February 13, 2012 MiPCT Performance Incentive Committee Report Revised Program Description with Six Month Metrics

1. February 13, 2012 MiPCT Performance Incentive Committee Report
Revised Program Description with Six Month Metrics
On December 5, 2011, the MiPCT Steering Committee expressed support for the basic elements
of the Performance Incentive Program for 2012 and suggested the program be distributed for
general review and feedback prior to formal adoption. The Performance Incentive Committee
subsequently distributed the program description to PO leadership, the Data and Evaluation
Subcommittee and the Clinical Subcommittee and requested feedback. In addition,
information on the Performance Incentive Program was presented to PO leadership during a
MiPCT webinar on December 15, 2011.
The two Subcommittees and representatives from several POs sent valuable feedback. The
Committee met twice during January and twice during February to consider all the
recommendations and concerns received. To date, all issues regarding the program description
and 6 month metrics have been addressed. The 12 month metrics require a bit more work.
In view of the urgency in getting the 6 month measures identified and distributed to POs, the
Committee presents the revised program description and 6 month performance incentive
metrics for review and recommends they be approved for implementation.
The 12 month metrics will be presented for action in a subsequent meeting.
Respectfully,
Ewa Matuszewski, Performance Incentive Committee co-chair
David Livingston, Performance Incentive Committee co-chair
Performance Incentive Committee
Co-chairs: Ewa Matuszewski, David Livingston
Members: Carol Callaghan, Charlie Carpenter, Ruth Clark, Jim Forshee, Carla Galligan, David
Livingston, Craig Magnatta, Diane Bechel Marriott, Margaret Mason, Ewa Matuszewski,
Devorah Rich, Alicia Simmer, Betsy Wasilevich, and Dana Watt
Committee Consultants: Gwen Thompson and Clare Tanner
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2. Proposed MiPCT Performance Incentive Program for 2012
The MiPCT Performance Incentive Program provides financial rewards to physician organizations/
physician hospital organizations/independent practice associations (POs) and primary care practices
during the 3 years of the demonstration for achievements in primary care practice transformation. A
multi-stakeholder MiPCT Committee has met regularly since September 2011 times to design the
performance incentive program and to select metrics for 2012. Metrics for 2013 and 2014 will be
identified in 2012.
Objectives of the MiPCT Performance Incentive Program
1. To provide financial rewards to support deep transformation within the participating primary care
practices and the provision of patient-centered healthcare.
a. Reward primary care practices for their transformation efforts and for achieving desired
outcomes.
b. Reward POs for their transformation efforts and for achieving desired outcomes.
c. Compensate POs for the services provided to assist primary care practices in achieving practice
transformation.
2. To align financial incentives with desired program outcomes.
a. Reward improvement and optimal performance on quality and cost measures at a population
level.
b. Select measures that support the Demonstration’s Objectives:
i. improved patient health care status,
ii. improved patient experience of care, and
iii. decreased or stabilized cost of care – with the goal of budget neutrality within 3 years.
Performance Incentive Payment Process
1. Participating health plans will contribute $3.00 PMPM to the incentive program pool.
2. Performance incentive metrics will be assessed every six months of the calendar year and all funds
Practices starting in April 2012
accumulated during that 6 month period will be awarded.
will follow the same incentive period schedule as those starting in January,
i.e. their first incentive period will be three months and payments will be
adjusted accordingly.
a. The Michigan Data Collaborative will calculate a performance incentive score for each PO.
Year one metrics are a combination of infrastructure/process and
outcome measures. Infrastructure metrics will be assessed at the practice level and rolled
up to the PO level. Other metrics, such as utilization, that are more reliable for larger
populations than for smaller populations will be assessed at the PO level on all the MiPCT
beneficiaries in the PO.
b. The Michigan Data Collaborative will calculate the payment due each PO based on the total
PO scores will be ranked
performance incentive score and the number of beneficiaries.
from high to low and placed into payment deciles, ranging from 82% to
118% of the mean payment. Each decile will contain one tenth of the
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3. MiPCT beneficiaries. The Data Collaborative will also determine the beneficiary payer mix
See
for each PO and the portion of the total PO payment each health plan is to pay.
