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CCO Quality Pool Methodology

February 7, 2014Lori Coyner, Accountability and Quality Director

Quality Pool• A bridge strategy in moving from capitation to paying for

outcomes• Quality pool awards depend on CCO performance on the 17

CCO Incentive Measures.• CCOs must meet either the benchmark OR the improvement

target for each measure to qualify.

Benchmarks and improvement targets online at: www.oregon.gov/oha/Pages/CCO-Baseline-Data.aspx

Quality Pool methodology online at: http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf

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Overall Pool Parameters

• 2013 quality pool = 2% of aggregate CCO payments made to all CCOs for CY 2013 services.– Payments made through March 31, 2014 for 2013 services

are included in calculation• Entire pool disbursed by June 30, 2014• Aggregate amount expected to increase annually• OHA required to issue parameters of 2014 pool (for 2015

distribution) by December 1, 2014

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CCO Eligibility for Pool Funds• Two stage process

– Stage 1: All CCOs eligible for up to 2% of a CCO’s actual paid amounts in 2013

– Stage 2: All CCOs eligible to participate in a challenge pool for any remaining funds

• $1m minimum payment if targets are met– Pro-rated if a CCO was only in place a portion of the year

• Revised DRAFT estimates for potential CCO incentive payments (based on 2% of CCO payments) are posted at: http://www.oregon.gov/oha/CCOData/Quality%20Pool%20Estimates%20by%20CCO.pdf

• Final estimates will be posted by April 30 to reflect actual payments for 2013 (through March 31, 2014)

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Stage 1 Distribution Overview

• Based on performance on 17 Incentive Measures• All measures treated as pass/fail and independent of each

other – For 13 of the measures, success based on whether a CCO meets the

benchmark or improvement target– For PCPCH, measured according to a tiered formula– For 3 clinical measures, success based on submitting a technology plan

and proof of concept data for those measures• As a CCO meets more benchmarks or improvement targets, it

receives a higher payment.

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Stage 1 Distribution Overview (cont.)• A CCO would receive 100% of the pool funds for which it is eligible if:

– Meets or exceeds the benchmark, improvement target, or the measurement and reporting requirements for the clinical measures, on at least 75 percent of the incentive measures (12 of 16 measures); and

– Meets or exceeds the benchmark or improvement target for the Electronic Health Record (EHR) adoption measure as one of the 12 measures above; and

– Scores at least 0.6 on the PCPCH enrollment measure using the tiered formula;

• If the EHR measure is not met, the maximum payment a CCO could receive = the second tier (90% of the maximum).

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Number of targets met (benchmark or improvement, or

measurement and reporting)

Percent of quality pool payment for which the CCO is eligible

At least 12.6 (including EHR adoption)

100%

At least 12.6 (not including EHR adoption)

90%

At least 11.6 80%At least10.6 70%At least 8.6 60%At least 6.6 50%At least 4.6 40%At least 3.6 30%At least 2.6 20%At least 1.6 10%At least 0.6 5%

Fewer than 0.6 No quality pool payment

Stage 1 Distribution:

Payment Thresholds

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• Goal = all CCO members enrolled in a Tier 3 PCPCH.

• CCO performance measured using tiered formula:

(# of members in Tier 1*1) + (# of members in Tier 2*2) + (# of members in Tier 3*3)

--------------------------------------------------------------------------------------Total number of members enrolled in the CCO * 3

Stage 1 Distribution:

Patient Centered Primary Care Home (PCPCH) Enrollment

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Stage 1 Distribution:

PCPCH EnrollmentExample of Tiered Formula

CCO Results of Tiered Formula

CCO A 0.4

CCO B 0.6

CCO C 0.7

CCO D 0.9

Increasing number of members enrolled in Tier 3 PCPCHs

Results of the tiered formula are added to the number of measures on which a CCO meets the benchmark or improvement target.ExampleCCO C has met 11 of the 16 measures and scored 0.7 on the PCPCH measure. CCO C’s score = 11.7, qualifying it for 80% of its possible Stage 1 funds (see next slide).

