Tennessee: Preparing for MIPS with PCMH and pay for performance


Major changes to the healthcare payment and delivery system are on the horizon at the federal level, but many states have also been working on reforming healthcare in their regions for several years. In Tennessee, these changes include reforms that come from both government agencies and commercial health insurers in the state.

Patient-centered medical home model

In December 2014, the state of Tennessee received a $65 million State Innovation Model (SIM) testing grant from the Centers for Medicare and Medicaid Services (CMS). This grant helped to launch the Tennessee Primary Care Transformation strategy, which aims to assist providers in promoting higher-quality care, improving population health, and reducing cost of care.

One of the major initiatives under the Primary Care Transformation strategy is a focus on patient-centered medical homes. Patient-centered medical homes focus on prevention and management of chronic disease and seek to increase coordinated and integrated care among provider teams. Using funds from the CMS SIM grant, Tennessee plans to engage at least 65% of the state’s primary care providers in multi-payer Patient-Centered Medical Home (PCMH) programs by 2020. The State will encourage provider organizations in the state to participate by first requiring the three TennCare (Medicaid) Managed Care Organizations to participate in a statewide joint PCMH program starting with approximately 25 practices starting in January 2017. From there, the state and other participating payer organizations will continue to build up to a statewide aligned commercial and Medicaid PCMH program.

BCBS of Tennessee quality programs

Blue Cross Blue Shield (BCBS) of Tennessee is one of the largest health insurers in the state, covering over 75% of the large group market, 67% of the small group market, and 45% of the individual market. BCBS payers throughout the United States are known for investing in programs that promote quality, and BCBS of Tennessee is no exception.

To ensure that BCBS providers are delivering the best care to members in the state, BCBS of Tennessee has developed and implemented a number of quality improvement programs that financially incentivize both providers and members to place value on better health. The Quality Rewards Program offers financial incentives for providers to deliver appropriate screenings and preventive care services to Medicare Advantage PPO and HMO members, using the CMS Star program measures to evaluate performance, just as the plan is evaluated by CMS.

Another program, MyHealthPath, partners with BCBS of Tennessee members as they take steps toward a healthier lifestyle. Members who opt in to the program are educated about the importance and completion of preventive screenings while being rewarded via gift card for receiving the screenings that apply to them.

Managing requirements across programs

For provider organizations in Tennessee, there are many opportunities to earn additional revenue by participating in both state and commercially supported quality improvement and pay-for-performance programs. And beyond state and commercial opportunities are federal programs like the Physician Quality Reporting System (PQRS) and the upcoming Merit-Based Incentive Program (MIPS), which will be administered under MACRA.

For providers who see Medicare patients, while PQRS may be sunsetting this year, the first performance period for MIPS, which starts January 1, 2017, is rapidly approaching. Managing state, commercial, and federal programs will become increasingly challenging, but staying on top of requirements and deadlines is one way to ensure that your organization is informed. Subscribe to our newsletter to stay informed.

If your organization is participating in state or commercial quality programs, we would love to hear if you’ve started preparing for MIPS as well. Comment below and share with us your questions or stories!

Further reading:
How using the MIPS 90-day reporting period will increase your 2017 Composite Score
Avoiding a penalty in 2018 MIPS: the nuts and bolts

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