Appendix A for additional details regarding payment calculation
c. Payments will be made within 2 months of the close of each six month
period.
3. POs will retain the approved portion specified in the MiPCT implementation
Plan (not to exceed 20%) to reward their contribution to primary care practice
transformation efforts. The remaining funds will be distributed to the
participating primary care practices.
a. POs may opt to distribute the funds equally to their primary care
practices or to use a preapproved distribution method having specific
criteria and variable payment rates.
b. POs will provide MiPCT with an accounting for how the funds retained
by the PO were used. POs will also report the amount distributed to
each primary care practice and the distribution criteria used.
4. The majority of performance incentive funds should flow to the providers of care.
a. In most cases the providers of care will be the primary care physicians and practices.
b. In some instances, this will include Physician Organizations who have employed care managers
and other care management team members.
c. Health systems are encouraged to implement processes to ensure incentive funds are passed on
to the primary care practice unit level.
5. Funds retained by Physician Organizations are to be used to support primary care practice
transformation activities through provision of one or more of the following:
a. clinical leadership support,
b. implementation of tools and care processes that enable the primary care practices to achieve
practice transformation, and
c. analytical support with generation of reports to measure transformation progress.
6. A funding and crediting process is in place to determine what portion of the performance incentive
payments for PCMH activities contained within the participating health plan’s regular performance
incentive programs will be credited toward MiPCT Performance Incentive Program payments. All
credited payment amounts will be subtracted from the amount(s) otherwise owed to POs and
primary care practices by the participating health plan.
Performance Incentive Metrics
Selection Criteria
1. Performance metrics are intended to promote and reward behaviors that improve the quality of
healthcare, improve the experience of care, and decrease healthcare costs including
a. Integrating care managers within primary care practice settings.
b. Developing processes that enable primary care practice teams to engage patients and their
caregivers and/or families, as appropriate, in their own care through:
i. Self-management support,
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4. ii. Navigation/coordination of care,
iii. Effective transitions of care,
iv. Care management, and/or
v. Linking patients with community resources.
c. Enhancing access to quality care through:
i. Same day appointments,
ii. After hours care , and
iii. Electronic access to care, e.g. email, e-visits, patient portal, etc.
d. Utilizing all-patient electronic registry functionality to facilitate provision of proactive, evidence-
based care.
2. Performance metrics will be phased - in over time. The metrics are to reflect
the special focus of the Demonstration for each of the three years and years 2
and 3 will build on previous year(s).
a. Year One (2012): Develop primary care practice infrastructure including enhanced
access, all patient registry system and embedding care managers within the primary care
practices.
b. Year Two (2013): Optimize care management, improve quality metrics and
avoid high cost care.
c. Year Three (2014): Achieve the “Triple Aim” of improved quality of care, improved
patient and primary healthcare team experience of care and reduced /stabilized costs of care.
Data Sources for Metrics:
1. Claims Data: All participating health plans will submit claims data to the Michigan Data Collaborative
which can be used to calculate utilization and cost metrics. Claims data will be calculated for each
Health Plan and aggregated across all contracted plans. Confidence intervals at 95% will be provided.
2. MiPCT Quarterly Reports: The report will document updates to the MiPCT Implementation Plan and
progress to date in developing PCMH infrastructure capabilities and carrying out MiPCT clinical
initiatives.
3. Self-Reported Data (SRD): PGIP POs currently report to BCBSM twice a year on their practice’s PCMH
capabilities. BCBSM applies accuracy, validity and inter-rater reliability checks and balances to the
reports. Financial penalties are imposed on POs for inaccurate reporting of capabilities and are
reflected proportionally on the distribution of funds to the PO.
