TMA Supports Bridges to Excellence Model
Quality Feature – September 2013
Tex Med. 2013;109(9):59-62.
By Amy Lynn Sorrel
Physicians have always been dedicated to improving the health of their patients, but they want to be compensated for it. Health plans and employers want to see costs come down alongside those quality improvements. The Bridges to Excellence (BTE) program is one place where all of those interests intersect, says Lisa Ehrlich, MD, chair of the Texas Medical Association's Council on Health Care Quality.
As the national quality recognition program gains momentum in Texas, "this is an area of involvement in quality that physicians, patients, and health plans are all impacted positively," the Houston internist said. Physicians in the Lone Star State "can now be compensated for delivering this care, while at the same time providing savings in the system."
That's a major reason the council and the TMA House of Delegates in May voted to support best-practice models like Bridges to Excellence to help physicians prepare for a value-based care system that will start paying them based on quality measures. The council also developed a toolbox to help physicians determine whether BTE participation makes financial sense for their individual practices.
BTE is a recognition program that measures the quality of care delivered by physicians and other clinicians. Many payers have adopted the program to financially reward those who earn BTE recognition. The program emphasizes managing patients with chronic conditions and offers recognition in more than a dozen different areas, including diabetes, cardiac care, depression, and medical home readiness. Roughly 3,000 Texas physicians participate in at least one BTE recognition program.
Since 2009, BTE-recognized physicians in the Blue Cross and Blue Shield of Texas (BCBSTX) network are eligible for cash bonuses for meeting evidence-based clinical performance standards in diabetes care. The health plan added cardiac and asthma care modules in 2010 and 2013, respectively. In mid-2012, Aetna began offering the BTE Diabetes Care Recognition Program for physicians who treat members of the Teacher Retirement System of Texas.
Whereas some payer programs rely solely on claims data to issue quality rankings on physicians, TMA's Council on Health Care Quality found that BTE uses standardized sets of measures and criteria to analyze care quality. BTE draws those measures from nationally recognized organizations, including the National Quality Forum, the American Medical Association, the Physician Quality Reporting System (PQRS), and the National Committee for Quality Assurance (NCQA). Also, a panel of primary care physicians and specialists help develop each program.
"These are measures that have been around a long time, and these are things physicians are already doing or should be doing," said Keller family physician and Council on Health Care Quality member Gregory M. Fuller, MD. The program provides "a way to quantify that you are providing quality care. If you qualify, you get recognition for providing that quality care. And you can earn additional monies, and that's very important for primary care practices."
So far, BTE has been responsive to physician input on quality measures, another key factor in the council's decision to support the program, Dr. Ehrlich added. And because the program involves a certification, rather than a ranking, "100 percent of physicians can qualify."
To test the program and its potential benefits, TMA and the Harris County Medical Society (HCMS) began a Diabetes Reporting Pilot Program in 2011 with 48 TMA member physicians in 17 practices in family medicine, endocrinology, and internal medicine. They saw potential earnings of $3,950 on average and $189,363 as a group for the initial submission of their quality data to both the diabetes and cardiac programs.
Dr. Ehrlich says her participation in the program has been worthwhile: BCBSTX pays $150 per covered diabetic patient per year; Aetna pays $100. Her group sees between 25 and 60 diabetic patients per physician per year in those two plans, which means anywhere from $2,500 to $9,000 in annual incentive payments for each doctor.
For the most part, the bonuses compensate Dr. Ehrlich's practice for the work it was already doing. "But one benefit we have seen is an improvement in our office process to make sure that we are able to identify gaps in care, including everything from patient noncompliance to finding patients who have not yet had their pneumonia vaccine and the like."
Payers also are reaping rewards, as quality care turns into cost-effective care.
For BCBSTX, the bonuses in the diabetic program have translated to $1,000 more in annual per-patient savings, when compared with diabetics treated by non-BTE-recognized doctors. Those savings helped fund more than $3 million in cash payouts to physicians since the Blues plan adopted BTE.
"If we look at cost of care for those physicians recognized for BTE, we see a higher spend in professional services and a lower spend in hospital admissions and emergency visits, and it flip-flops for non-BTE-recognized physicians. And we want to incentivize physicians to pay attention up front and keep patients healthier to avoid those costly things on the back end," said Scott Albosta, BCBSTX vice president of network performance management.
At the same time, "we know those patients are getting quality care," he said. "We believe rewarding physicians for excellence in chronic condition care influences provider behavior, which increases the quality of care delivered. The more physicians who are recognized, the better the chance our members are going to go to a physician practicing with a high degree of expertise in chronic condition care management."
The savings generated by BTE are catching employers' eyes, too, who also are looking for high-quality, cost-effective coverage options for their workers. That's just one reason payers like BCBSTX are enhancing and expanding their BTE programs, matched by what appears to be a growing physician interest.
The Texas Blues, for example, increased the incentive payments in the diabetes program from $100 to $150. Network physicians who either earn BTE recognition for the first time or renew the two-year designation in the diabetic program can earn another $500 bonus. It also extends to the new asthma program to encourage physicians to join.
From 2009 to 2013, participation by Blues physicians in the BTE diabetes program jumped from 40 to more than 600. The cardiac care program started with 80 physicians in 2010, and that number grew to about 240 this year. Four doctors signed on to the asthma track.
Those numbers have a lot to do with the incentives offered by a growing list of interested payers. BTE also continues to add more programs since it began in 2002.
But the mission has not changed, says Jessica DiLorenzo, program implementation leader for Health Care Incentives Improvement Institute (HCI3), a nonprofit organization that runs Bridges to Excellence. That goal is "to provide incentives to clinicians to demonstrate high levels of patient care."
