10/6/2017. FQHC Incentive Payments: A Critical Practice for Quality and Patient Satisfaction. Agenda. Incentives in PPS: what does excludable mean?

Transcription

1 FQHC Incentive Payments: A Critical Practice for Quality and Patient Satisfaction Meaghan McCamman Assistant Director of Policy California Primary Care Association Agenda Incentives in PPS: what does excludable mean? Best practices in FQHC P4P Health plan P4P Incentive programs Standardized P4P in Medi-Cal: A Statewide Effort 3 1

2 Overview of P4P in Medi-Cal California s Department of Health Care Services (DHCS & DMHC) monitor plans quality of care, access to and timeliness of services External Accountability Set - Reporting on selected HEDIS measures Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consumer satisfaction surveys DMHC Timely Access to Care Surveys Plans have implemented pay for performance (P4P) programs for their providers to drive improvement in the quality of care and patient experience of their members 4 P4P at FQHCs FQHCs participate in a wide variety of P4P quality incentive programs with Medi-Cal managed care plans Each Medi-Cal managed care plan and/or their subcontractors creates their own P4P program, leading to an assortment of measures upon which each FQHC must report 5 P4P at FQHCs State and federal law clearly allows that FQHCs can participate in these programs and exclude incentive payments from their PPS Managed Care annual reconciliation 6 2

3 State and Federal Law 42 USC 1396: Medicaid managed care plans are required to pay FQHCs not less than they would pay non-fqhc providers for the same medical services, and states must pay a direct supplemental payment [to FQHCs] equal to the amount by which an FQHCs reasonable costs exceed the amount of payments that the FQHC receives from the managed care plan 7 State and Federal Law 42 CFR (a)(2): Any financial incentives provided to Federally Qualified Health Centers under their Medicare Advantage Contracts, such as risk pool payments, bonuses, or withholds, are prohibited from being included in the calculation of supplemental payments due to the Federally Qualified Health Center 8 State and Federal Law Welfare and Institutions Code (h): if FQHC or RHC services are partially reimbursed by a third-party payer, such as a managed care entity the department shall reimburse an FQHC or RHC for the difference between its per-visit PPS rate and receipts from other plans or programs on a contract by contract basis and not in the aggregate, and may not include managed care incentive payments that are required by federal law to be excluded from the calculation 9 3

4 CMS Weighs In September 27, 2000 State Medicaid Directors Letter: MCOs frequently use their own funds to include financial incentives in their contracts with subcontracting providers Financial incentives provide the subcontractor with an incentive to reduce unnecessary utilization of services or other wise reduce patients costs Such incentives may be negative, such as withholding a portion of the capitation payments If utilization goals are not satisfied, the subcontractor forgoes the withhold amount in whole or part Incentives may also be positive, such as a bonus that is paid if desired utilization outcomes are achieved 10 San Mateo Issue CPCA was recently alerted that an FQHC received an adverse determination related to their Medi-Cal P4P program The FQHC had excluded their incentive payments for their managed care reconciliation calculation Currently undergoing appeal 11 San Mateo Issue Raises the Question: what Medi-Cal managed care revenue can be excluded from reconciliation and why? 12 4

5 Rules to live By 1 Plan payments to FQs for primary care must be no less than plan pays other similar primary care providers 2 P4P payments should be completely separate from payments for services (cap or FFS) 3 Clear documentation of P4P programs and payments 13 Rules to live By 4 Payments are at risk 5 Rules apply whether P4P payments come directly from Medi-Cal managed care plan or from IPA 6 P4P payments should be independent of providing any individual service that generates a PPS payment 14 Performance is Measured Against a Set Benchmark: - Year over year improvement by the FQHC - Performance compared to set benchmark (MPL, HPL, utilization/1000, etc ) - FQ s performance compared to overall plan performance - Rewarding improvement and/or performance level achieved 15 5

6 Quality of Care HEDIS Measures from EAS Plans may select measures for which they have performed poorly IHA Core Measure Set CAHPS 16 Utilization/Cost Hospital use (ER, inpatient) Generic drug use Total cost of care 17 Health Plan Perspective Reaction & Action re: San Mateo Examples of P4P program changes being made Remaining questions Priorities going forward 18 6