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5. MiPCT 2012 Performance Incentive Metrics
6 Months
Metric Data Source Numerator Denominator Maximum
Points
Enhanced Access
1. 30% same day SRD report (5.7) Number of practices in PO with Number of 10
appointments capability practices in PO N/D x 10
2. Appointments SRD report (5.3) Number of practices in PO with Number of 10
outside regular capability practices in PO N/D x 10
hours: 8 hrs/week
All Patient Registry Functionality
3. Electronic Sum of the points each practice Number of 10
patient registry MiPCT Quarterly received for registry capability. practices in PO N/D
functionality Report for
1. Practice has electronic • 0 points for
numbers 1 & 2
registry** entire metric
2. Registry has interface if registry is
SRD Reports for not
capability
3 = 2.3 electronic
3. Incorporates evidence-based
4 = 2.5
care guidelines • 1 point each
5 = 2.4
4. Identifies individual attributed for numbers
6 = 2.6 1-8 and up
practitioner
7 = 2.7 to 2 points
5. Information available and
8 = 2.8 for number
used by the practice unit
9 = up to 2 9
team at the point of care
points for
6. Used to generate
a. Diabetes communications to patients
(SRD 2.1) regarding gaps in care
b. Asthma 7. Used to flag gaps in care
(SRD 2.10) 8. Patient demographics
c. Cardio- 9. Registry identifies and tracks
vascular care for patients with at least
Disease 2 of the following:
(SRD 2.11) • diabetes
d. Pediatric • asthma
Obesity • cardiovascular disease
(SRD 2.17) • pediatric obesity
Care Managers
4. Moderate care MiPCT Quarterly 1. Number of MCM hired/ 1. Number of 10
managers report contracted by practices required 1. N/D x 5
(MCM) trained and/or PO MCM per plus
and working* 2. Number of MCM within PO PO**
2. N/D x 5
that have completed the 2. Number of
required training MCM hired/
contracted
5. Complex care MiPCT Quarterly 1. Number of CCM hired/ 1. Number of 10
managers report contracted by practices required 1. N/D x 5
(CCM) trained and/or PO CCM per plus
and working* 2. Number of CCM in PO that PO**
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6. have completed the required 2. Number of 2. N/D x 5
training CCM hired/
contracted
* Attribute “hybrid” care managers to Moderate and Complex categories according to their FTE assignment.
** Number specified and approved in the MiPCT Implementation Plan
Metric Criteria
1. ENHANCED ACCESS
A. 30% Same Day Appointments (SRD 5.7)
Advanced access scheduling is in place, reserving at least 30% of appointments for same-day
appointments for acute and routine care (i.e., any elective non-acute/urgent need, including
physical exams and planned chronic care services, for established patients)
• 30% of the day’s appointments should be available at the start of business for same-day
appointments for both acute and routine care needs
o In unusual, extenuating circumstances (such as a solo primary care practice in a rural or
urban under-served area), primary care practice units may meet the requirements by
having a routine, systematic procedure that practice unit clinicians remain after-hours
as necessary to see the majority of patients requesting routine or acute care
• Written policy for advanced access is available
o Patients are aware of policy and do not feel that they must self-screen to avoid imposing
on primary care practice unit staff
• Patients can be accommodated throughout the day (not only during lunch or after-hours)
• Patients are seen on a timely basis with no excessive waiting time
• Patients can be seen by PAs/NPs or by any physician in primary care practice
• Primary care practices that do not have an approach to scheduling that closely follows the
structure and process of formal open access scheduling consistent with the sources cited
herein, must have a documented policy and procedures demonstrating that the practice’s
advanced access approach has the following attributes referenced at the following sites:
o http://www.aafp.org/fpm/20000900/45same.html .