While there still is some work involved for physicians in reporting clinical data to get those bonuses, "there's very little downside," she said.
The program is voluntary. It's also confidential in that the clinical information used in the quality recognition is not derived from or sent to any specific payer. "So [physicians] remain in control of clinical data from beginning to end," she explained.
For example, to gain recognition, physicians choose a minimum sample of 25 qualifying patients to report, regardless of payer, which they can do on their own or with the help of an electronic medical record (EMR) vendor. And their scores are not shared publically, whether or not they earn BTE recognition.
The quality measures used also emphasize processes and other elements that have the most impact on patient outcomes, such as preventing complications, which also tend to drive cost savings, Ms. DiLorenzo added.
Even without the benefit of incentive payments, "there's value for clinicians who want to see how they are doing compared with their peers," she said, adding physicians can use their performance reports "to demonstrate to payers that you are consistently delivering high-quality care, and that's a good place to be in contract negotiations."
TMA officials say BTE also is an opportunity for practices of any size to participate in emerging value-based payment models that factor in quality versus straight fee-for-service payments. Whereas medical homes and accountable care organizations tend to require larger groups with a certain level of infrastructure, BTE allows smaller practices to take steps toward those models, while getting compensated for delivering high-quality care along the way, said then-TMA Director of Clinical Advocacy Joseph Gave.
For example, the process to become BTE-recognized, in addition to ongoing participation, can help a practice evaluate "how ready you are to deal with population health and provide a panel of care versus patient-by-patient treatment," he said.
Dr. Fuller says participation in BTE's diabetes recognition program helped his practice, North Hills Family Medicine, put certain processes in place when it became a certified medical home.
"We understood how these kinds of measures were used, and that helped us in looking at our medical home processes for diabetic care," he said, which included everything from measuring patients' weight, blood pressure, lipid levels, and hemoglobin A1c, to discussing and educating patients on weight loss and routine dental, eye, and foot care. "We knew what those processes were because they were part of programs like BTE and NCQA certification for diabetes care."
Is BTE Right for Me?
Because many primary care practices are cash-strapped these days, however, TMA's Council on Health Care Quality developed a suite of tools to help practices evaluate their return on investment in BTE before jumping in.
The first step to BTE participation involves applying for recognition, which does take time and money. TMA's BTE Eligibility Tool takes physicians through a series of steps to determine which patients will meet BTE eligibility requirements, which vary by condition. As patient information is entered – such as relevant diagnosis and dates of the visit and diagnosis – the calculator will automatically determine patient eligibility and notify physicians when they've reached the required number of eligible patients.
Once physicians earn BTE recognition, they are eligible for payer incentives. Again, to collect those payments, doctors must do some homework in gathering quality data on that plan's eligible beneficiaries and submitting it for approval. TMA's BTE Return on Investment Tool calculates the potential incentive dollars available after inputting the number of BTE-eligible patients (you must contact the health plan for this information) and any costs associated with BTE reporting, such as staff time to gather patient data or fees to apply for BTE recognition.
Drs. Ehrlich and Fuller say the eligibility process definitely required some homework to pull the necessary data, although using their EMR systems to upload the information was relatively easy. Dr. Fuller says his reporting to payers takes roughly five minutes per chart using an EMR.
The TMA/HCMS test pilot revealed that while some BTE-eligible practices had to adjust their operations and patient flow, most had a return on investment. Although paper-based practices had a tougher time adjusting, some still benefitted.
TMA will continue to monitor payers' use of the program to make sure the quality information is used only to incentivize, not punish, physicians, Dr. Ehrlich says, adding that so far, there has been no evidence of such misuse. The Council on Health Care Quality also is looking at ways to help practices simplify and streamline the data collection for reporting.
One way to do that would be to get other major payers on board, she says, adding that so far the BTE program is less labor-intensive than Medicare's quality reporting programs in which physicians are not seeing similar financial rewards.
Because BTE recognition overlaps NCQA recognition, doctors also would like to see the timelines for the two programs aligned, Dr. Fuller added. BTE recognition is renewed every two years; NCQA, every three.
To help lower reporting burdens on physicians, BTE leader Ms. DiLorenzo says her organization has projects under way, such as cloud-based platforms, aimed at aligning clinical quality measures in BTE with other reporting programs such as Medicare's PQRS and Electronic Health Record Incentive Program, as well as maintenance-of-certification programs.
Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
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Crossing the BTE Bridge
There are several pathways for physicians to earn recognition in the Bridges to Excellence (BTE) quality measurement program, each with a different cost. Physicians must demonstrate they have met certain benchmarks for a specific condition and then submit their data in one of four ways:
- Directly from their electronic medical record or registry system (no charge);
- By uploading data online to the Bridges to Excellence IPRO Direct Submission Portal (http://pao.ipro.org) ($95 per physician or $295 per group);
- Through the National Committee for Quality Assurance recognition programs (roughly $400); or
- Through the American Board of Internal Medicine (ABIM) maintenance-of-certification modules (ABIM fees plus the $95 IPRO fee).
More information on the BTE performance assessment is available at www.hci3.org/?q=node/43/.
So far in Texas, Blue Cross and Blue Shield of Texas and Aetna offer financial bonuses for BTE-recognized physicians in diabetes, cardiac, and asthma care. Once recognized, the health plans will identify members with those conditions that the physician manages and request patients' biometric information. The Blues and Aetna will then notify the physician of approval to submit a claim with a specific code for reimbursement.
To help determine whether BTE is right for your practice, TMA has assembled a toolkit that includes eligibility and return-on-investment calculators and instructional videos (www.texmed.org/ClinicalQualityTools/). More information on the BTE program can be found at www.texmed.org/BTE.aspx.