2012 QUEST Primary Care HMSA. Patient-Centered Medical Home. and. Pay-for-Quality. Getting Started and Ongoing Management

Transcription

1 2012 QUEST Primary Care HMSA Patient-Centered Medical Home and Pay-for-Quality Getting Started and Ongoing Management P r o g r a m G u i d e

2 Table of Contents Overview....2 Introduction....4 Basic Requirements, Exclusions, and Patient Attribution QUEST PCMH Expectations and Guidelines...6 Population Health Management Levels and Requirements...7 PCMH Requirements for Physician Organizations Physician Organization Leadership Responsibilities Integrated Support Team Overview Evaluation of PCMH Collaboration Additional Reporting Requirements...15 Pay-for-Quality Program Summary Cozeva...17 Pay-for-Quality Data Sources and Supplemental Data Process Inquiry and Request for Reconsideration of Pay-for-Quality Award Payment and Methodology Adult Primary Care Pay-for-Quality Clinical Measures Preventive Health Screening Heart Disease...20 Diabetes Appropriate Respiratory Care Pediatric Primary Care Pay-for-Quality Clinical Measures Preventive Health Screening Childhood Immunizations Appropriate Respiratory Care Immunizations for Adolescents Pay-for-Quality Payment Maximum Payment Potential Award Payment Conditions Quality Payments Example Baseline Quality Performance Report Quarter One Quality Scoring Calculations Step 1: Calculation of Maximum Payment for Each Measure Importance Weight Factor Tables Step 2: Performance and Improvement Points Earned Schedule A: National Percentile Threshold Rates-Pediatric Measures Schedule B: National Percentile Threshold Rates-Adult Primary Care Measures Schedule C: National Percentile Threshold Rates-Generalist Overlapping Measures Performance and Improvement Points by Percentile Range Table 1: Baseline Period Performance < 10th Percentile Table 2: Baseline Period Performance 10th Percentile Table 3: Baseline Period Performance 25th Percentile Table 4: Baseline Period Performance 50th Percentile Table 5: Baseline Period Performance 75th Percentile Table 6: Baseline Period Performance 90th Percentile Step 3: Calculation of Actual Payment for Each Measure Appendix A: Pay-for-Quality Measure Detail Appendix B: Provider Toolkit for PCMH Appendix C: PCMH Care Coordination Appendix D: PCMH Level Verification Request Process QUEST PCMH & Pay-For-Quality Program Guide 1

3 Overview The HMSA QUEST value-driven health care initiative will consist of a Patient-Centered Medical Home (PCMH) program, a pay-forquality program, and a Hospital Value-Driven Health Care Program. These programs represent the goals of value-driven health care by aligning payment with quality and efficiency. In 2010, HMSA adopted the PCMH model for primary care providers (PCPs) as its value-based health care initiative. This model puts the patient at the center of care and surrounds the patient with a care coordination team led by a PCP. Currently, HMSA has more than 410 PCPs servicing more than 330,000 commercial members in PCMH and is working toward engaging all PCPs and their members in PCMH. To support PCPs in this process, HMSA has implemented a new hybrid reimbursement model that incorporates fee-for-service with a population health management fee. The population health management fee is calculated using the members attributed to a PCP and is paid on a per member per month (PMPM) basis in recognition of the physician s responsibilities in managing the overall health and health care needs of the member. The PCP s population health management fee is intended to help you transform your practice into a medical home with a focus on patient-centeredness, performance measurement, greater accessibility, comprehensiveness, coordination, and evidence-based care. Additionally, HMSA s new pay-for-quality program began in 2011 for all contracted primary care providers (PCPs). It builds on experience gained through the PPO Practitioner Quality and Service Recognition (PQSR) and HMO Quality and Performance (Q&P) initiatives to create a program aligned with the challenges and opportunities of PCPs. The program is designed to focus on preventive care and chronic disease measures, reward performance, use best practice initiatives, improve the health status of members, and achieve HMSA s health and quality objectives. In 2012, HMSA is expanding the pay-for-quality program to include QUEST providers and is incorporating Hawaii Department of Human Services (DHS) Value Based Purchasing (VBP) measures as part of this program. HMSA has created a program aligned with the challenges and opportunities of the Med-QUEST medical home model for primary care providers. The QUEST pay-for-quality program is designed around adult and pediatric primary care and will include all of the commercial pay-for-quality measures. Recognizing that HMSA s QUEST membership is nearly 60 percent children (age 0-18), HMSA s plan for the pediatric measures for 2012 is as follows: Build on the overarching components (access to care, immunizations, asthma, and appropriate respiratory care). Expand well-child care to all three age bands (newborn through adolescent care). Adjust provider profiling reports to focus on well-child care and immunization performance. HMSA s plan for adult care will focus on various components including preventive care, diabetes, heart disease, and asthma. The first year of the QUEST PCMH and pay-for-quality program will run from July 2012 through June For the first year, providers with 100 or more QUEST members will be eligible to participate in the QUEST pay-for-quality and/or PCMH programs. In the future, HMSA is planning to expand eligibility to all primary care providers. 2 QUEST PCMH & Pay-For-Quality Program Guide

4 Preface The Patient-Centered Medical Home: A Path to Quality, Affordable Health Care PCMH is a health care model that facilitates partnerships between individual patients and their personal providers (as well as the patient s family, when appropriate). This model puts the patient at the center of care and surrounds the patient with a care coordination team led by a PCP. It s a way to give the patient better, more personal care. HMSA s PCMH program adopts the Joint Principles of the PCMH as developed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. 1 The Joint Principles of the Patient-Centered Medical Home Personal Provider Payment Structure Enhanced Access to Care Provider & Patient Care Team Provider- Directed Medical Practice Whole-Person Orientation Quality and Safety Coordinated Care Across Health Care System 1 PCMH definition and Joint Principles of PCMH are available at QUEST PCMH Program Guide 3

5 Introduction Building a Sustainable Health Care System for Hawaii Our overall objectives in implementing the patient-centered medical home model for care with our PCPs include collaborating with key stakeholders to build a sustainable health care system for Hawaii, encouraging HMSA members to select a PCP, and improving provider and patient experiences. In addressing the overall need to transform the health care system, HMSA s ultimate goal is to create and support a sustainable health care system in Hawaii. The use of an integrated health care model will help physicians achieve PCMH domains and result in providing the best quality and most affordable care to QUEST members. HMSA will work with physician organizations to meet this goal by integrating the concept of the Institute for Healthcare Improvement (IHI) Triple Aim, which is the simultaneous pursuit of three goals: Improving the experience of care. Improving the health of populations. Reducing per capita costs of health care. 1 1 IHI Triple Aim: Improvement Aims for a Sustainable Health Care System Ultimate Goal: Access to affordable, quality care at the right time in the right place Sustainability Optimize performance in three dimensions of care to improve the health care system IHI s Triple Aim Population Health Patient Experience Per Capita Cost Adoption of core beliefs for delivering quality health care IOM s 6 Aims for Improvement Safe Effective Patient- Centered Timely Efficient Equitable 4 QUEST PCMH Program Guide

6 Basic Requirements, Exclusions, and Patient Assignment Basic Requirements The following basic requirements apply to those PCPs interested in contracting with QUEST pay-for-quality and/or PCMH. 1. Providers are one of the following: A general practice, internal medicine, family practice, or pediatric physician. (Other specialties may also be eligible, subject to HMSA s program requirements.) An advanced practice registered nurse (APRN) licensed in a discipline to provide primary care. A physician assistant, under the supervision of a PCMH-eligible physician. Note: In instances where QUEST members are assigned directly to a health clinic or Federally Qualified Health Center (FQHC), the clinic or FQHC will be considered the member s PCP. 2. Providers are covered under an HMSA QUEST agreement and execute a PCMH agreement with a physician organization that has contracted with HMSA for PCMH. Non-FQHC providers and clinics assigned as a PCP must have 100 or more QUEST members and an existing commercial PCMH contract for inclusion in QUEST PCMH. 3. Providers and clinics choose a single physician organization with which they are affiliated for PCMH. HMSA will link the clinic or provider s QUEST members to this physician s organization for program purposes. 4. Providers agree to meet population health management (PHM) requirements outlined in this guide and be held accountable by the physician organization. 5. Providers agree to share quality and other clinical data with the physician organization and with HMSA, including administrative, biometric, and lab values on HMSA members for quality improvement purposes. 6. Non-FQHC providers and clinics assigned as a PCP must have 100 or more QUEST members in their patient panels for inclusion in the QUEST pay-for-quality program. Eligibility will be evaluated quarterly. Patient Assignment Process HMSA s QUEST members are included in the QUEST PCMH/ pay-for-quality patient panel of the PCP, health clinic, or federally qualified health center that is recorded in HMSA s QUEST membership system. Additional pay-for-quality expectations are described on Page 16. Exclusions: 1. Providers with the above specialties who are predominantly practicing as hospitalists based on claims submitted to HMSA. 2. Providers with the above specialties who do not practice as PCPs based on submitted claims as determined by HMSA (e.g., internal medicine physician who practices primarily as a cardiologist) as determined by established CMS standards and guidelines. QUEST PCMH & Pay-For-Quality Program Guide 5