o Reference Institute for Healthcare Improvement articles at
http://www.ihi.org/IHI/Topics/OfficePractices/Access/Changes/IH for information on
implementing advanced access
B. Appointments Outside Regular Hours - 8 hours per week (SRD 5.3)
Provider has made arrangements for patients to have access to non-ED after-hours provider for
urgent care needs during at least 8 after-hours per week and, if different from the PCP office, after-
hours provider has a feedback loop within 24 hours or next business day to the patient's PCMH
• After-hours is defined as office visit availability during weekday evening (e.g., 5-8 pm) and/or
early morning hours (e.g., 7-9 am) and/or weekend hours (e.g., Saturday 9-12), sufficient to
reduce patients’ use of ED for non-ED care
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7. • After-hours provider may be at Primary care practice Unit site or may be in a physically
separate location (e.g., an urgent care location or a separate physician office) as long as it is
within 30 minutes travel time of the PCMH
• Services provided by the after-hours provider must be billable as an office visit or an urgent
care visit, not as an ER visit
• After-hours services provided in a different setting (e.g., urgent care center or a physician
who shares on-call responsibilities) requires an established arrangement for after-hours
coverage, and feedback to the PCP by the next business day regarding the care received.
• Primary care practice Units may team with other practice units/physicians to provide after-
hours urgent care
2. ALL PATIENT REGISTRY FUNCTIONALITY
Electronic Registry (see Appendix B for crosswalk with other programs)
Each of the following metrics will be reported at the PO level.
A. 6 Month Process Measures Relating to Registry Implementation
The registry or EHR registry must be electronic – paper or Excel spreadsheet registries do not
meet this qualification. If the registry is not electronic, then the incentive portion related to
registry capability achievement is forfeited (MiPCT Quarterly Report).
1. The registry or EHR registry is capable of electronic interfaces (MiPCT Quarterly Report).
2. The registry or EHR registry incorporates evidence-based care guidelines (SRD 2.3).
3. The registry or EHR registry contains information on the individual attributed practitioner
for every patient currently in the registry who has a medical home in the primary care
practice unit (SRD 2.5).
4. The information in the registry or EHR registry is available and in use by the primary care
practice unit team at the point of care (SRD 2.4).
5. The registry or EHR registry is being used to generate routine, systematic communication to
patients regarding gaps in care (SRD 2.6).
6. The registry or EHR registry is being used to flag gaps in care for every patient currently in
the registry (SRD 2.7).
7. The registry or EHR registry incorporates information on patient demographics for all
patients currently in the registry (SRD 2.8).
8. The primary care practice must be using the registry or EHR registry to identify, track, and
manage patients with at least 2 of the following conditions as defined in the MiPCT clinical
metrics:
a. Diabetes (SRD 2.1)
b. Asthma (SRD 2.10)
c. Cardiovascular Disease (SRD 2.11)
d. Pediatric Obesity (SRD 2.17)
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8. 3. CARE MANAGERS
MiPCT recognizes two categories of care managers: moderate and complex. The
two roles have different responsibilities, qualifications and training and are typically performed by
different individuals.
• The number of care managers to be engaged in a PO is approximately 1 moderate care manager and
1 complex care manager for each 5000 MiPCT beneficiaries attributed to internal medicine and
family medicine settings. Pediatric practices typically see fewer complex patients and are expected
to engage 2 care managers per 5000 MiPCT beneficiaries, but the ratio of moderate to complex
care managers may be greater.
• In unique circumstances, such as practices with a relatively small number of
MiPCT patients and/or pediatric practices, one individual may assume both
care manager roles. For performance incentive purposes, these “hybrid”
care managers are counted as a partial FTE in both the moderate and
complex care manager categories. For example, 0.5 FTE is reported as a moderate care
manager and 0.5 FTE is reported as a complex care manager.
A. Moderate Care Managers Trained and Working
6 Months
• The number of moderate care managers employed/contracted by POs and/or primary care
practices on June 30, 2012 compared to the approved number in the MiPCT
Implementation Plan.
• The number of employed/contracted moderate care managers that have
completed a MiPCT approved self-management training course. A course
certificate or CME credits will serve as evidence of self-management
training.
B. Complex Care Managers Trained and Working
6 Months
• The number of complex care managers employed/contracted by POs
and/or primary care practices on June 30, 2012 compared to the approved
number in the MiPCT Implementation Plan.
