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Provider Transparency

Provider Transparency FAQs

Cost of Care & Effectiveness Report Descriptions

Provider Transparency FAQs

Pay For Performance Request For Information (P4P RFI)

Why has Blue Cross of Northeastern Pennsylvania (BCNEPA) implemented transparency?

Transparency is not unique to BCNEPA; consumers need to have cost and quality information available to them to guide them in their healthcare decisions. A number of external constituencies such as URAC, Federal and State Governments, employer groups and national accounts are requiring transparency.

  1. Many of our BCNEPA employer accounts submit Requests for Information (RFI) when making their health care coverage decisions for their employees. Employers are looking for ways to decrease healthcare costs while maintaining quality of care. Employer groups are routinely asking BCNEPA through such RFI processes if their employees will have access to transparency information;
  2. The Patient Protection and Affordable Care Act1 (PPACA) will be introducing consumer directed health plans for which consumers will need to have cost and quality data available to them to guide them in their healthcare decision making; and
  3. All other major health plans have moved, or are moving, in the transparency direction. It is important for all health plans to define their transparency initiatives.

Furthermore, BCNEPA, as a member of the Blue Cross Blue Shield Association (BCBSA), is required to follow the standards of the BCBSA whose strategy is to engage consumers in their personal healthcare decisions; thus, BCNEPA’s transparency initiative is underway.

How did BCNEPA decide on which transparency tool to utilize?

BCNEPA’s goal is to provide clinical measures and subsequently cost metrics, with a peer group comparison that is fair, meaningful, and usable in a manner that assists in the healthcare decision-making process and helps raise the level of quality care. The cost of care and quality metrics can be found in BCNEPA's Doctor/Hospital Finder.

In keeping with these objectives, BCNEPA performed a 15-month evaluation of transparency software tools that are available in the marketplace. After careful consideration and evaluation, BCNEPA decided to utilize the Cave Consulting Group tool under the name of the CCGroup Marketbasket SystemTM. This software tool uses a predefined set of medical conditions for a specialty type derived from each respective practitioner’s First Priority Health (FPH) and First Priority Life Insurance Company (FPLIC) claims data and calculates episode of care statistics across the predefined set of medical conditions. BCNEPA found the CCGroup Marketbasket SystemTM to be the most reliable and consistent tool available.

How does BCNEPA get the data used to determine quality and cost metrics?

The cost estimations and quality information generated for this tool are updated on a semi-annual basis and are based upon a moving three (3) years of FPH and FPLIC medical and pharmacy claims data.

What quality metrics will BCNEPA be using?

Please contact your provider relations consultant for specific quality measures for the applicable specialty. All quality measures are nationally recognized measures and are approved by national organizations such as the National Quality Forum (NQF), National Committee for Quality Assurance (NCQA), and numerous other groups that have extensive physician representation and vetting.

Will BCNEPA be sharing practitioner quality scores with each respective practitioner before posting the data?

Yes. BCNEPA began introducing the transparency and the CCGroup Marketbasket SystemTM early in 2010 to the provider community through focus groups consisting of a variety of practitioner specialties. Each individual practitioner will have an opportunity to review the quality measures and scores before data is posted on BCNEPA’s new provider directory tool.

When will quality results be posted on the web?

BCNEPA’s objective is to have the quality (effectiveness) metrics (results) available to our membership by the 1st quarter of 2011.

When will cost results be posted on the web?

BCNEPA’s objective is to have the cost (efficiency) results available to our membership and posted on the web in the latter half of 2011.

What if I disagree with the quality scoring?

An opportunity to discuss any disputed data with the appropriate BCNEPA representatives will be forthcoming.

What if I do not agree to have my quality information posted on WebMD’s Provider Selection Advisor?

BCNEPA has adopted participation in transparency as a contracting standard, which is currently in force for all physicians applying for participation. The current initiative is to bring our current networks into compliance with our new participation standards. Additionally, going forward, a physician will not be eligible to participate in any future BCNEPA incentive program.

1 BCNEPA’s review of the Patient Protection and Affordable Care Act (PPACA) finds at least the following statutory provisions that have some component of disclosure/transparency attached to them.

The first provision is §§ 3013, 10303 of PPACA that calls for the development of quality and outcome measurements for providers. These standards will be developed by HHS and requires some detail study of performance data on providers with a focus on quality of care and outcomes, including patient satisfaction.

The second provision is § 10331 of PPACA that calls for, by 1/1/2011, the development by HHS of a website that compares Medicare physicians participating in the PQRI program and by 1/1/2013 to implement a plan to publicly report information on physician performance – the scope of this portion will be to the extent HHS can do it be a report on all patients not just Medicare patients.