Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.
Program Selection Criteria:
Fertility Care
Released October 2018
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p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 1
Blue Distinction Centers for Fertility Care | Program Selection Criteria
About This Document
The Program Selection Criteria outlines the selection criteria and evaluation process used
to determine eligibility for the Blue Distinction Centers for Fertility Care program (the
Program).
This document is organized into five sections:
1. Overview of the Blue Distinction Specialty Care Program
2. Evaluation Process and Data Sources
3. Quality Selection Criteria
4. Business Selection Criteria
5. Cost of Care Selection Criteria
About the Blue Distinction Specialty Care Program
Blue Distinction Specialty Care is a national designation program recognizing healthcare
providers that demonstrate expertise in delivering quality specialty care — safely,
effectively, and cost efficiently. The goal of the program is to help consumers find both
quality and value for their specialty care needs, while encouraging healthcare professionals
to improve the overall quality and delivery of care nationwide, and providing a credible
foundation for local Blue Cross and/or Blue Shield Plans (Blue Plans) to design benefits
tailored to meet employers’ own quality and cost objectives
1
. The Blue Distinction Specialty
Care Program includes two levels of designation:
Blue Distinction Centers (BDC): Healthcare providers recognized for their
expertise in delivering specialty care.
Blue Distinction Centers+ (BDC+): Healthcare providers recognized for their
expertise and cost efficiency in specialty care.
Quality is key: only those providers that first meet nationally established quality measures
for BDC will be considered for designation as a BDC+.
Executive Summary
In early 2018, local Blue Plans invited 245 providers across the country to be considered
for the Fertility Care designation under this Program; 145 providers applied and were
evaluated on objective, transparent selection criteria with Quality, Business, and Cost of
Care components. This Program focuses on in vitro fertilization (IVF), which is the most
common assisted reproductive technology (ART) treatment and is widely becoming
the preferred option for fertility treatment. This Program evaluates IVF ART providers in
various care settings, including individual physicians, physician groups, and clinics, with
the designation awarded to individual physicians who meet the Program’s Selection
Criteria. Table 1 outlines the Fertility Care Program Highlights.
1
Benefit design is determined independently by the local Blue Plan and is not a feature of any Blue Distinction program.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ....... 1
Executive Summary ............. 1
Understanding the Evaluation
Process ................................. 2
Quality Selection Criteria .... 4
Business Selection Criteria . 5
Cost of Care Selection Criteria
................................................ 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 2
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Table 1: Fertility Care Program Highlights
PROGRAM HIGHLIGHTS
Designated Provider
Individual Physician
Designation Levels
BDC
BDC+
Membership
Society for Assisted Reproductive Technology (SART)
Member
Structure and Process
Elective Single Embryo Transfer (eSET)
Provider Volume and
Outcome Evaluation
Total Cycle Volume
Cumulative Cycle Starts
Singleton Live Births
Triplets or More Live Births
Quality Sources
Provider Survey
SART Registry Data
Business Sources
Plan Survey
Blue Brands Evaluation
Cost Sources
Blue Plans’ Healthcare Claims Data, with procedures
occurring between January 1, 2014 and December 31,
2016 and paid through March 31, 2017
Blue Female Patients ages 25-45 years
Local Blue Plan Criteria
Local Blue Plan Criteria for Quality, Business, and/or Cost
(if applicable)
Note: The complete Selection Criteria and evaluation process are described fully throughout the
remainder of this document.
Understanding the Evaluation Process
Selection Process
The selection process balances quality, cost, and access considerations to offer
consumers meaningful differentiation in quality and value for specialty care providers that
are designated as BDC and BDC+. Guiding principles for the selection process include:
Quality
Nationally consistent approach to evaluating quality and safety was used, incorporating
quality measures with meaningful impact, including delivery system features and
specific quality outcomes to which all can aspire.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ...... 1
Executive Summary ............. 1
Understanding the Evaluation
Process ................................. 2
Quality Selection Criteria .... 4
Business Selection Criteria 5
Cost of Care Selection Criteria
............................................... 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 3
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Cost
Nationally consistent and objective approach for selecting BDC+ was used to address
market and consumer demand for cost savings and affordable healthcare.
Access
Blue members’ access to Blue Distinction Centers was considered to achieve the
Program’s overall goal of providing differentiated performance on quality and, for the
BDC+ designation, cost of care.
Data Sources
Objective data from a detailed Provider Survey, Society for Assisted Reproductive
Technology (SART) Registry Data, Plan Survey, and Blue Plans’ Healthcare Claims Data
information were used to evaluate and identify providers that meet the Program’s Selection
Criteria. Table 2 below outlines the data sources used for evaluation under this Program.