• The number of employed/contracted complex care managers that have completed the intensive
MiPCT training program. The UM Care Management Resource Center will verify
completion.
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9. Appendix A: Calculation of MiPCT Performance Incentive Decile Ranked Payments
The Performance Incentive payment for 2012 will range from 82%
below the mean of $18.00 per member ($3.00 per member per month X
6 months) to 118% above the mean. See the attached example
calculations using the method. The dollar amount in the example is based on
1. Calculate a total performance incentive score for each PO and identify the number of MiPCT
beneficiaries attributed to each PO.
2. Rank POs by score from high to low. If two or more POs receive the same score do a secondary
ranking based on number of beneficiaries , listing the PO with the largest number first.
3. Divide the total number of MiPCT beneficiaries by 10 to determine the number of beneficiaries to
be attributed to each decile.
4. Fill decile 1 with the number of beneficiaries from the top scoring PO. If this is fewer than the total
beneficiaries allotted to decile 1 (one tenth), add the beneficiaries from the next highest ranking
PO and repeat until decile 1 is complete. Any remaining beneficiaries from the last PO will then
begin filling decile 2 and the process continues until all beneficiaries have been assigned.
5. The amount to be paid to each PO is the amount of beneficiaries attributed to a decile x the
payment amount for the decile. If a PO’s beneficiaries are assigned to 2 or more deciles, the
amount for each decile is calculated and the totals summed.
MiPCT Decile Payment Schedule
Decile 1 118% x $18.00 = $21.24
Decile 2 114% x $18.00 = $20.52
Decile 3 110% x $18.00 = $19.80
Decile 4 106% x $18.00 = $19.08
Decile 5 102% x $18.00 = $18.36
Decile 6 98% x $18.00 = $17.64
Decile 7 94% x $18.00 = $16.92
Decile 8 90% x $18.00 = $16.20
Decile 9 86% x $18.00 = $15.48
Decile 10 82% x $18.00 = $14.76
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12. Appendix B: MiPCT 6 Month Registry Metric Crosswalk
High-level program references of PCMH and Medicare incentive programs that additionally support the MiPCT
incentivized activities
Metric BCBSM NCQA URAC Meaningful Other
PCMH Measure / Element/ Use
Capability Capability Capability Measure
The registry or EHR registry functionality 2.9 N/A N/A New survey
must be electronic – paper or excel for MiPCT.
registries do not meet this qualification.
• If the registry is not electronic, then
the incentive portion related to
registry capability achievement is
forfeited.
The registry or EHR registry functionality 2.9 2D PR-3 MU, Menu New survey
must be capable of electronic interfaces. EPR-1 Req. 3 for MiPCT
The registry or EHR registry functionality 2.3 3-A EPR-2 MU, Core
incorporates evidence-based care Req. 11
guidelines.
The registry or EHR registry functionality 2.5 PR-3
contains information on the individual
attributed practitioner for every patient
currently in the registry who has a medical
home in the primary care practice unit.
The information in the registry or EHR 2.4
registry functionality is available and in use
by the practice unit team at the point of
care.
The registry or EHR registry functionality is 2.6 2-D PR-3 MU, Menu
being used to generate routine, systematic Req. 4
communication to patients regarding gaps in
care.
The registry or EHR registry functionality is 2.7 PR-2
being used to flag gaps in care for every EPR-3
patient currently in the registry.
The registry or EHR registry functionality 2.8 2-A, 2-B PR-2 MU, Core
incorporates information on patient EPR-1 Req. 7
demographics for all patients currently in the EPR-2
registry.
The primary care practice must be using the 2-B PR-1 MU, Core
registry or EHR registry functionality to Req.8
identify, track, and manage patients with at
least 2 of the following conditions: 1. 2.1
1. Diabetes 2. 2.10
2. Asthma 3. N/A
3. Hypertension 4. 2.11
4. Cardiovascular Disease 5. 2.17
5. Obesity (Peds)
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