Provider Quality Portal
Biography




Emily Bagley
Director, Provider Analytics and Partner Solutions
BlueCross BlueShield of Tennessee
Responsibilities
 Clinical data exchange with providers
 Provider Implementation of tools and technology
 Provider Performance Assessment
o Episode Bundles to Support the State of TN Health Care Innovation
Initiative (THCII)
o Provider Directory Validation and NCCT
o Hospital Analytics Tool
o Clinician and Facility Dashboards
o Efficiency Practice Pattern Analysis (PPA)
 Provider Measurement Analytics (Provider Incentive Program Overview)
 Contact Info:
Phone: 423-535-7046
Email: emily_bagley@bcbst.com
2
Biography
 Jyothi Anantha
Business Intelligence Applications Lead
 Responsible for building business intelligence and external
facing agile applications to meet business demands.
 Contact Info:
Phone: 423-535-6346
Email: Jyothi_Anantha@bcbst.com
3
Chattanooga, Tennessee
4
BlueCross BlueShield of Tennessee
5
Who We Are
6
BCBST Provider Quality Incentive Programs

PCMH (Enterprise-wide initiative)
 Moving from a chronic model to a Transitions of Care (TOC) model for
chronic and non chronic populations

Commercial programs
 Quality Care Partnership Initiative (QCPI)
o Fee schedule re-basement program based upon HEDIS quality scores
for a group
o 8 pilot groups for 2015
o Total cost of care criteria to be added in future QCPI phases
 Commercial Pay for Gaps (P4G)
o 38 groups in 2015 with quality bonus payments for gap closures
 Provider Transparency (i.e. Physician Quality Measurement Tool)
o Association initiative that measures providers 2 times a year and
publishes those scores in our Provider Directory tool for members
7
BCBST Provider Quality Incentive Programs
 BlueCare Programs (Medicaid)
 BlueCare and BlueCare Plus Pay for Gaps (P4G)
o 45 groups in 2015 and quality bonus payments for gap closures
 Community Mental Health Pay for Gaps (P4G)
o Incentivize the mental health facilities to close gaps on members who
seek services at mental health facilities versus a PCP
 BlueCare Pay for Performance (P4P)
o Quality and utilization program to incentivize PCPs to see patients
that are assigned to their practice
 BlueCare Provider Practice Patterns Assessments (PPAs)
o Quarterly report that measures individual providers across 7
cost/utilization metrics and compares them to their peers
 Medicare Advantage Programs (STARs)
 Medicare Advantage Physician Quality (STARs)
o Fee Schedule re-basement program that measures groups on 18 STARs
measures
8
Business Need for Provider Quality Portal
 As the market shift towards value-based contracting and a quality
emphasis, BCBST felt the need to develop tools and technology to
support the providers in this transition.
 Since the accreditation measures are moving towards outcomes based
scoring, BCBST needed to obtain clinical data that is not currently
captured on a submitted claim.
 BCBST developed a portal for providers to access a member’s health
information at the point of care that allows for the following:
 Review and close gaps in care
 Complete attestations
 Complete a Provider Assessment Form (PAF)
9
Product Development and Delivery
 Developed first phase that was available to providers in 3 months
 Ability to obtain supplemental data through provider
attestations
 Developed in an Agile manner (incremental product delivery)
 Obtained feedback from providers and further refined
product
 Leveraged platform development for other lines of business
(changed measures and financial incentives model)
 Implemented the portal for all major lines of businesses across the
enterprise within a year
 Utilized the development efforts to also support a Risk/Gain share
contracting model to display financial opportunities
 Automated the incentive payments generated within the portal to
disburse payments to providers
10
Project Outcomes-Medicare Advantage Portal
 Third highest source of gap closures by supplemental data to
support HEDIS (EMR data and biometric screenings were first and
second, respectively)
 Primarily impacted Medicare Advantage
 Significantly impacted the Adult BMI and Colorectal Cancer
Screening measures
 Gap closures via attestations by different lines of business (as of
9/11/15):
 37, 962 gaps closed for Medicare Advantage between (Jun
2014 – Dec. 2014) and 42,373 gaps closed YTD 2015
 4, 970 gaps closed for BlueCare and BlueCare Plus since an
April 2015 portal go live
 6, 103 gaps closed for the Commercial line of business since a
mid-July 2015 go live
 Passed (100%) the HEDIS audit for primary source verification
11
Supplemental Data Repository
Clinical Data Exchange
• Electronic Medical Records
• Lab Feeds
Quality Care Programs
•
•
•
•
•
Attestations
PCMH Data
Pay for Quality Data
Transparency Data
Patient Assessment Forms
Immunization Data
• Tennessee
• North Carolina
12
Provider Performance Module Overview
13
Architecture
Source Systems
DB2
SQL
Sybase
Flat
File
Copy
Staging
Teradata
ETL
Integration
Clinical Data Warehouse
ETL
Data Marts
Provider Facing Agile
Solutions/Applications
P4P
Clinician
FCIR
SIMS
Empower Business
Users
14
15
16
17
18
19
20
21
22
Software Structure
SOLID Design
Our Software Quality Goals
25
Consolidated Portal – Future State

Build a single provider module that aggregates information for a
practice/group
 Aggregates information across the multiple provider incentive
programs
 Includes metrics across the different lines of business
 Provides interactive capabilities to close gaps
 Automates reports that are currently static pdf reports
 Contains a member roster for the different lines of business
 Allows for a member/provider search across the differing
programs
 Look at performance as compared to state/regional benchmarks

Centralized the login process for all provider portals
26
Future State – Example Landing Page
27
28