Table 2: Data Sources
EVALUATION
COMPONENT
DATA SOURCE
BLUE
DISTINCTION
CENTERS
(BDC)
BLUE
DISTINCTION
CENTERS+
(BDC+)
Quality
Information obtained from a
provider in the Provider Survey
Data from Society for Assisted
Reproductive Technology
(SART): http://www.sart.org
Business
Information obtained from the
local Blue Plan in the Plan Survey
and Blue Brands evaluation.
Cost of Care
Blue Plan Healthcare Claims
Data.
Measurement Framework
Blue Distinction Specialty Care programs establish a nationally consistent approach to
evaluating quality and safety by incorporating quality measures with meaningful impact.
Selection Criteria will evolve through each evaluation cycle, consistent with medical
advances and measurement in this specialty area. The measurement framework for this
and other Blue Distinction value-based initiatives were developed using the following
guiding principles:
Utilize a credible process and produce credible results with meaningful,
differentiated outcomes.
Align with other national efforts using established measures, where appropriate
and feasible.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ...... 1
Executive Summary ............. 1
Understanding the Evaluation
Process ................................. 2
Quality Selection Criteria .... 4
Business Selection Criteria 5
Cost of Care Selection Criteria
............................................... 5
Questions ............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 4
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Simplify and streamline measures and reporting processes.
Enhance transparency and ease of explaining program methods.
Utilize existing resources effectively to minimize costs and redundancies.
Meet existing and future demands from Blue Plans, national accounts, and Blue
members.
Quality Selection Criteria
Providers were evaluated on quality metrics developed through a process that included:
input from the medical community and quality measurement experts; review of medical
literature, together with national quality and safety initiatives; and a thorough analysis of
meaningful quality measures. The quality evaluation was based on provider responses to
the Provider Survey and Society for Assisted Reproductive Technology (SART) data, 2015
Final Clinic Summary Report (CSR).
The Quality Selection Criteria includes structure, process, and outcome metrics specific to
fertility care. Each provider must be a SART member in ‘good standing’ and offer elective
single embryo transfer (eSET). The SART 2015 Final Clinic Summary Report (CSR) was
used to evaluate a provider’s volume and outcomes.
Quality Selection Criteria
Table 3 below identifies the Quality Selection Criteria used in the evaluation of each
provider. A provider must meet all Quality Selection Criteria requirements, as well as all
Business Selection Criteria (outlined below in Table 4) to be considered eligible for the
Blue Distinction Centers for Fertility Care designation.
Table 3: Quality Selection Criteria
ALL SELECTION CRITERIA MUST BE MET FOR ELIGIBILITY CONSIDERATION
DOMAIN
METRIC NAME
QUALITY SELECTION CRITERIA DESCRIPTION
Program
Structure/
Process
SART Membership &
Registry Data
Provider is a member in good standing with the Society for
Assisted Reproductive Technology (SART) and has SART
2015 Final Clinic Summary Report (CSR) data for in vitro
fertilization (IVF) procedures.
Elective Single
Embryo Transfer
Provider offers and performs elective Single Embryo
Transfer (eSET).
Volume and
Outcomes
SART 2015
Final Clinic
Summary
Report (CSR)
Total Cycle Volume
Provider’s Total Cycle Volume for the reporting year is
greater than or equal to 75 cycles.
Cumulative Cycle
Starts (Analytic
Volume)
Provider’s Cumulative Number of Cycle Starts for the
reporting year is greater than or equal to 20 cycles for
patients less than 35 years of age.
Singletons Live Birth
Rate
Provider’s Cumulative Singletons live birth rate is greater
than or equal to 30.00% for patients less than 35 years of
age.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ....... 1
Executive Summary ............. 1
Understanding the Evaluation
Process.................................. 2
Quality Selection Criteria..... 4
Business Selection Criteria . 5
Cost of Care Selection Criteria
................................................ 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 5
Blue Distinction Centers for Fertility Care | Program Selection Criteria
ALL SELECTION CRITERIA MUST BE MET FOR ELIGIBILITY CONSIDERATION
DOMAIN
METRIC NAME
QUALITY SELECTION CRITERIA DESCRIPTION
Triplets or More Live
Birth Rate
Provider’s Cumulative Triplets or more live birth rate is less
than or equal to 3.00% for patients less than 35 years of
age.
Local Blue Plan Quality Criteria
(if applicable)
Provider meets all Local Blue Plan Quality Criteria, if
applicable
Business Selection Criteria
The Business Selection Criteria (Table 4) consists of the following components:
1. Physician Participation;
2. Blue Brands Criteria; and
3. Local Blue Plan Criteria (if applicable)
A provider must meet all components listed in Table 4 to meet the Business Selection
Criteria for the Blue Distinction Centers for Fertility Care designation.
