

PGIP is now open to all M.D.s, D.O.s, podiatrists and chiropractors who participate in the BCBSM Traditional and PPO networks. All physician specialties are also eligible to participate in the program except anesthesiology; however, some anesthesiologists will be eligible based on the services provided and billed.

Participating in PGIP

All health care providers, including specialists, must enroll in PGIP through a participating physician organization on a bi-annual basis. Specialists may only participate with one physician organization for the purposes of PGIP. There are currently 40 PGIP physician organizations, which are located across the state. View a complete list (PDF) of participating physician organizations. Additionally, your BCBSM provider consultant is familiar with PGIP physician organizations in your area. You may contact him or her for information. If you are not sure who your provider consultant is, please visit bcbsm.com/provider and click on Contact Us in the left-hand column.

Current PGIP opportunities for specialist physicians

Following are brief descriptions of current PGIP initiatives and professional collaborative quality initiatives that are designed to involve specialists:

Advance Care Planning – This initiative is intended to give physician organizations the opportunity to assess and prepare their practice units for addressing patient needs for advance care planning and managing end-of-life care issues and concerns.

Physician specialty focus: All PGIP-participating primary care physicians and specialists. This initiative may be most pertinent for physician specialties that involve advance care planning or end-of-life care, including oncology, cardiology, nephrology, and pulmonary medicine. Due to the unique nature of end-of-life care within the pediatric population, pediatricians are currently not eligible for participation in this initiative.

Cardiac Care Initiative – This initiative consists of three phases, which collectively address the diagnosis and treatment of cardiovascular disease with an emphasis on reducing unnecessary cardiac tests and procedures, and improving the quality of cardiac care.

Physician specialty focus: Cardiology (cardiothoracic surgeons are eligible to participate in Phase III of this initiative)

Chronic Kidney Disease Initiative – This initiative is designed to improve identification and management of individuals with CKD by primary care physicians in conjunction with nephrologists. The initiative includes several nephrologist-specific measures and an objective to increase timely consultation with and referral to nephrologists.

Physician specialty focus: Primary care, nephrology

Electronic Prescribing Initiative – This initiative aims to improve the safety, quality and cost-effectiveness of the prescription process through widespread adoption and increased use of electronic prescribing and clinical decision-support tools among both primary care physicians and specialists.

Physician specialty focus: All PGIP-participating primary care physicians and specialists (with the exception of psychologists, as they do not write prescriptions)

Michigan Quality Oncology Consortium – This professional CQI supports Michigan oncologists' participation in the American Society of Clinical Oncologists Quality Oncology Practice Initiative and promotes high-quality, effective and cost-efficient care for cancer patients.

Physician Specialty Focus: Hematology/oncology, hematology, medical oncology and oncology

Michigan Oncology Clinical Treatment Pathways Program – This professional CQI is designed to improve quality and decrease variation in oncology clinical practice among Michigan physician practices. The Pathways Program provides recommended treatment plans developed by the Michigan oncology community for newly diagnosed patients with breast, colon, lung, lymphoma, myeloma, ovarian, prostate and renal cancers who are receiving chemotherapy for the first time or receiving a new line of chemotherapy due to disease progression or metastases.

Physician specialty focus: Hematology/oncology, hematology, medical oncology, oncology and gynecological oncology

Michigan Urological Surgery Improvement Collaborative – This professional CQI will create an all-payer Michigan registry that will collect data on prostate cancer patient demographics, cancer severity, and utilization and outcome metrics. Preliminary efforts will be focused on Improving patterns of care in the radiographic staging of men with newly-diagnosed prostate cancer, reducing variation in the discretionary use of androgen deprivation therapy, and improving patient-centered decision making among men considering local therapy for early-stage prostate cancer Data will be analyzed to determine performance of each participating Michigan urology practice in comparison to peers.

Physician specialty focus: Urology

Patient-Centered Medical Home – All 12 PCMH initiatives continue to be open to all specialists. We encourage physicians to discuss the role of affiliated specialists in PCMH initiatives, which may vary depending on the specialty and the characteristics of the population served by the physician organization. The following PCMH initiatives, in particular, may be most relevant for specialist participation:

• PCMH Patient Registry - This initiative encourages PGIP participants to establish a comprehensive patient registry that can be used to manage a population of patients, improve patient health status and ultimately lower health care costs.
• PCMH Test Tracking and Follow-Up - This initiative aims to help practices implement a standardized, reliable system to ensure that patients receive needed tests, timely test results and appropriate follow-up care, and that each step in the test tracking process is properly documented.
• PCMH Coordination of Care - The goal of this initiative is to coordinate patient care across the health system through active collaboration and communication among providers, caregivers and the patient.
• PCMH Web Portal - This initiative supports optimal management of patients with chronic conditions by using a patient web portal for electronic communication between patients and physicians, and providing greater access to medical information and technical tools.
• PCMH Specialist Referral Process - This initiative focuses on seamlessly coordinating patient referrals from primary care to specialty care, with both providers receiving timely access to the information they need to provide optimal care to the patient.

