|If you have a question or issue in regards to a health care insurer, please first seek to resolve this directly by contacting the insurer or posting your concerns to other members on the MPA list serv. The Insurance Committee focuses on macro issues affecting Michigan psychologists and is unable to function as a "help desk" of sorts. If you are unable to resolve the issue directly, please contact the Insurance Committee Chair to see whether this is an issue which the committee can address. Thank you all for your understanding.|
Article: The Future of Psychological Practice in the Era of Integrated Care
By Dr. Joy Wolfe Ensor
Article: Psychologists and BCBSM’s Physician Group Incentive Program
By Dr. Louis Post
Introduction: Over the last few months, MPA members have expressed strong concerns about BCBSM's Physicians Group Incentive Program (PGIP). These concerns have centered on a variety of issues, including the rationale of the program; the relationship between psychologists in independent practice and Physician Organizations (POs); and above all, the reimbursement withholds as they relate to Blue Cross's allowed/published fees.
In response to our members' concerns, the MPA Insurance Committee has had five meetings so far with BCBSM pertaining to the Physicians Group Incentive Program. We have sought to broaden and deepen our understanding of the PGIP, so as to be able to give MPA members the information you need to make a decision for yourself as to how you might wish to relate to this program. This blast summarizes what we have learned to date from our meetings with BSBSM. It has been our observation, however, that the process of the PGIP is one of evolution. Consequently, please assume that some of what we describe below will change in the future. Here are the broad points as we understand the PGIP.
Background: BCBS launched the PGIP program five years ago and is aggressively expanding it, as they see it as a signature effort in health care delivery, consistent with initiatives nationwide to de-fragment health care delivery across specialties. Until 2011, the PGIP was only open to participation by primary care physicians. Starting in 2011, it became open to a limited number of sub specialties. BCBSM is seeking to involve psychologists in the PGIP, starting in July of 2012.
Incentive withholds and reimbursement rates: From attending meetings at which physicians were present, and from our conversations with BCBSM, it is clear that the incentive withholds have been applied to all BCBS participating providers' fees, whether or not they are currently eligible to benefit from it. The Insurance Committee has had numerous conversations with BCBSM regarding the withholds and their very negative impact on psychologists' relationship to BCBSM. We started off from the position that the published rates are the rates psychologists should receive and that the withhold is taking money out of psychologists' pockets. BCBSM is adamant that our understanding is not correct. The company does acknowledge that many health care professionals, including psychologists, have been subjected to the withholds without the ability to participate in the PGIP. You can find the most recent explanation of the withhold process in the April, 2012 issue of the Record http://www.bcbsm.com/newsletter/therecord/record_0412/Record_0412b.shtml. According to BCBS the incentive withholds will increase on July 1, 2012, from 4.2% to 4.7%.
In our conversations with BCBSM we have communicated the deleterious impact of the successive rates cuts since 2008, on the delivery of mental health services in Michigan. We have communicated that while we understand that the application of the withholds is not specific to psychologists, that in our opinion the cuts in rates have taken place disproportionately in the area of mental health services, as compared to overall medical spending. We have argued that the application of the withholds has further aggravated this serious discrepancy.
In response to the Insurance Committee's seeking an increase in reimbursement for mental health services, BCBSM has implemented, "as good faith gesture", starting on July 1, 2012, increases for the CPT codes most frequently billed by psychologists. The increases are for Traditional BCBS, Blue Preferred (Trust), Community Blue PPO, and Blue Preferred Plus.
Traditional BCBS, Blue Preferred (Trust), Community Blue PPO, 2012, fees compared to 2011, fees
90847 + 3.73%
The increases, while modest, do reverse the four year trend of across the board fee decreases for all mental health services. Less commonly used CPT codes are seeing further decreases in rates of reimbursement. The issue of rate cuts for mental health services continues to be an extremely high priority issue for the Insurance Committee. We intend to continue to press our arguments with BCBSM regarding the levels of reimbursement for these services.
PGIP and Physician Organizations: BCBSM plans for future rate increases to occur predominantly within the framework of the PGIP. The PGIP is being implemented through forty one Physician Organizations (POs) around the state. These organizations were established long prior to the initiation of the PGIP. Each PO has a different structure, bylaws, and dues for new members. The initial focus within the PGIP is integration/coordination of care via increasing communication between the various treating providers. In order to participate in the PGIP providers must join a PO. For purposes of the PGIP all providers, other than pcps, are classified as specialists. Consequently, within the PGIP psychologists have a specialist designation.
BCBS has not yet determined how the financial incentives for behavioral health care providers will work. In one model, that is currently being used, the PGIP does not evaluate the performance of individual health care providers. Rather, BCBS sets out the population based metrics which POs have to meet to qualify for incentive uplifts. It is up to each PO to determine for itself how it seeks to achieve the PGIP metrics. A PO qualifies for upgrades based on aggregate, not individual, measures for the patient population treated. Success depends on the aggregate measures based on population based performance. Individual providers' performance is not evaluated or compared to other providers' performance. In another model BCBS's aim is to "incent for practices that deliver high value, well-coordinated, relationship-based, cognitive services". Clearly these are very different models, with different risks and benefits for psychologists. We will pursue further with BCBS the practice implications of these two models. The emphasis on "cognitive services" will also require attention from MPA, as it implies the exclusion of other equally effective treatment approaches and implies that BCBS can prescribe the kind of treatment delivered by behavioral health care providers.