Table 4: Business Selection Criteria
BUSINESS SELECTION CRITERIA
Physician
Participation
Physician Specialists are required to participate in the local Blue
Plan’s BlueCard PPO Network.
Blue Brands
Criteria
Provider and any entity in which provider owns or controls a
majority interest meet BCBSA criteria for avoiding conflicts with
BCBSA logos and trademarks.
Local Blue Plan
Business Criteria
(if applicable)
An individual Blue Plan, at its own independent discretion, may
establish and apply local business requirements as additional
Selection Criteria for eligibility in a Blue Distinction Centers
Program, for providers located within its Service Area.
Cost of Care Selection Criteria
Cost of care measures were designed to address market and consumer demand for cost
savings and affordable healthcare. The Cost of Care Selection Criteria was used to provide
a consistent and objective approach to identify BDC+ providers. The inputs and
methodology used in the cost evaluation are explained below.
Quality is key: only those providers that first meet nationally established, objective
quality measures for BDC will be considered for designation as a BDC+.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ....... 1
Executive Summary ............. 1
Understanding the Evaluation
Process .................................. 2
Quality Selection Criteria ..... 4
Business Selection Criteria . 5
Cost of Care Selection Criteria
................................................ 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 6
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Cost Data Sources and Defining the Episodes
Cost of Care evaluation was based on a nationally consistent analysis of Blue Plan
healthcare claims data. The scope of this analysis included:
Claims were evaluated using adjusted allowed amounts derived from Blue Plan
healthcare claims data from January 1, 2014 through December 31, 2016, and paid
through March 31, 2017.
Fertility Care evaluation identifies individual claims (physician or facility) for the
embryo insertion as the trigger event for each IVF cycle in the evaluation. Fertility
Care episodes were identified using HCPCS and CPT procedure codes related to
embryo transfer (embryo insertion).
Provider episode costs were analyzed and adjusted separately for each procedure
type (i.e., IVF – w/ Fresh Oocytes w/ ICSI, IVF – w/o Fresh Oocytes w/ ICSI, IVF –
w/ Frozen Oocytes/Embryos), as follows:
Member exclusion criteria: No claims data was evaluated for members under 25
and over 45 years of age; members whose primary payer is not a Blue Plan; or
members not continuously enrolled for the duration of the episode.
Episode window for Fertility Care procedures begins 60 days before the index event
(embryo insertion) and ends 60 days after the index event.
Services and related costs were included if logically related to the episode, either if
provided for the same condition for which the procedure was performed, as a
supporting component of the procedure; or as likely complication of the procedure.
Adjusting Episode Costs
A geographic adjustment factor (CMS Geographic Adjustment Factors [GAF]) was
applied to the episode cost to account for geographic cost variations in medical
claims only. With regards to pharmacy cost, geography was not determined to be an
independent factor.
An age adjustment factor was applied to pharmacy costs for the two fresh embryo
cycles (IVF – w/ Fresh Oocytes w/ ICSI, IVF – w/o Fresh Oocytes w/ ICSI). An age
adjusted pharmacy cost was then added to the geographically adjusted medical
claims cost to obtain a total episode cost that could be passed through to the next
steps of the cost adjustment.
MS-DRG risk stratification, a risk adjustment that is commonly applied to many other
BDSC designation programs, does not apply to the Fertility Care cost evaluation.
Instead of adjustments for comorbid conditions, Fertility Care required adjustments
to account for differences in pharmacy cost based on age and the case mix, taking
into consideration both procedure type and pharmacy benefit status.
Pharmacy benefit status. Each of the three procedure types (i.e., IVF – w/ Fresh
Oocytes w/ ICSI, IVF – w/o Fresh Oocytes w/ ICSI, IVF – w/ Frozen
Oocytes/Embryos) were further divided into two subcategories (with and without
pharmacy benefits) for case mix adjustment.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ...... 1
Executive Summary ............. 1
Understanding the Evaluation
Process ................................. 2
Quality Selection Criteria .... 4
Business Selection Criteria 5
Cost of Care Selection Criteria
............................................... 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 7
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Managed outliers through winsorization. Outliers were identified as those values for
which costs were the top 2 percent and bottom 2 percent of episode costs
(geographically adjusted medical claims with age adjusted pharmacy costs). Outlying
cost values were truncated to these points, to preserve their considerations in
calculating the overall episode cost estimate, while moderating their influence.
