How Does Value-Based Reimbursement (VBR) Work?

When all criteria for achieving VBR are met, BCBSM pays claims for PPO members at an increased percentage of the normal reimbursement amount. The criteria are based on the previous year’s data. For example, MOQC receives the data for 2023, reports performance back to the consortium based on that data, and reports to BCBSM which practices/regions achieved VBR according to that data. If targets are met for a fee schedule increase opportunity of 3%, BCBSM then pays 103% of PPO claims in 2024, for those that achieved VBR in 2023.

Each year the MOQC Coordinating Center’s Measures Committee (comprised of practice members, patients, and caregivers) and assisted by the Coordinating Center, proposes a set of measures to be eligible for VBR the following calendar year. Once approved by BCBSM, those VBR measures are announced, usually in October for the next year and each measure has a specific target that must be met. In general, not all targets need to be reached for the VBR requirement to be met. Performance on the measures is measured at the regional level rather than the practice level.

All the following criteria must be true to receive the VBR:

Medical Oncology Practices

• Regional level: The entire region’s mean performance must meet the required targets.
• Practice level: At least one physician and practice manager from the practice must attend both MOQC regional meetings and at least one biannual meeting during that year. A different physician or practice manager designee may attend the meetings.
• Physician level: The individual provider must be enrolled in a PGIP physician organization for at least one year.

Gynecologic Oncology Practices

• Regional level: The entire region’s mean performance must meet the required targets.
• Practice level: Each practice must meet the required participation eligibility points.
• Physician level: The individual provider must be enrolled in a PGIP physician organization for at least one year.