Uplifts are based on retrospective measures and are prospective for one year. If a PO achieves the PGIP metrics, all the providers within the PO are eligible for a 10% fee uplift, for their entire BCBS fee schedule, for the subsequent twelve months. Patients are viewed as being within the PO to which their pcp belongs.
It is not clear yet whether the 10% uplift would apply to all BCBS covered patients treated by a specialist or only to those patients whose pcps are members of the PO to which the specialist belongs. One option,we are told, is being considered is that if a specialist's BCBS patients are treated by pcps who are in a number of POs than the specialist's uplift might be an average of the POs to which his/hers patients belong. This is not yet clear. It appears that there is a number of other formulas being discussed within BCBS to address this issue.
To participate in the PGIP a specialist has to be a member of only one PO. Specialists, however, can choose to be members of more than one PO. The total number of BCBS patients treated by a provider during a year, does not impact the degree of uplift the provider qualifies for.
BCBS considers specialists to be neighbors of the Patient Centered Medical Home (PCMH). In order to qualify for an uplift specialists have to be nominated by the PO for the uplift. There are presently no formal criteria for whether or not to nominate a specialist for an uplift. Presently POs have nominated specialists for attending PO meetings, though specialists have been nominated who have attended no meetings. A specialist might have patients who belong to more than on PO. One of those POs may qualify for an uplift while the other(s) do not. If the specialist is not a member of the PO which qualifies for the uplift, in order to qualify for the uplift, the specialist needs to be nominated by the qualifying PO.
We have raised the issue that because of the relatively small number of patients psychologists treat at any one time, they will not be known by many pcps, as would other specialists such as oncologists and cardiologists, which may make it much easier for POs to ignore the psychologists in nominating them. We believe that this an issue which will require considerable attention as we proceed.
In order to qualify for uplifts specialists within the PGIP need to bill using Evaluation and Management (E&M) CPT codes. At this time psychologists are unable to bill under E&M codes. We have been told by BCBS that they will address this issue. To our knowledge this has not, so far, been resolved.
We have been very direct with BCBS about the need to address with POs language which classifies psychologists in any terms other than as full PO members. We have been told that the objective of the PGIP is to be inclusive of all professionals and that BCBS will work with POs to address this problem, if it arises.
A major issue, which BCBS has made us aware of, is that it is not clear how many POs are keen to include psychologists (and psychiatrists) in their membership and how many see the integration of mental health services as being important to achieving the objective of developing an organized processes of care co-designed by PCPs, specialists, and hospitals to de-fragment the American health care system. As such there is the major issue that we are not clear at this point how open respective POs will be to psychologists seeking to join. BCBS is now engaged in devising an initiative aiming to address this problem. While this clearly could become a major issue we do not have sufficient information to determine its scope. If it is prevalent that it will have to be up to BCBS to solve it.
Blue Cross seeks input from content experts regarding metrics for integrating behavioral health into the PGIP. Of the forty-one POs around the state, only two or three currently include psychologists, which complicates this effort moving forward.
What does this mean for psychologists and for MPA?: Participating in the PGIP is entirely optional. One can continue to practice entirely outside the PGIP without any changes. However, if BCBS is successful in what it is seeking to do it will be difficult for a provider to qualify for substantive fee increases outside the PGIP. Some psychologists will see the PGIP as a way to reinvigorate their clinical practice and as a means of increasing their income. Others will perceive the PGIP as being alien to how they practice and will want no involvement with it.
MPA cannot take the position either with BCBSM that it should exclude psychologists from participation in the PGIP, nor with MPA members that psychologists should not participate. Either position would constitute a restraint of trade, and could potentially put MPA in legal jeopardy.
MPA could have taken the position that it will refuse to engage with BCBS regarding the PGIP. It appeared to us, however, that a decision by MPA to not engage BCBS in discussions about the PGIP would on balance be more damaging to psychologists, than engaging with BCBS regarding psychologists' participation. In the service of those psychologists who may have an interest in participating in the PGIP, the Insurance Committee has focused in its meetings with BCBSM on removing the structural and procedural impediments to successful participation by psychologists.
We have come to see possibilities in the PGIP for making some significant changes in the relationship psychology has with the medical establishment. Specifically, in the possibility of opening the door to a greater integration of psychological services in the delivery of health care overall, and of establishing psychologists on a par with medical professionals in the delivery of care. It is a needle to thread, but BCBS is not going to abandon what they are viewing as a signature effort in health care delivery, so our effort is to shape BCBS'd effort to the benefit of psychologists generally .
Psychologists are currently, for the most part, far removed from the medical system. The PGIP aims to change that for those psychologists who have an interest in doing so. Because of the significant differences in how psychologists' practices differ from those of physicians', we expect that problems will need to be overcome to enable those psychologists who wish to do join a PO, to succeed within the PGIP. We are committed to assisting those psychologists who have an interest in joining a PO, in being successful in this endeavor.
Thanks again to you all,
Dr. Louis Post