Blue Cross Blue Shield of Texas Accountable Practice Model
Region Within State:
Dallas Fort Worth, Austin, Tyler, Houston
Project Category:
Insurer-Based
The Accountable Practice Model (APM) seeks to reduce medical and pharmacy inflation while improving clinical quality and patient experience. The design of the APM reflects the unique market and regulatory environment in which BCBSTX operates, which is characterized by a predominance of POS and PPO business. Although alternative provider payment models are encouraged by state legislation, there are still state and federal legal obstacles to provider integration and full provider payment reform. The APM works within these constraints by establishing incentives for cost containment and quality alongside the existing fee-for-service payment structure through a shared savings model. The APM is part of a broader BCBSTX effort to move away from traditional fee-for-service payments toward a system that rewards providers for efficiency, clinical quality, and investment in infrastructure to improve patient access and health.
Type of Practices:
Other
Participating Stakeholders:
Self Funded Employers
Employees Retirement System of Texas
Fully Insured Employers
Participating Organization Types:
Private Payer
Technology Characteristics at Start of Pilot:
All practices were required to have EMR or reporting/tracking capabilities
Consumer Involvement:
Notification was sent to all affected members with information pertaining to the APM as well as a Patient Rights and Responsibilities document
Payment Model:
Practices are paid an additional per-member-per-month (PMPM) Care Coordination Fee to compensate practices for additional outreach and coordination activities for the attributed population.
Participating primary care practices are paid their regular fee-for-service payments, but are eligible to receive additional monies through a shared savings program. If the practice reduces the total actual cost of care trend for its patient population below a set target trend, the practice is eligible to earn a portion of the generated savings. However, no savings are shared with participating practices unless the quality performance threshold for the population is achieved.
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