Calculated a Cost Ratio by taking the mean of the episode costs within each
procedure type and dividing it by the overall mean episode cost.
The Cohort/Case Mix Adjustment Factor (which is the inverse of the Cost Ratio) is
multiplied by each provider’s adjusted and winsorized provider episode costs for
each procedure combination to normalize for procedure and benefit type, resulting in
a final episode cost that is both geographically, age, and cohort adjusted.
Establishing the Cost Measure
Each provider being evaluated has a number of fertility procedure episodes attributed to
that provider, based on the trigger events that occurred at that provider’s location, for each
of the three procedure types that were adjusted into a single IVF clinical category. For the
IVF clinical category, the median value of the adjusted expected episode costs for that
Provider is called the Clinical Category Provider Cost (CCPC). Each provider will have a
single Clinical Category Provider Cost (CCPC) for all IVF procedures performed.
Confidence intervals (90 percent) were calculated around each Clinical Category Provider
Cost (CCPC). The Upper Confidence Limit (UCL) of the Clinical Category Provider Cost
(UCL of CCPC) for the clinical category (above) was divided by the national benchmark, to
calculate the Clinical Category Provider Cost Index (CCPCI).
Using the Clinical Category Provider Cost Index (CCPCI) value, an overall Composite
Provider Cost Index (CompPCI) was calculated for the provider. Since there is only a
single clinical category for the Fertility Cost of Care evaluation, the combined cost index
results will match the individual IVF clinical category results prior to rounding. The
combined cost index of the median UCL was rounded down, to the nearest 0.025, in order
to give providers the benefit of the doubt and to avoid situations where a provider very
narrowly missed BDC+ eligibility by an immaterial margin.
The CompPCI was then divided by the national median to normalize/standardize the
values. While this does not change the results in any way, it allows for greater
transparency by having a CompPCI of 1.0 equivalent to the national median with values
greater than 1.0 indicating more expensive providers and values less than 1.0 indicating
more efficient providers. In the final step, the CompPCI was compared to the National Cost
Selection Criteria to achieve the final cost evaluation decision.
Overlapping Service Area
For providers in CA, ID, NY, PA, and WA, who may lie in overlapping areas served by
more than one local Blue Plan, the same method for cost evaluation was used but the
claims data and results were evaluated separately for each of those local Blue Plans,
resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether
one or both cost of care evaluation(s) must meet BDC+ national criteria.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ....... 1
Executive Summary ............. 1
Understanding the Evaluation
Process.................................. 2
Quality Selection Criteria..... 4
Business Selection Criteria . 5
Cost of Care Selection Criteria
................................................ 5
Questions .............................. 8
p2013 Benefit Design Plan Capabilities Survey
Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 8
Blue Distinction Centers for Fertility Care | Program Selection Criteria
Minimum Case Volume Requirement
A provider must have five or more in vitro fertilization (IVF) episodes to consider the
Clinical Category Provider Cost (CCPC) valid. All valid Clinical Category Provider Costs
are included in the final calculations. If the Clinical Category Provider Cost is not valid, it
was not used in further calculations. Any provider that did not meet this episode minimum
did not meet the Cost of Care Selection Criteria.
Cost of Care Selection Criteria
In addition to meeting the nationally established, objective Quality and Business Selection
Criteria for Blue Distinction Centers, a provider also must meet all of the following Cost of
Care Selection Criteria (Table 5) requirements to be considered eligible for the Blue
Distinction Centers+ (BDC+) designation.
Table 5 – Cost of Care Selection Criteria
COST OF CARE SELECTION CRITERIA
A provider must have 5 or more in vitro fertilization (IVF) matched episodes of cost
data.
The Composite Provider Cost Index must be lower than the nationally established
threshold of 1.125.
Local Blue
Plan Cost
Criteria
(if applicable)
An individual Blue Plan, at its own independent discretion, may
establish and apply local cost requirements as additional
Selection Criteria for eligibility in a Blue Distinction Centers
Program, for providers located within its Service Area.
Questions
Contact your local Blue Plan with any questions.
Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with
input from the medical community. A Local Blue Plan may require additional criteria for providers located in its
own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost
measures that address consumers’ need for affordable healthcare. Each provider’s cost of care is evaluated using
data from its Local Blue Plan. Providers in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas,
resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of
care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on
www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s
coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross
and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or
damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction
or other providers.
About This Document .......... 1
About the Blue Distinction
Specialty Care Program ....... 1
Executive Summary ............. 1
Understanding the Evaluation
Process.................................. 2
Quality Selection Criteria..... 4
Business Selection Criteria . 5
Cost of Care Selection Criteria
................................................ 5
Questions .............................. 8