7 Standardization in Medi Cal Sarah Lally, Project Manager Medi-Cal Core Measure Set Integrated Healthcare Association All All rights rights reserved reserved 20 Medi-Cal P4P Core Measure Set Starting in 2015, IHA has led an effort among Medi-Cal plans and provider organizations to create a standardized performance measure set for all Medi-Cal P4P programs IHA recruited an Advisory Committee of representatives from Medi-Cal managed care plans, providers serving Medi-Cal patients, DHCS, and other stakeholders to support this work Through a voluntary, collaborative process, the Committee reached consensus on a core measure set that all Medi-Cal managed care plans could incorporate into their existing P4P programs Domain Measures NQF # Annual Monitoring for Patients on Persistent Medications: ACE or ARB indicators 0021 Cardiovascular Annual Monitoring for Patients on Persistent Medications: Diuretics indicator 0021 HbA1c Testing 0057 Diabetes Care HbA1c Control 0575 Eye Exam 0055 Maternity Timeliness of Prenatal Care 1517 Childhood Immunizations, Combo Prevention Well Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life 1516 Cervical Cancer Screening 0032 Respiratory Asthma Medication Ratio Integrated Healthcare Association All All rights rights reserved reserved 21 7

8 IHA s Medi-Cal Core Measure Set Project membership Health Plans Provider Representatives Collaborators Associations Integrated Healthcare Association All All rights rights reserved reserved 22 Performance Measurement Crosswalk Measures EAS QRS CMS IHA NCQA Overlap % Annual Monitoring for Patients on Persistent Medications: ACE or ARB Annual Monitoring for Patients on Persistent Medications: Diuretics X X X 60% X X X 60% CORE MEASURE SET HbA1c Testing X X X X (2 tests) 80%* HbA1c Control X X 60% (<80%) X Eye Exam X X 40% Timeliness of Prenatal Care X X 60% X Childhood Immunizations, Combo 3 X X X Combo 10 Combo %* Well-Child Visits in 3 rd, 4 th, 5 th, and 6 th Years of Life X X 40% Cervical Cancer Screening X X X X X 100% Asthma Medication Ratio X X X 60% Integrated Healthcare Association All All rights rights reserved reserved 23 Core Measure Set Adoption Full Adoption Partial Adoption Developing P4P Program Alameda Alliance Anthem Care1st Central CA Alliance California Health & Wellness CenCal Inland Empire Health Plan CalOptima Gold Coast Kern Family Health Health Net UnitedHealthcare San Francisco Health Plan HP of San Joaquin HP of San Mateo LA Care Molina Partnership Health Plan Integrated Healthcare Association All All rights rights reserved reserved 24 8

9 Value Based P4P in Medi-Cal Integrated Healthcare Association All All rights rights reserved reserved 25 Value Based Pay for Performance Program 200+ Medical Groups & IPAs 9 Health Plans Common Measurement Public Report Card PARTICIPATING IN Public Recognition Value Based Incentives Common quality, patient experience, & cost measures One of the nation s first & largest <20% of medical groups achieve Triple Aim IMPACTING 95 Million Californians Over $550 paid to date Integrated Healthcare Association All rights reserved 26 Copyright 2015 Integrated Healthcare Association All rights reserved 26 Value Based P4P in Medi-Cal As Medi Cal expands, more medical groups/ipas serving both commercial and Medi Cal enrollees Opportunity for greater alignment of performance measurement across sectors To support any expansion, IHA could leverage existing VBP4P data flows and program infrastructure, similar to the current Medicare Advantage effort Focus: Medi Cal Managed Care Plans in Los Angeles County When is a 2 plan model actually a 6 plan model Potential Impact: If implemented by all Medi Cal managed care plans in LA County, the program would cover nearly 30% of total Medi Cal enrollment Integrated Healthcare Association All rights reserved 27 9

10 Value Based P4P in Medi-Cal Crosswalks of provider organizations contracted with Medi Cal managed care plans in LA County found between 34 64% already participating in VBP4P Overlap of provider networks across LA County Medi Cal MC plans 130 total provider organizations identified 17% contract with all 5 health plans (LA Care, Care1st, Anthem, Health Net, Molina) 37% contract with at least 2 4 plans Care1st Health Plan plans to participate in VBP4P in upcoming cycle Integrated Healthcare Association All rights reserved 28 QUESTIONS? 29 10