7 QUEST PCMH Expectations and Guidelines Expectations and Guidelines for PCPs When agreeing to participate in a PCMH, PCPs commit to put forth good-faith efforts to meet program requirements, goals, and expectations. This means that each PCP agrees to: 1. Actively engage with patients identified as in need of care management, including the development, maintenance, and oversight of care plans for such patients. 2. Communicate in a timely fashion and cooperate with HMSA s PCMH integrated support team as well as other involved providers in the execution of care plans and patient health-risk mitigation efforts. 3. Use high-quality, cost-efficient institutions and specialists who participate in HMSA s QUEST network. 4. Deliver high-quality and medically appropriate care in a cost-efficient manner. 5. Cooperate with HMSA in its efforts to carry out program rules and requirements as set forth in this guide and related addendums. 6. Not withhold, deny, delay, or underutilize any medically necessary care. 7. Not selectively choose or de-select members. HMSA has observed a key element in PCMH development collaboration among providers on improvement activities for their practice. A collaborative environment offers the opportunity for providers to discuss and learn about best practices, share strategies to reach PCMH goals, and improve the quality of care provided to their patients. The PCMH program assesses the performance of PCMH collaborations through reporting from physician organizations. PCMH collaborations may also be subject to onsite reviews, audit visits, or other means of assessment. 6 QUEST PCMH Program Guide

8 Population Health Management Levels and Requirements The requirements for QUEST PCMH PCPs are listed in the matrix below, with examples of how PCPs can demonstrate achievements of those requirements. The QUEST PCMH requirements closely mirror the commercial PCMH requirements. HMSA will coordinate with the PCP s physician organization as needed to review and validate that criteria are being met. Providers should maintain and make available documentation supporting the achievement of the accountability criteria. HMSA will coordinate with physician organizations to ensure expectations are being met without causing undue or unnecessary burden to providers when they are asked to show evidence of achievement. Provider practices that are able to implement the criteria as part of their standard workflow should be better positioned to improve quality of care and will earn a larger PMPM payment with each level they attain. To submit a request for level verification, please refer to the instructions for completing the PCMH level verification form in Appendix D. Activities REASON/INTENTION Requirements Accountability Criteria EXAMPLES OF ways to meet the REQUIREMENTS Level 1 ($1.00 PMPM) Learn how to transform your practice into a PCMH. Practice transformation requires continuous application of the concepts and operational changes of PCMH facilitated by collaboration within the physician organization. Meetings are intended to improve providers understanding of PCMH principles and enhance collaboration and teamwork over time. 1. Attend educational meetings with other providers regarding PCMH (coordinated/ held by physician organization leadership). In the 12 months after execution of PCMH agreement: - Attend a minimum of 9 of the physician organization-scheduled PCMH meetings per PCP agreement year. - Attend a minimum of 1 training program, conference, or webinar with the National Committee for Quality Assurance (NCQA), TransforMED, IHI, or other locally/ nationally sponsored PCMH educational event (with a minimum of 3 CME units or 3 hours of instructional time) per PCP agreement year. Complete assessment within the first 90 days after the effective date of the executed PCMH agreement. Physician organization s meeting attendance records that indicate the provider has attended a minimum of 9 of the physician organizationscheduled PCMH meetings. Attendance documentation and CME certificate confirming that the provider has attended a minimum of 1 PCMH training program, conference, or webinar (with a minimum of 3 CME units or 3 hours of instructional time). To improve/expand the patient experience and quality of care provided, it is important to evaluate and assess a practice s current performance and capabilities. Results of the assessment will help provide baseline information to better position our providers in the transformation to a PCMH. 2. Assess practice for PCMH readiness. Assessment report using one of the following PCMH readiness assessment tools (or others as agreed upon with HMSA) 1 : NCQA PCMH Survey Tool ( TransforMED MHIQ survey ( com/mhiq/welcome.cfm). CMHI Medical Home Index and Medical Home Family Index (medicalhomeimprovement.org/ knowledge/practices.html). 1 1 Use of the assessment tool may require registration and/or payment of fees. Refer to the individual organizations for details. QUEST PCMH Program Guide 7

9 Activities REASON/INTENTION Requirements Work to improve care coordination in your practice. Enhanced access is a key component for a PCMH (e.g., open scheduling, expanded hours). It is important to offer patients additional options to access a provider or care team for routine or urgent care during and after office hours, either via office visit, telephone, or secure electronic messaging. This promotes continuity in care and patient-centeredness. Improving care coordination in your practice is intended to: Prevent miscommunication between PCPs and specialists. Reduce medical errors that may result from transitions in care. Reduce poor outcomes for transitions in care that are not optimized. Increase efficiencies and reduce redundancies in care. 1. Enhance care between visits by improving access via phone or secure Improve coordination between specialists and sites of care. Accountability Criteria Ensure patient access to a clinician after hours when needed. Note: An answering machine directing patients to the emergency room (ER) does not qualify for this activity. Assess patients care coordination needs and create a care plan during their visit. Provider/staff facilitates and documents transition to other care resources as needed. Include care coordination capabilities within provider s practice (e.g., re-tool medical assistant functions, use external care coordinator) within 12 months of execution of PCMH agreement. EXAMPLES OF ways to meet the REQUIREMENTS Evidence that patients have access to care beyond regular office hours and are able to obtain timely clinical advice by telephone, , or other means when the office is not open, including: Information provided to patients on how to access care (e.g., after-hours care policies, office postings, other materials indicating coverage via Physicians Exchange or coverage arranged with other PCPs). Evidence that individualized care plans are developed, communicated to patients, and reviewed/ updated at each visit, including: Care plan templates or other documentation that show patient care needs have been identified, treatment goals established, and appropriate review and follow-up completed at each visit. Evidence that individualized care plans indicate referrals to other resources (external or internal) for additional care management support as applicable, including: Referrals to disease management services, case management services, mental health/substance abuse services, community resources, or health education programs. Evidence that practice has a process to track and follow up on referrals, including: Documented process or procedure and documentation for at least 1 month of referrals (e.g., referral forms, specialist report, electronic or paper reports/logs, and medical record notes [P section of SOAP notes]). Evidence that the practice has organized and trained office staff to support coordination of care activities and/or the use of external resources, including: Self-reported statement of practice process and staff roles/responsibilities in care coordination. Evidence that reflects care coordinated for patients for hospital stays, emergency room (ER) visits, specialist care, and other services as defined by the provider, including: Indication of care coordination in care plan. Electronic or paper logs/reports of the most recent month s data for coordinated care arranged by provider or of which the provider has knowledge. 8 QUEST PCMH Program Guide

10 Activities REASON/INTENTION Requirements Add population health management to your practice. Make your practice more patientcentered. Expand PCP s focus from the individual to a population health management level. Registries ensure attention to patients who are seen rarely or non-compliant with followup visits. To document outcomes of care/processes that are important components of the PCMH model of care. Physician has process to track and monitor patient clinical values and quality outcomes. Self-improvement through continuous quality improvement (QI) is necessary to measure interventional outcomes. Patientcenteredness is a specific goal of the PCMH model of care. 1. Plan care proactively by using registries for preventive care and chronic diseases. 2. Share data for clinical outcomes and show trends toward improvement. 1. Implement quality improvement (QI) projects to improve patientcenteredness, effectiveness, and efficiency. Accountability Criteria Conduct review of registries for preventive care and chronic disease at least quarterly and perform outreach to patients as needed. Maintain non-claims data related to identified quality measures for PCMH (Adult: Diabetes measures [BP, LDL, A1c >9%] and Hypertension measure [BP]; Pediatrics: BMI & submission of CSHCN screening [or other tool]). Complete a minimum of 2 QI projects that focus on different quality measures within 12 months of execution of PCMH agreement (e.g., improvement on quality metric or patient access to services). At least 1 QI plan and related activities are in conjunction with physician organizationdefined QI priorities. EXAMPLES OF ways to meet the REQUIREMENTS Documentation of regular log-in to the reporting platform and access to care planning registry OR documentation of condition-specific disease registry from electronic health record (EHR). Policy and procedure on how provider/staff incorporates registry data into workflow of patient office visit. Documentation of outreach to patient by telephone, , or mail for preventive care and chronic diseases (e.g., outreach reminders). Documentation of closure of gaps in care over time. Use of information from reports to manage specific populations of patients, including: -- Tracking blood pressure of patients with hypertension. -- Tracking A1c of patients with diabetes. -- Tracking LDL of patients with diabetes and CAD. -- Tracking BMI of children and adults. For Internal Medicine, General, and Family Practice: The practice must demonstrate the capability to collect and maintain data on 4 PCMH adult measures (see PCMH Additional Reporting Requirements on page 15). For Pediatricians: The practice must demonstrate the capability to collect and maintain data on 4 PCMH pediatric measures (see PCMH Additional Reporting Requirements on page 15). Evidence that provider has participated in at least 2 QI initiatives per year, including the review of their patient population, which may include unique registries, baseline metrics, and post-intervention evaluation measurements. Documentation of provider s understanding of the Plan-Do-Study-Act (PDSA) process and their role in the QI project. Documentation that each component of the PDSA cycle or its equivalent has been addressed. Analysis to include the lesson learned from the QI activity. QUEST PCMH Program Guide 9

