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WVMGMA 2014 FALL CONFERENCE
TRANSFORMATION AND TRANSITIONTO PAY FOR VALUE
SEPTEMBER 19, 2014
- TRANSFORMATION -
It is generally recognized that the current “system” for the delivery of healthcare in the United States is broken.
“Fee for service” has led the US to spiraling costs and average quality. Medical inflationary rates are nearly double the rest of the economy.
For Highmark WV, “Transformation” is the transition in the way care is delivered to our members.
Highmark has developed several programs that promote this transition from Fee for Service to Pay for Value.
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- HIGHMARK GOAL -
The Highmark Goal is that at least 75% of the Highmark membership will be cared for in at least one Pay for Value program by the end of 2015.
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2014 Pay for Value Programs
• Quality Blue Physician P4V (Level 1)• Quality Blue Patient Centered Medical Home (PCMH)• Quality Blue ACA• Highmark MA Incentive Program (STARS)• Quality Blue Hospital
Future Programs
• ACO Gain Share• Specialist Pay for Value
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Highmark Pay for Value Programs
Quality Blue Physician P4V (Level 1)
• Quality Blue Level 1 is Pay for Value program, similar to existing PCMH Programs
• Quality Blue Level 1 will Launch in WV in October 2014
• Practices are now receiving information on participation
• All practices are eligible to participate, if the have at least 100 attributed patients and are Navinet users
• There is no special contracting required, if a group is successful, they will receive incentive
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Overview of the Quality Blue Physician P4V (Level 1) Program
• The are three components to the Quality Blue Level 1 Program
– Quality
• The practices are measured on the same 24 measures that
are included in the Quality Blue PCMH Program
• A successful quality score in Level 1 is 25% lower than PCMH
– There are two efficiency measures to gauge successful
reduction of costs
• Generic Prescribing
• ED Utilization Efficiency
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Overview of the Quality Blue Physician P4V (Level 1) Program
Quality Component
• Participants will be measured on their performance on claims-based clinical quality metrics
• In order to qualify for the fee increase in the Program, Participants will be required to meet a minimum quality threshold
• Participants are scored for successfully achieving the better of: (1) the 50th percentile of the national HEDIS® Commercial PPO metric benchmark; or (2) the 50th percentile of the Highmark network benchmark; or (3) the 2015 projected 4 Star cut-point as determined by CMS
• Participants can receive up to 50 points from quality
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Quality Measures
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Overview of the Quality Blue Physician P4V (Level 1) Program
Generic Prescribing
•Rates of generic drug prescriptions will be compared to network specialty averages for Family Practice, Internal Medicine and Pediatrics
•The Program awards between five and twenty-five points for ordering more generic prescriptions than the specialty average. Ordering the same amount of generic drugs as the specialty average earns zero points; ordering 1% more generic drugs than the specialty average earns 5 points, and so on, to a maximum of 25 points
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Overview of the Quality Blue Physician P4V (Level 1) Program
ED Utilization Efficiency
•This metric will calculate the rate of Emergency Department visits per 1,000
•The ED Utilization rate is compared to the WV market averages and scored
•Practices Earn up to 25 points for being below the 50th %tile in ED Utilization
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Overview of the Quality Blue Physician P4V (Level 1) Program
•Each measurement facet will carry a different weight (50 points for Quality; 25 points for Generic Prescribing; 25 points for ED Utilization) for a total of 100 possible points. A Participant must earn a minimum of 10 points in one of the two Operational Efficiency Measures -- Generic Dispensing or ED Utilization -- in addition to a minimum of 15 Quality points
•Successful participation provides a $3 Fee Incentive Paid on E and M services through claims payment (as in PCMH)
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Quality Blue Patient Centered Medical Home (PCMH)
As practices evolve in their transformation, Highmark WV can extend the opportunity to participate in the Quality Blue Patient Centered Medical Home.
Practices participating PCMH receive a greater incentive, consultant assistance, access to more detail reporting.
Practices who successfully participate in PCMH will initially receive a $10 fee incentive for each E and M code billed. There is also a $2 incentive for Meaningful Use Attestation and $5 for PCMH Accreditation. Additionally advanced success in scoring creates the opportunity to receive a total of $27 in incentives added to E and M codes.
The PCMH participants meet monthly with the Highmark Clinical Consultant team to assist with the transformation process.
The PCMH participants also receive access to the Provider Intelligence reporting tool to assist with population management activities.
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Overview of the Quality Blue PCMH Program
Quality Scoring:
The PCMH Participants are evaluated on the same 24 quality measures previously mentioned (for Level 1).
A minimum quality score of 20 is required for continuing in the program. There are 50 quality points possible.
Participants are evaluated for cost and utilization control. A Medical PMPM is developed for each practice. For success in the program, a practice will need to manage the cost of care for their patients to a level less than the average annual increase of their peers (trend). There are 50 cost and utilization points possible.
