Draft for MiPCT Steering Committee Consideration February 13, 2012 Page 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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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

accumulated during that 6 month period will be awarded. Practices starting in April 2012

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

performance incentive score and the number of beneficiaries. PO scores will be ranked

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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MiPCT beneficiaries. The Data Collaborative will also determine the beneficiary payer mix

for each PO and the portion of the total PO payment each health plan is to pay. See

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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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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MiPCT 2012 Performance Incentive Metrics

6 Months

Metric Data Source Numerator Denominator Maximum

Points

Enhanced Access

1. 30% same day appointments

SRD report (5.7) Number of practices in PO with capability

Number of practices in PO

10 N/D x 10

2. Appointments outside regular hours: 8 hrs/week

SRD report (5.3) Number of practices in PO with capability

Number of practices in PO

10

N/D x 10

All Patient Registry Functionality

3. Electronic patient registry functionality

MiPCT Quarterly Report for numbers 1 & 2 SRD Reports for 3 = 2.3 4 = 2.5 5 = 2.4 6 = 2.6 7 = 2.7 8 = 2.8 9 = up to 2 points for

a. Diabetes (SRD 2.1)

b. Asthma (SRD 2.10)

c. Cardio- vascular Disease (SRD 2.11)

d. Pediatric Obesity (SRD 2.17)

Sum of the points each practice received for registry capability.

1. Practice has electronic registry**

2. Registry has interface capability

3. Incorporates evidence-based care guidelines

4. Identifies individual attributed practitioner

5. Information available and used by the practice unit team at the point of care

6. Used to generate communications to patients regarding gaps in care

7. Used to flag gaps in care 8. Patient demographics 9. Registry identifies and tracks

care for patients with at least 2 of the following: • diabetes • asthma • cardiovascular disease • pediatric obesity

Number of practices in PO

10

N/D

• 0 points for entire metric if registry is not electronic

• 1 point each for numbers 1-8 and up to 2 points for number 9

Care Managers

4. Moderate care managers (MCM) trained and working*

MiPCT Quarterly report

1. Number of MCM hired/ contracted by practices and/or PO

2. Number of MCM within PO that have completed the required training

1. Number of required MCM per PO**

2. Number of MCM hired/ contracted

10

1. N/D x 5

plus

2. N/D x 5

5. Complex care managers (CCM) trained and working*

MiPCT Quarterly report

1. Number of CCM hired/ contracted by practices and/or PO

2. Number of CCM in PO that

1. Number of required CCM per PO**

10

1. N/D x 5

plus

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have completed the required training

2. Number of CCM hired/ contracted

2. N/D x 5

* 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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• 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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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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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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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 PCMH

Capability

NCQA Measure / Capability

URAC Element/ Capability

Meaningful Use

Measure

Other

The registry or EHR registry functionality must be electronic – paper or excel registries do not meet this qualification.

• If the registry is not electronic, then the incentive portion related to registry capability achievement is forfeited.

2.9 N/A N/A New survey for MiPCT.

The registry or EHR registry functionality must be capable of electronic interfaces.

2.9 2D

PR-3 EPR-1

MU, Menu Req. 3

New survey for MiPCT

The registry or EHR registry functionality incorporates evidence-based care guidelines.

2.3 3-A EPR-2 MU, Core Req. 11

The registry or EHR registry functionality 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.

2.5 PR-3

The information in the registry or EHR registry functionality is available and in use by the practice unit team at the point of care.

2.4

The registry or EHR registry functionality is being used to generate routine, systematic communication to patients regarding gaps in care.

2.6 2-D

PR-3 MU, Menu Req. 4

The registry or EHR registry functionality is being used to flag gaps in care for every patient currently in the registry.

2.7 PR-2 EPR-3

The registry or EHR registry functionality incorporates information on patient demographics for all patients currently in the registry.

2.8 2-A, 2-B PR-2 EPR-1 EPR-2

MU, Core Req. 7

The primary care practice must be using the registry or EHR registry functionality to identify, track, and manage patients with at least 2 of the following conditions:

1. Diabetes 2. Asthma 3. Hypertension 4. Cardiovascular Disease 5. Obesity

1. 2.1 2. 2.10 3. N/A 4. 2.11 5. 2.17

(Peds)

2-B PR-1 MU, Core Req.8