11 2 Activities REASON/INTENTION Requirements 10 QUEST PCMH Program Guide Accountability Criteria EXAMPLES OF ways to meet the REQUIREMENTS Level 2 ($1.50 PMPM) Level 1 activities are annual expectations and are required as part of level 2. To promote support and alignment in meeting CMS meaningful use requirements and coordinate technology with improvements in the care and safety of patients. To help individual providers identify the strengths and weaknesses patients see in their practice. To promote support and alignment in meeting CMS meaningful use requirements and coordinate technology with improvements in the care and safety of patients. Defines expectations of provider and patient regarding roles and responsibilities in the PCMH. 1. Actively use EHR for e-prescribing, maintaining electronic charts, and electronic receipt of lab results. 2. Gain patientcentered care insights through an annual PCMH providerspecific survey on patient experience. Demonstrate active use of EHR as determined by CMS, Hawaii Pacific Regional Extension Center (HPREC), the Office of the National Coordinator for Health Information Technology (ONC), or other agreedupon source. Send/provide survey to a percentage of the patients who received care within the year or to all patients during one quarter of the year, sufficient to accumulate responses from at least 50 patients. Level 3 ($2.00 PMPM) Levels 1 and 2 are required activities as part of Level Achieve objectives of meaningful use. 2. Implement use of providerpatient medical home agreements. Demonstrate achievement of meaningful use objectives of EHR as defined by CMS. Demonstrate the process and tracking of agreements with patients regarding PCMH obligations. HPREC certification/attestation. Copies of output from work with the HPREC (e.g., secure two-way communication system and website access for appointment scheduling, medication refills, referrals, and test results). Note: HPREC will provide documentation (certification/attestation) to the PCP s physician organization that the requirement has been met. Evidence that the provider or practice conducted a patient experience survey via telephone, paper, or electronic means, with a random sample of patients who received care during the year, and responses from at least 50 patients per provider, including: HMSA-accepted surveys that include 2 : -- CAHPS PCMH Survey ( Surveys-Guidance/CG/Get-Surveys-and- Instructions.aspx). -- CAHPS Clinician and Group Survey ( Get-Surveys-and-Instructions.aspx). -- CAHMI Promoting Healthy Development Survey ( -- Family Voices Family-Centered Care Self- Assessment Tool (org2.democracyinaction. org/o/6739/images/fcca_familytool.pdf). A report summarizing the results of patient feedback. HPREC or ONC certification/attestation. Copies of output from work with HPREC (e.g., secure two-way communication system and website access for appointment scheduling, medication refills, referrals, and test results). Note: HPREC will provide documentation (certification/attestation) to the PCP s physician organization that the requirement has been met. HPREC will produce a Meaningful Use Gap Analysis report indicating the percent of meaningful use core priorities and overall assessment. Evidence that the practice has a process for providing patients with information and materials about PCMH obligations and tracks the number of completed agreements, including: A patient compact (a written agreement between the practice and patient specifying their roles in PCMH). Patient brochure. Written statement for the patient. 2 Use of the assessment tool may require registration and/or payment of fees. Refer to the individual organizations for details.

12 PCMH Requirements for Physician Organizations The physician organization plays an instrumental role in supporting PCPs for PCMH. The physician organization leads PCP collaboratives, supports quality improvement, coordinates resources, and facilitates education and training, regardless of the plan a member is enrolled in, once providers contract to become a PCMH. The physician organization s leadership and support is critical to achieving the goals of the PCMH program. Below are the requirements for any physician organization that contracts to participate in the PCMH program. Minimum Structure (meets all criteria) 1. Physician organization has an executed PCMH agreement with HMSA. 2. Physician organization has a QI committee or structure. 3. Physician organization has a designated physician leader who serves as a medical director or in a comparable role, provides leadership, and interacts with providers on a regular basis. 4. Physician organization is a legal entity. 5. Physician organization includes at least five PCPs. 6. Physician organization is able to provide budget and financial statements for the organization as needed. Operations (implements all criteria) 1. Physician organization meets with HMSA s PCMH integrated support team to support the accomplishment of PCMH goals and transformation activities. 2. Physician organization s medical director(s) participates in HMSA s PCMH collaborative. 3. Physician organization collaborates with industry experts to learn effective PCMH leadership techniques. 4. Physician organization shares its PCMH contract template with HMSA to ensure consensus on PCP roles and responsibilities before the physician organization enrolls the first provider into the PCMH, and notifies HMSA of any material changes. 5. Physician organization contracts with providers, facilitates provider enrollment in PCMH, and reports to HMSA monthly. 6. Physician organization provides oversight and ensures that PCMH providers meet their obligations under the PCMH agreement. 7. Physician organization supports and tracks providers progress on PCMH level 1, 2, and/or 3 requirements and is responsible for reviewing, validating, and submitting level verification change requests for PCPs. 8. Physician organization provides reports to HMSA on PCMH activities: PCPs achievement of levels 1, 2, and/or 3 for financial payout, transformation activities, etc. 9. Physician organization informs member providers of its PCMH support services. 10. Physician organization determines inclusion/exclusion of physician extenders and physician specialists as defined PCPs for PCMH. HMSA enrolled only PCPs in certain specialties in PCMH in Beginning in 2012, HMSA will continue to develop its program to include the addition of other specialties and physician extenders. The leadership responsibilities of physician organizations as needed for PCMH are described in detail on the next page. The primary source of information about all HMSA services for physician organizations is HMSA s PCMH integrated support team. The team will provide resources to support each physician organization in the development and execution of its respective PCMH, including data and analytics, education and training, and many other services. The details of this support will be discussed during the contracting phase with each physician organization and further during the post-contracting planning meeting. QUEST PCMH Program Guide 11

13 Physician Organization Leadership Responsibilities The matrix below describes the types of physician organization leadership responsibilities needed for PCMH with examples of proof that responsibilities have been met. The requirements are critical in working toward meaningful results for PCMH and are based on experience with existing PCMH collaborations. In addition, physician organizations should refer to their PCMH contract for additional obligations. Physician Organization Leadership Responsibilities Examples of proof that responsibilities have been met LC 1 Provide leadership and coordinate regular meetings. LC 2 Engage providers to develop PCMH. LC 3 Use an assessment to determine provider readiness for PCMH. QI 1 Establish a minimum of 3 QI priorities. QI 2 Monitor performance, distribute quality reports, and facilitate discussion on QI activities. QI 3 Reduce variation in quality metrics among PCPs. QI 4 Implement a minimum of 2 utilization reduction activities. Leading Provider Collaborative (LC) Meetings with PCMH PCPs at least 12 times per year. Meeting minutes reflect attendance and topic related to PCMH and/or QI. Report summarizing the following: -- Number of PCPs with PCMH agreements. -- Number of PCPs participating in QI action planning. -- Number of PCMH-readiness assessments completed by PCPs. Reports reflecting PCMH PCPs progress on levels 1, 2, or 3. Apply physician organization resources toward practice transformation and QI projects. Quality Improvement (QI) Report summarizing number of PCPs with QI action plans and a description of the focus of action plans. Physician organization QI work plan. Copy of QI discussion and planning documents facilitated by the physician organization. Improvement in quality metrics/reduction in variation (results should be achieved within 6 9 months). Utilization reduction activities, which may include ER visit reduction, inpatient re-admission reduction, or pharmacy cost compliance. Coordinated Resources (CR) & Advanced Technology CR 1 Direct effective use of shared resources. Report summarizing the following: -- Number of PCPs with EHR. -- Number of meetings/sessions promoting active use of EHR. CR 2 Support implementation of care coordination. -- Number of sessions to educate PCPs on use of care coordinators. Redesign of functions within the PCP s office that includes care coordination by current staff. CR 3 Support use of EHR and other technologies Implementation of high-risk care coordination/patient education/group visits. (EHR, E-visits, etc.). Assistance with implementation of patient/family-centered care surveys. ET 1 Coordinate orientation for new PCMH providers. Education and Training (ET) Report of new PCMH orientation sessions conducted, including attendance record. Orientation materials for PCMH PCPs available for review. After a physician organization enrolls in a PCMH, HMSA s PCMH integrated support team will help it develop a plan to meet PCMH requirements, including establishing regular meetings and a structure for status reporting. The physician organization may hold planning sessions and PCMH orientation sessions at its discretion to discuss PCMH roles and responsibilities and develop a work plan to assist the PCP in developing a PCMH. 12 QUEST PCMH Program Guide