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Quality Blue ACA
• The Quality Blue ACA is an off-shoot of the Quality Blue PCMH
• The ACA includes a “Network” of providers and facilities
• Practices are measured on the same 24 PCMH Measures with the same requirements for success in the program
• Practices are measured on Cost and utilization control as in the PCMH. However, there are 20 points possible for Cost and Utilization as opposed to 50 in the PCMH
• The practices are measured on their ability to refer within the ACA “Network”. There are 30 points possible for this component of the ACA
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Highmark MA Incentive Program (STARS)
This program is structured to assess and improve the process of care for Highmark Medicare Advantage patients provided by their primary care practices using specific CMS Stars measures as the clinical quality component. The program will have two defined components:
1. Care Gap Closure 2. Star Performance Results
Care Gap Closure Assessment Incentive Component
• Participating practices will receive Care Gap Patient listing reports that identify attributed members and eligible per measure gaps in care as attributed at time of report run date. These lists will update based upon claims received by Highmark throughout the course of the measurement year.
• Care gaps are defined as Medicare Advantage patients that are identified by Highmark claims as patients that have not yet received the expected care as indicated by the national HEDIS® measurements or CMS Star measurements.
Each gap in care closed on identified static measures between January 1, 2014 and September 30, 2014 will be noted to be eligible for care gap incentive payment.
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Highmark MA Incentive Program (STARS)
Program Performance Level Incentive Component
Highmark will calculate a practice level star rating using administrative claims data reflecting a date of service of January 1, 2014 through December 31,2 014. All claims for consideration must be submitted to Highmark by January 31, 2015.
At the conclusion of the measurement period, performance will be assessed and the practice will receive a lump –sum performance level incentive payment based upon practice level overall star rating. Incentives will be made for performance levels ≥3.5 stars overall.
Results and Scoring
Care Gap Component Each of the static measures with care gaps closed by date of service September 31, 2014 is eligible to receive a $10 incentive per gap.
Star Performance Measurement- A minimum of a 3.50 overall weighted star rating must be obtained to receive the performance level incentive payment.
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Highmark MA Incentive Program (STARS)
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Overall Payment PerStar Score Attributed MA Member
5 $150 4.75-4.99999 $125 4.50-4.74999 $90 4.25-4.49999 $75 4.00-4.24999 $50 3.75-3.99999 $20 3.50-3.74999 $10
< 3.50 $0
Highmark MA Incentive Program (STARS)Quality Measures
C01: Breast Cancer screening C02: Colorectal Cancer screening C03: Cholesterol Management for patients with Cardiovascular Conditions: LDL-C Screening C04: Comprehensive Diabetes Care: LDL-C Screening C10: Adult BMI Assessment C14: Osteoporosis Management in Women who had a fracture
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C15: Comprehensive Diabetes Care: Eye Exam (retinal) performed C16: Comprehensive Diabetes Care: Medical Attention for Nephropathy C17: Comprehensive Diabetes Care: HbA1c Control (≤9%) C18: Comprehensive Diabetes Care :LDL-C Control (<100mg/dL)
C18: Comprehensive Diabetes Care :LDL-C Control (<100mg/dL)
Highmark MA Incentive Program (STARS)Quality Measures (continued)
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C20: Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis C23: All cause readmissions: Medicare Advantage D11: Use of High Risk Medications D12: Diabetes: Appropriate Treatment of Hypertension D13: Medication Adherence for Diabetes Medications
D15: Medication Adherence for Cholesterol (Statins) C51: Annual Wellness Visit and Initial Preventive Physical Exam Rate DMC16: Pharmacotherapy Management of COPD Exacerbation: Systemic Corticosteroids within 14 days DMC17: Pharmacotherapy Management of COPD Exacerbation: Bronchodilator within 30 days
Quality Blue Hospital
• Hospitals are evaluated and scored based on a series of quality measures:
– Readmissions
30- day acute 3- day acute 7- day return to ED
– Healthcare Associated Adverse events (HAAE)
CAUTI CDI LabID CLABSI SSI- IP SSI – OP VTE
– Advance Care Planning and/or Palliative Care for Complex Patients
– Perinatal
– Efficiency Measure (Medicare Spending Per Beneficiary –MSPB)
• In addition, hospitals are evaluated on the success of their employed physicians on a set of Medicare Advantage quality measures. The employed physicians are required to maintain a minimum Star Measurement on a subset of the Senior Quality Measures.
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Future Programs
ACO Gain Share
As PCMH / ACA mature in West Virginia, we will begin talking to entities about gain share opportunities. These will be regional groups of providers who will use the reporting tools and information and share in the gains from efficiency.
Specialist Pay for Value
Currently piloting or evaluating Specialist Pay for Value programs including Oncology and Orthopedics. These opportunities will be advancing in the coming months.
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Source: Patient-Centered Primary Care Collaborative, “Benefits of Implementing the Primary Care Medical Home: A Review of Cost & Quality Results, 2012”
Benefits of Transformation
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What About West Virginia?
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What you have to do to succeedYour obligations may vary in precise details according to your contract, but all participants will be required to commit to:
•Support a physician champion
•Support a clinical champion
•Educate your entire team
•Encourage your team to practice to “top of license”
Highmark helps you succeedHighmark’s Medical Directors, Clinical Transformation Consultants (CTC) and Provider Relations Representatives work every day with your peers who are undergoing the same transformationsAmong many resources we can make available through channels such as in-person
meetings, online webinars and print publications, we will share:
•Best Practices in transformation
•Expertise in attesting to Meaningful Use
•Expertise in achieving certification as a PCMH