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Stage 1 Distribution:

Advance Distribution for Clinical Measures

• CCOs are able to access incentive pool funds earlier for measuring and reporting on 3 clinical quality measures (3/17ths of available pool funds)– Diabetes blood sugar control– Hypertension control– Depression screening

• CCO submits technology plan by February 1, 2014– Qualifies to receive 75% of the 3/17ths funding early (advance)– Can submit earlier and receive 75% earlier

• CCO submits proof of concept data for the three measures by May 1, 2014– Qualifies to receive remaining 25% of 3/17ths

• Final pool distribution will be net of any advanced funding

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Stage 2 Distribution Overview

• Quality pool funds remaining after stage 1 distribution = “Challenge Pool”

• Distributed to CCOs that meet the benchmarks, improvement targets, or data submission requirements on 4 measures:

Diabetes Control Depression Screening PCPCH Enrollment SBIRT

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Stage 2 Distribution:

Step 1Determine the number of instances in which CCOs have achieved the improvement target or benchmark

For ExampleChallenge Measure # of CCOs meeting targets

PCPCH Enrollment 16*

SBIRT 5

Depression Screening 3 (submitted proof of concept data)

Diabetes Control 6 (submitted proof of concept data)

Total: 30

*Assume all CCOs met the PCPCH target (since using the tiered formula instead of benchmark)

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Stage 2 Distribution:

Step 2Calculate the “base payment” using formula:

Quality Pool funds remaining after Stage 1----------------------------------------------------------

# of instances CCOs met the targets

For ExampleAssume $1,000,000 remaining after

Stage 1 Payment------------------------------------------------------------ = $33,333.33 30 instances (previous example)

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Stage 2 Distribution:

Step 3

Adjust the “base payment” based on average monthly CCO enrollment relative to the mean for those CCOs that met the challenge measure targets.

This calculation is performed separately for each of the three measures: depression screening, SBIRT, and diabetes control.

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CCO Name Base Payment Member Months (MM)

CCO’s ratio of MM to mean

MM

Adjusted challenge pool payment

CCO A $33,333.33 29,588 1.459 $33,333.33*1.459 =

$48,633.33

CCO B $33,333.33 23,343 1.151 $33,333.33*1.151 =

$38,366.66

CCO C $33,333.33 22,788 1.124 $33,333.33*1.124 =

$37,466.66

CCO D $33,333.33 18,014 0.889 $33,333.33*.889 =

$29,633.33

CCO E $33,333.33 16,394 0.808 $33,333.33*.808 =

$26,933.33

CCO F $33,333.33 11,521 0.568 $33,333.33*.568 =

$18,933.33

$200,000 (total challenge pool for the diabetes control measure)

121,648 (Total MM)

$200,000(total)

20,274.67 (Mean MM)

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Stage 2 Distribution:

Step 4For the PCPCH enrollment measure, adjust the “base payment” based on average monthly CCO enrollment adjusted by the results of the tiered formula.

CCO Name

Base Payment Result of Tiered

Formula

Member Months (MM)

Adjusted Member Months

Adjusted MM relative to the mean

Adjusted challenge pool payment

CCO A $33,333 0.4 * 29,588 =11,835 0.969 $ 33,333 *.969=

$32,299

CCO B $33,333 0.5 * 23,343 =11,671 0.956 $ 33,333 *.956=

$31,866

Repeat calculation for all 16 CCOs – all CCOs are assumed to have met the benchmark for the PCPCH measure

$533,333(total challenge pool for PCPCH measure)

73,273 (Total adjusted

member months)

$533,333(total)

12,212(Mean adjusted

member months)

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Questions?More information:

Quality Pool Reference Document at: http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf

Lori Coyner: lori.a.coyner@state.or.us

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