14 Integrated Support Team Overview HMSA s PCMH integrated support team is available to help coach and support physician organizations to develop a sustainable PCMH. Once a PCMH contract has been signed and executed, the team can begin working with the physician organization on their PCMH obligations through a series of collaborative sessions. While the team s support may vary depending on the goals and priorities of each physician organization, it will ensure that all meet the same goals and objectives of HMSA s PCMH program. The team will provide the following services to physician organizations: Manage the relationship between HMSA and physician organizations that are participating in HMSA s PCMH and pay-for-quality programs. Facilitate understanding of and leadership in the PCMH. Provide tactical support for both HMSA s PCMH and pay-for-quality programs. The team will evolve over time to provide appropriate support to the physician organizations. To learn more, please contact your Provider Relations and Advocacy representative. Tier 0 - Internet Physician Organization (PO) User Guides? FAQs Inquiry or Issue Tutorials Escalate Inquiry or Issue Tier 1 Integrated Support Team (IST) Leaders Tier 2 IST Members Tier 3- Program Leadership Escalate Acknowledge 1 business day Close Loop *5 business days * If the inquiry or issue goes to the IST Team, it may take up to 7 business days HMSA PO Leader Healthways Service Leader Acknowledge 1 business day Resolve 3 business days Care Liaison Data Analyst PO Resource Pool of Resources Program Leadership & Advisory Team Resolve 7 business days QUEST PCMH Program Guide 13

15 Evaluation of PCMH Collaboration 3 As stated in the introduction, the ultimate goal for the PCMH program is to build a sustainable health care system that enables access to affordable, quality care at the right time in the right place. While quality may be difficult to define and measure, there is growing consensus among health professionals, consumers, employers, health plans, and a number of third-party entities around a core set of quality measures that encompass both process and outcome metrics. The multi-stakeholder organization National Quality Forum (NQF) is the gold standard for evaluation and endorsement of these measures. In recent years, the NQF has expanded its measures to include additional quality measures that cover the entire continuum of care across all settings. NCQA has continued to refine the Healthcare Effectiveness Data and Information Set (HEDIS) measurement system, which has been widely applied to health plans for the past 20 years and is seen throughout the medical profession as a highly credible set of measures. HEDIS is updated annually to reflect best medical practices consistent with scientific advancement. The technical specifications are transparent and can be applied to health plans, providers, and physician organizations. NCQA has also developed an objective process for PCMH certification of provider practices. measure rates of inpatient hospitalizations that could have been avoided with access to optimal outpatient management, particularly of chronic conditions. In addition, there are a number of standardized instruments to measure patient satisfaction, which can be used in their entirety or as a subset. The PCMH program will use all of these nationally recognized quality measurement standards as well as a number of other measures that are directly applicable to the goals of the program. HMSA plans to use the FOCUS framework to measure the overall success of implementing PCMH. FOCUS stands for: Financial. Operations. Clinical. Utilization. Satisfaction. HMSA will work with the physician organizations to develop incremental measurements to monitor progress on improving quality and containing overall health care costs. The Agency for Healthcare Research and Quality has also contributed care standards related to potentially avoidable poor outcomes (also called preventable quality indicators ), which 3 3 Source: CareFirst s PCMH Program and Guidelines. 14 QUEST PCMH Program Guide

16 Additional Reporting Requirements One of PCMH s core principles is to improve quality of care for the patient. HMSA s primary care pay-for-quality program builds upon experience gained through the Practitioner Quality and Service Recognition and Quality & Performance programs to create a pay-for-quality program aligned with the challenges and opportunities of PCPs. It is a single program with a single set of metrics servicing HMSA s HMO and PPO populations. A complete description of HMSA s primary care pay-for-quality program is available on hmsa.com. PCMH builds on the pay-for-quality program to improve health outcomes for the patient. Additional quality metrics, designed to better use non-claims data, have been established to move us along the quality continuum. PCPs participating in PCMH are required to report the following new, additional metrics. Generalists (i.e., general practice and family practice physicians, APRNs, and physician assistants) and physicians doubleboarded in internal medicine and pediatrics will be responsible for all adult and pediatric requirements. Internal medicine physicians will be responsible for only adult requirements; pediatricians will be responsible for only pediatric requirements. HMSA is developing a process to support the submission of these reports and will notify providers when it is established. Pediatric Requirements: PCMH Pediatric Measures Weight assessment and counseling for nutrition and physical activity for children/adolescents (BMI measurement). Completion of the child with special needs screener. Completion of the familycentered self-care assessment tool family. Completion of the familycentered self-care assessment tool provider. Pediatric Measure Definitions Reporting Guidelines Non-claims data (e.g., BP readings, lab values, BMI). Submission (via Excel spreadsheet, the reporting platform, data feed from EHR, etc.) of non-claims data that are useable for HEDIS and can be mapped to codes such as CPT and Logical Observation Identifiers Names and Codes (LOINC). Weight assessment and counseling for nutrition and physical activity for children/adolescents (BMI measurement) The percentage of members age 3 17 years who had an outpatient visit with a PCP or ob-gyn and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year. Because BMI norms for youth vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. Completion of the child with special needs screener To be defined with assistance from the Hawaii Chapter of the American Academy of Pediatrics (HAAP). Completion of the family-centered self-care assessment tool family To be defined with assistance from HAAP. Completion of the family-centered self-care assessment tool provider To be defined with assistance from HAAP. Adult Requirements: PCMH Adult Measures CDC: Blood pressure control (<140/90). CDC: HbA1c (poor) control (>9%). CDC: LDL-C controlled <100 mg/dl. Controlling high blood pressure. Reporting Guidelines Non-claims data (e.g., BP readings, lab values, BMI). Submission (via Excel spreadsheet, the reporting platform, data feed from EHR, etc.) of non-claims data that are useable for HEDIS and can be mapped to codes such as CPT and LOINC. Adult Measure Definitions CDC: Blood pressure control (<140/90) Percentage of adult patients with diabetes age years whose most recent BP reading during the measurement year is <140/90. The member is not compliant if their BP is 140/90 mm Hg or if there was no BP reading during the measurement year. CDC: HbA1c (poor) control (>9%) Percentage of adult patients with diabetes age years whose most recent HbA1c test during the measurement year is >9.0% or whose HbA1c was not measured. (Note: A lower score indicates better performance.) CDC: LDL-C controlled <100 mg/dl Percentage of adult patients with diabetes age years whose most recent LDL-C level during the measurement year is <100 mg/dl, as documented through automated laboratory data or medical record review. Controlling high blood pressure The percentage of members age years who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90) during the measurement year. The member is not compliant if the BP is 140/90 mm Hg or if there was no BP reading during the measurement year. Quality and Performance Reports To help providers more effectively execute QI action plans and positively impact their pay-for-quality performance, HMSA will provide data and analytic reports on quality performance at least quarterly through the reporting platform. QUEST PCMH Program Guide 15

