WVMGMA 2014 FALL CONFERENCE
TRANSFORMATION AND TRANSITION
TO 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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Highmark Pay for Value Programs
2014 Pay for Value Programs
•
•
•
•
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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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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
Prevention
Chronic Condition Care
Pediatric and Adult Well Care
Breast Cancer Screening
Comprehensive Diabetes Care
Colorectal Cancer Screening
Pediatric Diabetes Care:
HbA1c Testing
Appropriate treatment for
children with URI
Cervical Cancer Screening
Geriatric Care
Glaucoma Screening in Older
Adults
Follow-Up Care for Children
on ADHD Medication:
CAD: Lipid Profile or LDL-C
Testing
Urinary Incontinence
Assessment for Older Women
Use of Spirometry Testing in
the Assessment and Diagnosis
of COPD
Urinary Incontinence Plan of
Care for Older Women
Diabetes, CHF, COPD: Office
Visits 2 or more per year
Fall Risk Assessment for Older
Adults
Use of Appropriate
Medications for People With
Asthma
Fall Plan of Care for Older
Adults
Cholesterol Mgmt. for Patients
with Cardiovascular
Conditions: LDL-C Screening
Appropriate Testing for
Children with Pharyngitis
Adolescent Well-Care Visits
Well-Child Visits in the First 15
Months of Life: Six or more
visits
Well-Child Visits in the Third,
Fourth, Fifth and Sixth Years of
Life
Adults' Access to
Preventive/Ambulatory Health
Services
Childhood Immunization
Status: MMR Vaccination
Childhood Immunization
Status: Varicella (VZV)
Vaccination
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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 MeasurementA 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)
Overall
Star Score
5
4.75-4.99999
4.50-4.74999
4.25-4.49999
4.00-4.24999
3.75-3.99999
3.50-3.74999
< 3.50
Payment Per
Attributed MA Member
$150
$125
$90
$75
$50
$20
$10
$0
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Highmark MA Incentive Program (STARS)
Quality Measures
C01: Breast Cancer screening
C15: Comprehensive Diabetes Care:
Eye Exam (retinal) performed
C02: Colorectal Cancer screening
C03: Cholesterol Management for
patients with Cardiovascular
Conditions: LDL-C Screening
C04: Comprehensive Diabetes Care:
LDL-C Screening
C16: Comprehensive Diabetes Care:
Medical Attention for Nephropathy
C17: Comprehensive Diabetes Care:
HbA1c Control (≤9%)
C18: Comprehensive Diabetes Care
:LDL-C Control (<100mg/dL)
C10: Adult BMI Assessment
C14: Osteoporosis Management in
Women who had a fracture
C18: Comprehensive Diabetes Care
:LDL-C Control (<100mg/dL)
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Highmark MA Incentive Program (STARS)
Quality Measures (continued)
C20: Disease Modifying AntiRheumatic 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
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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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Benefits of
Transformation
Source: Patient-Centered Primary Care Collaborative, “Benefits of Implementing the Primary Care Medical Home:
A Review of Cost & Quality Results, 2012”
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What About West Virginia?
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What you have to do to succeed
Your 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 succeed
Highmark’s Medical Directors, Clinical Transformation Consultants (CTC) and
Provider Relations Representatives work every day with your peers who are
undergoing the same transformations
Among many resources we can make available through channels such as in-person
meetings, online webinars and print publications, we will share:
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Best Practices in transformation
Expertise in attesting to Meaningful Use
Expertise in achieving certification as a PCMH
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Questions?
Jason Landers
Director, Provider Strategic Initiatives
304.424.7738 – jason.landers@highmark.com