Physician specialty focus: All PGIP-participating primary care physicians and specialists

Transitions of Care – This initiative is designed to improve quality and decrease variation in care transition practices among Michigan physician practices and hospitals (specifically primary care physicians and hospitalists). This initiative expands the Society of Hospitalist Medicine's "Better Outcomes for Older adults through Safe Transitions" care transitions methodology. This methodology is designed to improve care transition by using a team approach. Participants assess a patient's risk for re-hospitalization under the current health care delivery model, adjust the patient's plan of care and reassess the care to minimize the risk of errors.

Physician specialty focus: Primary care, internal medicine and hospitalist medicine

Women's Health: Encouraging Evidence-Based Utilization of Hysterectomy – This initiative encourages evidence-based utilization of hysterectomy, thereby reducing hysterectomy rates for patients 15 to 64 years old.

Physician specialty focus: Obstetrics and gynecology

Women's Health: Encouraging Evidence-Based Utilization of Labor Induction – This initiative encourages evidence-based utilization of labor induction, thereby reducing elective labor induction rates prior to 39 weeks completed gestation.

Physician specialty focus: Obstetrics and gynecology

Increasing Use of Generic Dispensing Rate Initiative – The GDR initiative dashboard for the 2011 program year includes more detailed information about generic prescribing patterns among various specialties. The dashboard includes data subsets for the following specialties: allergy and immunology, cardiology, dermatology, emergency medicine, family practice, gastroenterology, general surgery, hospitalist, internal medicine, neurology, obstetrics/gynecology, pediatrics, psychiatry, and pulmonary. These subsets report population-level generic prescribing patterns for attributed members who have received prescriptions from these specialty physicians. In order to improve overall GDR rates, the primary care and specialty physician communities must work together to ensure that patients are receiving appropriate medications at the lowest possible cost.

Physician specialty focus: All PGIP-participating primary care physicians and specialists

Organized Systems of Care – Specialist engagement is crucial to the successful development of OSCs (similar in concept to accountable care organizations) and effective population management. PGIP is providing physician organizations claims data analyses that indicate their specialist referral patterns to help physician organizations identify the specialists to whom their practice units most often refer. Two OSC initiatives were launched in 2011:

• OSC Integrated Patient Registry Initiative – This initiative is designed to enable OSC providers to perform OSC-wide management of the attributed patient population and reduce disparities in providing health care services.
• OSC Integrated Performance Measurement Initiative – This initiative is designed to enable OSCs to generate OSC-wide performance reporting for all patients.

A third OSC initiative is launching in early 2012:

• Organized Systems of Care Processes of Care Initiative – This initiative aims to ensure that care partners communicate, coordinate and collaborate to achieve clinical integration at the OSC level.

Physician specialty focus: All PGIP-participating primary care physicians and specialists

Areas of development for PGIP specialists

BCBSM continues to explore and develop additional initiatives to improve quality in areas such as behavioral health, emergency medicine, low back pain, osteoporosis, palliative care, and pediatric obesity, among others.

Additionally, BCBSM continues to further refine and develop specialist feedback/reporting mechanisms, including those described below.

Specialist Feedback/Reporting – Specialist participation in PGIP enables BCBSM to identify and potentially reward specialist practice units who work with primary care physicians to manage the care of a shared patient population. Specialist performance is assessed on quality, utilization and efficiency.

BCBSM uses a variety of assessment methods, such as claims analysis for utilization and quality metrics; and "CAVE" reports (using the CCGroup Marketbasket System^TM ), which are specialty-specific, condition-based episode efficiency reports. Physician organization-level CAVE reports were released in late 2011. In early 2012, BCBSM will release practice-unit level CAVE reports for four specialties: cardiology, emergency medicine, gastroenterology and orthopedic surgery. BCBSM plans to complement CAVE reports with reports on overall utilization to provide a more balanced picture of care at the specialist practice unit level.

Additionally, BCBSM will conduct further analysis of high-impact specialties and related CAVE data to determine the rollout of additional CAVE reports. In early 2012, BCBSM began providing fee increases to cardiology practice units that have contributed to successful population-based cardiac performance. During 2012, BCBSM will explore approaches to rewarding additional specialty types for population-based quality, utilization and efficiency performance.