17 Pay-for-Quality Program Summary As a pay-for-quality initiative, this program translates accepted evidence-based medicine into standards that can be objectively measured through analyses of claims and other verifiable data. Establishing measurable quality standards is a constantly evolving process as new clinical evidence is discovered and new treatments are developed. The standards adopted for the pay-for-quality program are reviewed and updated regularly to reflect new advances. Measurement Responsibility Generalists (family practice, general practice, urgent care, APRN, and physician assistant) and providers double-boarded in internal medicine and pediatrics will be responsible for all measures (adult and pediatric). Clinics or FQHCs who are directly assigned members will be treated as generalists and will be responsible for all pediatric and adult measures. Internal medicine providers will be responsible for only adult measures; pediatricians will be responsible for only pediatric measures. Please see Appendix A on page 32 for a detailed description of pay-for-quality clinical measures. Scoring Period Scoring Period First quarter Second quarter Third quarter Fourth quarter Measurement period Oct. 1, 2011, through Sept. 30, 2012 Jan. 1, 2012, through Dec. 31, 2012 April 1, 2012, through March. 31, 2013 July 1, 2012, through June 30, 2013 Baseline period Oct. 1, 2010, through Sept. 30, 2011 Jan. 1, 2011, through Dec. 31, 2011 April 1, 2011, through March 31, 2012 July 1, 2011, through June 30, 2012 The variable payment formula calculation will be based on: Patient panel count. Pay-for-quality per member per month (PMPM) budget (in 2012, the budget is $3 PMPM). Measure weighting. o Individual measure patient panel count. o Individual measure importance and effort. Current period performance compared to prior period performance and national performance percentile levels determine points earned per measure. (See Baseline Quality Performance Report, page 24.) Points earned and weighting are factors that determine the actual portion of the potential award earned. For a more detailed explanation, see Quality Scoring Calculations, page 25. Expectations Providers must agree to the following: Participate fully in the pay-for-quality program and the quality improvement activities necessary to evaluate their performance and improvement. Accept HMSA s determination of the pay-for-quality score and understand that the score will serve as the basis for any pay-for-quality award from HMSA. Providers may request reconsideration of their score and/or award, but must follow established procedures for reconsideration. Payment Philosophy Under the primary care pay-for-quality program, payment varies predictably with the provider s performance and improvement within the quality measures based on a predetermined formula. The provider is paid for performance as well as improvement in a given measure. Points scored for performance and points scored for improvement determine total points, which translate into monetary awards. 16 QUEST Pay-For-Quality Program Guide

18 Cozeva The Cozeva platform is a dynamic population health management tool that allows providers to access their data in a meaningful, actionable, and supportive manner. HMSA strongly encourages the use of Cozeva to help you maximize the quality of your care and your pay-for-quality awards. The use of Cozeva over time gives you an integrated approach to managing each of your patient s chronic conditions and comorbidities. Cozeva allows standards of care delivered by any and all providers caring for your patient to be reported and monitored accurately. It provides a care planning registry that identifies gaps in care in accordance with the best standards of care. You can track medication adherence by identifying prescriptions filled, display lab results when available, and add data from the medical record to demonstrate care in accordance with standards. Your ability to identify gaps in care and manage visits allows better engagement with your patients. These and other tools and reports are described below: Patient Panel: A monthly list of patients attributed to you by HMSA from all lines of business. Care Planning Registry: A platform that you and your care teams can use to identify patients who may benefit from additional care as related to pay-for-quality program metrics. The Care Planning Registry is refreshed every week. Supplemental Data: Allows you to supplement claimsbased data with information from your clinical records and immediately updates your Care Planning Registry. Member Engagement: Helps you deliver appointment reminders, alerts, and secure messages to your patients. You can also collaborate with your patients designated family members and friends to encourage better health care. Baseline Quality Report: A report of performance measured during the baseline period. The report shows you where you currently rank in comparison to national standards and presents the basis of comparison to determine improvement. Performance Quality Report: A report to measure your performance for each quarter and for the year as a whole. Provides access to a detailed view of each measure, including National Percentile Target Rate and Estimated Quality Pay by percentile ranking. QUEST Pay-For-Quality Program Guide 17

19 Pay-for-Quality Data Sources and Supplemental Data Process The pay-for-quality program will use claims data as the primary source to identify patients who meet the criteria to be in the denominator for a given measure. The program will also use claims data as the primary source to identify patients who meet the numerator criteria or satisfy the underlying care opportunity. Claims data, on occasion, may not be adequate to exclude a patient from the denominator. Claims data may identify patients as needing a service when they do not. For example, claims data may indicate that a woman needs a breast cancer screening when the medical record indicates that she has had a bilateral mastectomy. The pay-for-quality program will allow the provider to submit supplemental data and attest to the validity of the data to exclude a patient from the measure patient panel or satisfy the criteria for a favorable numerator score. The pay-for-quality program includes a supplemental data audit plan. The audit plan will select supplemental data submissions using various methods and request medical records to support supplemental data submissions. HMSA s Quality Improvement (QI) unit will conduct the supplemental data audits every July and December. If you do not comply with audit requests for medical records to support supplemental data, the data will not be counted toward your pay-for-quality results. You must submit the requested medical records by mail or fax by the date indicated in the request. HMSA will not pick up records or perform on-site chart reviews. All self-reported information must be consistent with the information that was recorded in the patient s medical record and must include the exact service and the date on which the service was performed. For example, a patient s medical record may reflect that a flexible sigmoidoscopy has been performed. To satisfy the colorectal cancer screening standard of care, the flexible sigmoidoscopy procedure date must be less than five years prior to the end of the measurement period. If the date is more than five years prior to the end of the measurement period, the standard will not be satisfied. Additionally, the medical record must include a result to show that a test has been ordered and performed. Some standards, such as HbA1c testing, do not require an actual lab value result to be reported. Other care standards, such as HbA1c poor control, do require an actual lab value result. The documentation for the supplemental submission process will make the submission requirements clear. Providers are able to submit requests for updates to information in the Care Planning Registry to allow for: Evidence of services that were rendered in the provider s medical record. Evidence that a patient is not eligible for a given measure. As provided for in their participating provider agreements with HMSA, practitioners or group administrators can submit an inquiry or official request for reconsideration of their pay-forquality score and/or award by HMSA. If you do not submit the requested medical record, the supplemental data entry that was audited will be deleted. If you submit the patient s medical record and it does not support the data entry, QI will send a warning letter that describes the discrepancy and allows for another opportunity to submit appropriate clinical evidence. You will then have 10 business days to submit the correct evidence before the entry in question will be deleted and 10 additional entries, or 10 percent of all other entries (whichever is less), will be audited. If the additional audit results in more than one invalid supplemental data entry, all of your supplemental data entries will be deleted. Appendix A identifies the supplemental data submission opportunities and requirements for each measure. 18 QUEST Pay-For-Quality Program Guide

20 Inquiry and Request for Reconsideration of Pay-for- Quality Award Payment and Methodology Inquiries An inquiry is defined as a request for additional information about the pay-for-quality program. General inquiries about the pay-for-quality program (not specific to scores or results) will be answered at any time throughout the year. HMSA will also accept any suggestions for program changes throughout the year with the understanding that there is no guarantee the proposed change will be implemented. Inquiries may be initiated by: Letter. Mail to Hawaii Medical Service Association, Attn: POA Rm. 503, P.O. Box 860, Honolulu, HI to PSInquiries@hmsa.com. Phone. Please call HMSA s Provider Services unit. For assistance identifying your contact, please call on Oahu or 1 (877) toll-free on the Neighbor Islands. Using the feedback button on the pay-for-quality website. Requests for Reconsideration Reconsideration is defined as a request for HMSA to change a determination it has made regarding a provider s reported scores and/or award. Note: When a particular service is shown as incomplete in the provider s Care Planning Registry, submission of supplemental data will show that the service was performed. When a situation does not match one of the Supplemental Data options, a Supplemental Data Request for Reconsideration may be submitted. Please submit the request within 30 days following the posting of performance reports for reconsideration. Request for Reconsideration Process The following describes the process for Supplemental Data Requests for Reconsideration: 1) Please submit one Supplemental Request for Reconsideration form per patient. The form is located on the reporting platform. 2) HMSA will review and respond to your request no later than 30 days from receipt of your request. An HMSA medical director will always be included in the review of your requests. 3) If you are dissatisfied with HMSA s response to your request for reconsideration, additional dispute resolution remedies are available to you under your HMSA participating provider agreement. Submit form to Provider Services: Fax: on Oahu psinquiries@hmsa.com Mailing address: Hawaii Medical Service Association Attn: POA Rm. 503 P.O. Box 860 Honolulu, HI Questions If you have questions, please contact HMSA s Provider Services unit. For assistance identifying your contact, please call on Oahu or 1 (877) toll-free on the Neighbor Islands. A request for reconsideration submitted within the criteria explained below should include supporting data, if available. (A request for reconsideration will not be accepted verbally.) Requests for consideration must communicate: Why the online supplemental data process did not enable the provider to record supplemental data that satisfies denominator exclusion criteria or numerator inclusion criteria. Clinical rationale and supporting citations for denominator exclusion or numerator inclusion. Measure. Patient. Medical record information to support denominator exclusion or numerator inclusion such as: o Service/procedure. o Date of service. o Diagnosis. o Lab result. QUEST Pay-For-Quality Program Guide 19

21 Adult Primary Care Pay-for-Quality Clinical Measures Preventive Health Screening Measure Breast cancer Cervical cancer Colorectal cancer Chlamydia High-Level Definition The percentage of women years of age who had one or more mammograms during the current measurement period or the prior measurement period. (USPSTF 2002 Guideline) The percentage of women years of age who received one or more Pap tests during the current measurement period or the two prior measurement periods. (USPSTF Guideline) The percentage of patients years of age who had appropriate screening for colorectal cancer through one of these measures: fecal occult blood test (FOBT) during the current measurement period, flexible sigmoidoscopy during the measurement period or the four prior measurement periods, or colonoscopy during the current measurement period or the nine prior measurement periods. (USPSTF Guideline) The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the current measurement period. (USPSTF Guideline) Heart Disease Measure Cholesterol management for patients with cardiovascular conditions - LDL-C Screening Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Annual monitoring for members on diuretics High-Level Definition The percentage of patients years of age who were discharged alive for AMI, coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) between the 1st and 305th days of the prior measurement period, or who had a diagnosis of ischemic vascular disease (IVD) during the current measurement period and the prior measurement period, and who also had an LDL-C screening during the measurement period. The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for ACE or ARB during the measurement period and at least one therapeutic monitoring event for the therapeutic agent. The percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for diuretics during the measurement period and at least one therapeutic monitoring event for the therapeutic agent. 20 QUEST Pay-For-Quality Program Guide

22 Adult Primary Care Pay-for-Quality Clinical Measures Diabetes Measure Eye exam LDL-C screening HbA1c testing Nephropathy High-Level Definition Percentage of patients with diabetes years of age who received a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the current measurement period, or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the prior measurement period. (American Diabetes Association Guideline) Percentage of patients with diabetes years of age receiving at least one lipid profile (or ALL component tests) during the current measurement period. (American Diabetes Association Guideline) Percentage of patients with diabetes years of age receiving one or more HbA1c test per measurement period. (American Diabetes Association Guideline) Percentage of diabetes patients years of age who had at least one test for microalbumin during the current measurement period or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria; ACE inhibitor/arb therapy during the measurement period is also acceptable evidence). (American Diabetes Association Guideline) Appropriate Respiratory Care Measure High-Level Definition Use of appropriate medications for people with asthma The percentage of patients identified as having persistent asthma during the current and prior measurement periods and who were dispensed appropriate medications. Use of spirometry testing in the assessment and diagnosis of COPD The percentage of members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. Avoidance of antibiotic treatment in adults with acute bronchitis The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. *This measure is reported as an inverted rate. Higher rate indicates inappropriate treatment of adults with acute bronchitis. QUEST Pay-For-Quality Program Guide 21

23 Pediatric Primary Care Pay-for-Quality Clinical Measures Preventive Health screenings Measure Chlamydia screening in women Well-child visits in the first 15 months of life Well-child visits in the third, fourth, fifth, and sixth years of life Individual Immunization Diphtheria, Tetanus, and Acellular Pertussis (DTaP) Inactivated Poliovirus (IPV) Measles, Mumps & Rubella (MMR) Haemophilus Influenzae Type b (HiB) Hepatitis B (HepB) Varicella (VZV) Pneumococcal Conjugate (PCV) High-Level Definition The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the current measurement period. The percentage of patients who turned 15 months old during the measurement period with six well-child visits with a PCP. The percentage of patients 3 6 years of age who received one or more well-child visits with a PCP during the current measurement period. High-Level Definition At least four DTaP vaccinations with different dates of service on or before the child s second birthday. DTaP administered prior to 42 days after birth cannot be counted. At least three IPV vaccinations with different dates of service on or before the child s second birthday. IPV administered prior to 42 days after birth cannot be counted. At least one MMR vaccination with a date of service on or before the child s second birthday. At least three HiB vaccinations with different dates of service on or before the child s second birthday. HiB administered prior to 42 days after birth cannot be counted. At least two outpatient HepB vaccinations with different dates of service on or before the child s second birthday. At least one VZV vaccination with a date of service on or before the child s second birthday. At least four PCV vaccinations with different dates of service on or before the child s second birthday. Appropriate Respiratory Care Measure Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Use of appropriate medications for children with asthma INDIVIDUAL IMMUNIZATION Meningococcal Tetanus, Diphtheria, and Acellular Pertussis (Tdap) or Tetanus and Diphtheria (Td) Immunizations for Adolescents High-Level Definition The percentage of children 2 18 years of age who were diagnosed with pharyngitis, prescribed an antibiotic, and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). The percentage of children 3 months 18 years of age who were given a diagnosis of upper respiratory infection and were not dispensed an antibiotic prescription. The percentage of patients identified as having persistent asthma during the current and prior measurement periods and who were dispensed appropriate medications. HIGH-LEVEL DEFINITION One meningococcal vaccine on or between adolescent s 11th and 13th birthday. One Tdap or one Td vaccine on or between adolescent s 10th and 13th birthday. Percentage of adolescents having all of the above immunizations on or before their 13th birthday. Childhood Immunizations Percentage of children having all of the above immunizations on or before their second birthday. 22 QUEST Pay-For-Quality Program Guide For more details, see Appendix A on page 32.

24 Pay-for-Quality Payment Maximum Payment Potential The QUEST pay-for-quality program counts the eligible patients in the PCP s primary care panel (the patient panel count) at the end of each month and multiplies this number by $3.00 to calculate maximum payment potential. For example: A provider starts the year with 1,050 HMSA QUEST patients. Month Primary Care Patient Count PMPM Amount Total Monthly Potential July 1,050 $3.00 $3,150 August 1,055 $3.00 $3,165 September 1,075 $3.00 $3,225 Quarter 1 3,180 $9,540 Subtotal October 1,070 $3.00 $3,210 November 1,065 $3.00 $3,195 December 1,055 $3.00 $3,165 Quarter 2 3,190 $9,570 Subtotal January 1,050 $3.00 $3,150 February 1,070 $3.00 $3,210 March 1,070 $3.00 $3,210 Quarter 3 3,190 $9,570 Subtotal April 1,095 $3.00 $3,285 May 1,070 $3.00 $3,210 June 1,067 $3.00 $3,201 Quarter 4 3,232 $9,696 Subtotal Annual Total 12,792 $38, Quality Payments Pay-for-quality payments are based on cumulative performance during a rolling 12-month period compared to a baseline corresponding to the rolling 12-month period that begins a year prior to the performance period. Scoring and payment are calculated quarterly. For example, the first quarter s payment and scoring will be based on the provider s performance over the 12-month period beginning on Oct. 1, 2011, and ending on Sept. 30, 2012, compared to a baseline performance during the same period the year before. The second quarter s payment and scoring will be based on the period of Jan. 1, 2012, to Dec. 31, 2012, and so on. See Scoring Period table on page 16 for details. Payments and reports will be sent out about two months after the close of a quarter to allow for a one-month claims run out and one month of processing. For the first quarter of 2012, payments and reports should be received in December Reconciliations will be made quarterly. The program establishes a maximum potential award and the portion a provider earns is determined by a threshold scoring model, which allocates performance and improvement points based on a provider s performance compared to national percentile levels and improvement over the percentile level achieved in the prior measurement period. In this example, the maximum pay-for-quality payment for the first quarter is $9,540. This equals the Est. Max Quality Pay at the top of the Baseline Quality Performance Report (page 24). Award Payment Conditions To be eligible for the QUEST pay-for-quality program, a provider must be participating in HMSA s QUEST plan and practicing in the state of Hawaii at the end of the quarterly period, and must have submitted claims to HMSA during the measurement period. If the provider or group administrator is eligible to receive an award, the award check and remittance report will be sent to the payee(s) that the provider or group administrator designated for HMSA claims payments as of the end of each quarter. QUEST Pay-For-Quality Program Guide 23

25 Example Baseline Quality Performance Report - Quarter One The table below represents the Baseline Quality Performance Report for Dr. Aloha Lee (internal medicine). Measurement Period: 10/1/2011 to 9/30/2012 Baseline Period: 10/1/2010 to 9/30/2011 Provider: Lee, Aloha Est. Patient Panel Size: 1,060 Est. Max Quality Pay*: $9,540 I. II. III. IV. V. VI. VII. Measure Your Estimated Panel Size Your Base Year Numerator Count Your Base Year Rate Your National % Rank Number of additional Patients to Achieve 90th National % Estimated Max Award Estimated Share of Max Quality Pay Breast cancer screening % 90th 0 $1, % Cervical cancer screening % 90th 0 $1, % Colorectal cancer screening % 50th 34 $1, % Chlamydia screening for women % 90th 0 $ % Comprehensive diabetes care - eye exam % 10th 37 $ % Comprehensive diabetes care - LDL-C screening % 90th 0 $ % Comprehensive diabetes care - HbA1c testing % 90th 0 $ % Comprehensive diabetes care - medical attention for nephropathy % 75th 2 $1, % Use of appropriate medications for people with asthma % <10th 4 $ % Cholesterol management for patients with cardiovascular conditions - LDL-C screening % 90th 0 $ % Use of spirometry testing in the assessment and diagnosis of COPD % 90th 0 $ % Avoidance of antibiotic treatment in adults with acute bronchitis % 90th 0 $ % Annual monitoring for patients on persistent medications - ACE/ARB % 25th 15 $ % Annual monitoring for patients on persistent medications - diuretics % 75th 1 $ % Total 2,290 $9, % * Est. Max Quality Pay = Member Months x PMPM Rate. 24 QUEST Pay-For-Quality Program Guide

26 Quality Scoring Calculations Step 1: Calculation of Maximum Payment for Each Measure To calculate the Estimated Max Award for each measure (column VI on the sample Baseline Quality Performance Reports), follow these steps. The figures below will use numbers for the breast cancer screening measure from Dr. Lee s sample summary. a. Weight Each Measure s Patient Panel Take your estimated panel size (column I) for each measure and divide by the total patient count across all (adult and/or pediatric) measures (sum of column I). The result is the patient panel weight factor for each measure. Example: Dr. Lee s breast cancer screening is 371/2,290 = b. Weight Each Measure s Importance and Effort Consult the tables on page 26 for Adult, Pediatric, and Generalist measures. Example: The breast cancer screening weight adjustment factor is 5.00 percent for Dr. Lee. c. Combine Weight Factors Multiply the patient panel weight factor (from section a) by the importance and effort weight factor (from section b) for a combined weight factor for each measure. Example: Dr. Lee s breast cancer screening combined weight factor is.05 X = d. Total Combined Weight Factors Add the combined weight factors (from section c) of all measures for total combined weight. Example: See table, below. e. Normalize Combined Weight Factors Divide the combined weight factor for each measure (from section c) by the total combined weight (from section d). This is your normalized combined weight factor for each measure. Total Combined Weight Factors (example) Dr. Lee (sum of combined weight factors for 14 measures) = (371/2,290) X.05 (399/2,290) X.05 (553/2,290) X.05 (4/2,290) X.05 (113/2,290) X.05 (113/2,290) X.05 (113/2,290) X.10 (113/2,290) X.20 (4/2,290) X.15 (47/2,290) X.05 (4/2,290) X.05 (82/2,290) X.05 (278/2,290) X.05 + (96/2,290) X.05 Total Combined Weight Factor is Example: Dr. Lee s breast cancer screening normalized weight factor is / = f. Calculate Max Award for Each Measure Multiply the normalized combined weight for each measure (from section e) by the Est. Max Quality Pay (from the Baseline Quality Performance Report) to calculate your Estimated Max Award for each measure. Example: Dr. Lee s breast cancer screening max award is $1,287 ( x $9,540). NOTE: The patient count, and hence potential award, patient panel weight factor, and all calculations involving those figures will not be accurate until the measurement period patient panel counts are finalized. Thus the figures in the Baseline Quality Performance Report and the potential award calculated at the beginning of the measurement period are estimates. QUEST Pay-For-Quality Program Guide 25

27 Importance Weight Factor Tables The importance weight factors are determined by the degree of difficulty required to complete the particular clinical process for each measure and the importance of the measure on HMSA s accreditation ranking. Adult Primary Care Importance Weight Adjustment Factor 1. Breast cancer screening % 2. Cervical cancer screening % 3. Colorectal cancer screening % 4. Chlamydia screening for women % 5. Comprehensive diabetes care - eye exam 6. Comprehensive diabetes care - LDL-C screening 7. Comprehensive diabetes care - HbA1c testing 8. Comprehensive diabetes care - medical attention for nephropathy 9. Use of appropriate medications for people with asthma 10. Cholesterol management for patients with cardiovascular conditions - LDL-C screening 11. Use of spirometry testing in the assessment and diagnosis of COPD 12. Avoidance of antibiotic treatment in adults with acute bronchitis 13. Annual monitoring for patients on persistent medications - ACE/ARB 14. Annual monitoring for patients on persistent medications - diuretics Pediatric primary care % % % % % % % % % % Importance Weight Adjustment Factor 1. Well-child visits in the first 15 months of life (six or more visits) % 2. Well-child visits in the third, fourth, fifth, and sixth years of life % 3. Childhood immunization status % 4. Appropriate testing for children with pharyngitis % 5. Appropriate treatment for children with upper respiratory infection % 6. Use of appropriate medication for children with asthma % 7. Immunizations for adolescents % 8. Chlamydia screening for women % Generalist Care Importance Weight Adjustment Factor 1. Breast cancer screening % 2. Cervical cancer screening % 3. Colorectal cancer screening % 4. Chlamydia screening for women % 5. Comprehensive diabetes care - eye exam % 6. Comprehensive diabetes care - LDL-C screening % 7. Comprehensive diabetes care - HbA1c testing % 8. Comprehensive diabetes care - medical attention for nephropathy % 9. Use of appropriate medications for people with asthma % 10. Cholesterol management for patients with cardiovascular conditions % LDL-C screening 11. Use of spirometry testing in the assessment and diagnosis of COPD % 12. Avoidance of antibiotic treatment in adults with acute bronchitis % 13. Annual monitoring for patients on persistent medications - ACE/ARB % 14. Annual monitoring for patients on persistent medications - diuretics % 15. Well-child visits in the first 15 months of life (six or more visits) % 16. Well-child visits in the third, fourth, fifth, and sixth years of life % 17. Childhood immunization status % 18. Appropriate testing for children with pharyngitis % 19. Appropriate treatment for children with upper respiratory infection % 20. Immunizations for adolescents % 26 QUEST Pay-For-Quality Program Guide

28 Step 2: Performance and Improvement Points Earned To calculate performance and improvement points and the portion of the Estimated Max Award earned for each measure, follow these steps. The figures below will use numbers from three measures on Dr. Lee s sample Baseline Quality Performance Report (page 24). NOTE: New PCPs without a pre-existing patient panel will be eligible for performance points only, because there is no baseline to compare for improvement points. a. Determine your baseline period percentile. Consult the following schedules detailing national percentile thresholds for pediatric (Schedule A) and adult (Schedule B) primary care measures. Schedule C denotes percentile thresholds that will be used for generalists when there are overlapping measures between adult and pediatric populations. Your Base Year Rate for each measure determines your prior year percentile rank (column IV on Baseline Report, page 24): <10th, 10th, 25th, 50th, 75th, 90th. The percentile threshold indicates which of the six tables on the following pages to use to determine performance and improvement points. Threshold Scale Selection Schedule A: Medicaid HMO Average National Percentile Threshold Rates - Pediatric Measures Minimum Rate for the following Percentile Levels: Measure 10th 25th 50th 75th 90th 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 Childhood immunization status Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Use of appropriate medications for people with asthma Immunizations for adolescents Chlamydia screening for women These percentile levels are from NCQA Quality Compass published in Percentile Ranks reflect the physician network performance for a large number of health plans (actual numbers vary by measure). Quality Compass is a registered trademark of the National Committee for Quality Assurance (NCQA). QUEST Pay-For-Quality Program Guide 27

29 Threshold Scale Selection Schedule B: Medicaid HMO Average National Percentile Rate Threshold - Adult Primary Care Measures Minimum Rate for the following Percentile Levels: Measure 10th 25th 50th 75th 90TH Breast cancer screening Cervical cancer screening Colorectal cancer screening** Chlamydia screening for women Comprehensive diabetes care - eye exam Comprehensive diabetes care - LDL-C screening Comprehensive diabetes care - HbA1c testing Comprehensive diabetes care - medical attention for nephropathy Use of appropriate medications for people with asthma Cholesterol management for patients with cardiovascular conditions - LDL-C screening Use of spirometry testing in the assessment and diagnosis of COPD Avoidance of antibiotic treatment in adults with acute bronchitis Annual monitoring for patients on persistent medications - ACE/ARB Annual monitoring for patients on persistent medications - diuretics These percentile levels are from NCQA Quality Compass published in Percentile Ranks reflect the physician network performance for a large number of health plans (actual numbers vary by measure). ** The Commercial Quality Compass Threshold will be used for the colorectal cancer screening measure. There is no Medicaid National Quality Compass Threshold for this measure. Threshold Scale Selection Schedule C: Medicaid HMO Average National Percentile Rate Threshold - Generalist Overlapping Measures Minimum Rate for the following Percentile Levels: Measure 10th 25th 50th 75th 90TH Chlamydia screening for women Use of appropriate medications for people with asthma These percentile levels are from NCQA Quality Compass published in Percentile Ranks reflect the physician network performance for a large number of health plans (actual numbers vary by measure). Quality Compass is a registered trademark of the National Committee for Quality Assurance (NCQA). 28 QUEST Pay-For-Quality Program Guide

30 Performance and Improvement Points by Percentile Range Examples: Dr. Lee s Base Measurement Period Rate for use of appropriate medications for people with asthma was 0.00 percent, which is below the 10th percentile. Use Table 1. Dr. Lee s Base Measurement Period Rate for comprehensive diabetes care eye exam was percent, which is at the 10th percentile. Use Table 2. Dr. Lee s Base Measurement Period Rate for cholesterol management for patients with cardiovascular conditions - LDL-C screening was percent, which is at the 90th percentile. Use Table 6. Performance and Improvement Points by Percentile Range Tables The following tables correspond to the six baseline period percentile ranges and detail the performance and improvement points earned based on current year performance. Locate the row that describes your current year percentage score and note the total points earned for each measure. Table 1: Baseline Period Performance: < 10th Percentile measurement period performance Performance Points Improvement Points Total Points 10th percentile th percentile th percentile th percentile th percentile Table 2: Baseline Period Performance: 10th Percentile measurement period performance Performance Points Improvement Points Total Points 10th percentile th percentile th percentile th percentile th percentile Table 3: Baseline Period Performance: 25th Percentile Measurement period performance Performance Points Improvement Points Total Points 10th percentile th percentile th percentile th percentile th percentile QUEST Pay-For-Quality Program Guide 29

31 Table 4: Baseline Period Performance: 50th Percentile measurement Period performance Performance Points Improvement Points Total Points 10th percentile th percentile th percentile th percentile th percentile Table 5: Baseline Period Performance: 75th Percentile Measurement period performance Performance Points Improvement Points Total Points 10th percentile th percentile th percentile th percentile th percentile Table 6: Baseline Period Performance: 90th Percentile Measurement period performance Performance Points sustained excellence Total Points 10th percentile th percentile th percentile th percentile th percentile Examples: Assume Dr. Lee s measurement period performance for use of appropriate medication for people with asthma is at the 10th percentile. On Table 1, this earns 1.5 performance points, 1.0 improvement points, and 2.5 total points. Assume Dr. Lee s measurement period performance for comprehensive diabetes care eye exam is at the 50th percentile. On Table 2, this earns 5.0 performance points, 3.0 improvement points, and 8.0 total points. Assume Dr. Lee s measurement period performance for cholesterol management for patients with cardiovascular conditions - LDL-C screening is at the 90th percentile. On Table 6, this earns 10.0 performance points, 2.5 sustained excellence points, and 12.5 total points. 30 QUEST Pay-For-Quality Program Guide

32 Step 3: Calculation of Actual Payment for Each Measure To calculate the actual payment earned for each measure, note the points earned for measurement period performance (Step 2, page 27) and follow the steps below. Note: Each measure has a budget of 10 points. A provider may exceed the target and earn bonus points on individual measures. Bonus points do not increase the maximum quality award. Multiply the Estimated Max Award for each measure (column VI on the Baseline Quality Performance Report) by the total points earned for each measure and divide by 10 to determine the actual award payment for each measure. Examples: Dr. Lee earned 2.5 total points for use of appropriate medications for people with asthma, with an Estimated Max Award of $ For this measure, the actual payment earned would be X 2.5/10 = $ Dr. Lee earned 8.0 total points for comprehensive diabetes care eye exam, with an Estimated Max Award of $ For this measure, the actual payment earned would be X 8.0/10 = $ Dr. Lee earned 12.5 total points for cholesterol management for patients with cardiovascular conditions - LDL-C screening, with an Estimated Max Award of $ For this measure, the actual payment earned would be X 12.5/10 = $ Member Eligibility for Specific Measures Members who meet the following criteria will be eligible for all measures (except the childhood immunization status measure): Members must be assigned to the provider s patient panel and be eligible HMSA members for at least nine of the 12 months in the rolling 12-month performance period. The childhood immunization status measure requires the following: Members must have a PCP relationship with a pediatrician (as defined by the patient panel rules) and be eligible HMSA members during at least 11 of the 12 months prior to turning 2 years old, as well as during the month the member turns 2 years old. QUEST Pay-For-Quality Program Guide 31

33 Appendix A - Pay-for-Quality Measure Detail Find the clinical measures indexed by patient population below. Adult Primary Care Measures Breast Cancer Screening Cervical Cancer Screening...35 Colorectal Cancer Screening Chlamydia Screening for Women...36 Comprehensive Diabetes Care - Eye Exam Comprehensive Diabetes Care - LDL-C Screening Comprehensive Diabetes Care - HbA1c testing Comprehensive Diabetes Care - Medical Attention for Nephropathy Use of Appropriate Medications for People with Asthma Cholesterol Management for Patients with Cardiovascular Conditions - LDL-C Screening Use of Spirometry Testing in the Assessment and Diagnosis of COPD Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis...42 Annual Monitoring for Patients on Persistent Medications - ACE/ARB Annual Monitoring for Patients on Persistent Medications - Diuretics Pediatric Primary Care Measures Well-Child Visits in the First 15 Months of Life...47 Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Childhood Immunization Status...48 Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory Infection...49 Use of Appropriate Medications for Children with Asthma Immunizations for Adolescents Chlamydia Screening for Women...51 * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 32 Appendix

34 Find the clinical measures indexed by patient population and alphabetically, below. Adult Primary Care Measures Annual Monitoring for Patients on Persistent Medications - ACE/ARB Annual Monitoring for Patients on Persistent Medications - Diuretics Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis...42 Breast Cancer Screening Cervical Cancer Screening...35 Chlamydia Screening for Women...36 Cholesterol Management for Patients with Cardiovascular Conditions - LDL-C Screening Colorectal Cancer Screening Comprehensive Diabetes Care - Eye Exam Comprehensive Diabetes Care - HbA1c testing Comprehensive Diabetes Care - LDL-C Screening Comprehensive Diabetes Care - Medical Attention for Nephropathy Use of Appropriate Medications for People with Asthma Use of Spirometry Testing in the Assessment and Diagnosis of COPD Pediatric Primary Care Measures Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory Infection...49 Childhood Immunization Status...48 Chlamydia Screening for Women...51 Immunizations for Adolescents Use of Appropriate Medications for Children with Asthma Well-Child Visits in the First 15 Months of Life...47 Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 33

35 Adult Primary Care Measures Breast Cancer Screening The percentage of women years of age as of the end of the measurement period who had one or more mammograms to screen for breast cancer during the measurement period or the prior measurement period. The purpose of this measure is to evaluate primary screening; claims for biopsies, breast ultrasounds, or MRIs will not count toward this measure because they are not considered appropriate methods for primary breast cancer screening. This measure currently follows 2002 recommendations from the U.S. Preventive Services Task Force (USPSTF) (www. uspreventiveservicestaskforce.org/uspstf/uspsbrca2002.htm). Numerator Patients who had one or more mammograms during the measurement period or the prior measurement period. This measure will use the billing codes from submitted claims to identify breast cancer screening. The following codes* identify services that satisfy the measure: Code Type Codes CPT HCPCS G0202, G0204, G0206 ICD-9-CM Procedure 87.36, UB Revenue 0401, 0403 This measure will use the billing codes from submitted claims to identify exclusions. The following codes identify bilateral mastectomy exclusions: Code Type Codes 19180, 19200, 19220, 19240, CPT with modifier 50 or modifier code ICD-9-CM Procedure 85.42, 85.44, 85.46, Note: Modifier codes.50 and indicate the procedure was bilateral and performed during the same operative session. Two unilateral mastectomies may also exclude a woman from this measure. A woman must have had two separate occurrences on two different dates of service to be excluded. The following codes identify two unilateral mastectomy exclusions: Code Type Codes CPT , 19200, 19220, 19240, ICD-9-CM Procedure 85.41, 85.43, 85.45, Supplemental Data Option Documentation Requirements Identify Breast Screening from Medical Records A physician s practice may attest that a breast cancer screening was performed by identifying the date, procedure, findings, and performing provider from the patient s medical record. Denominator Women years of age as of the end of the measurement period. Exclusion Exclude women who had a bilateral mastectomy and for whom administrative data does not indicate that a mammogram was performed. Look for evidence of bilateral mastectomy as far back as possible in the patient s history, through either administrative data or medical record review. (Exclusionary evidence in the medical record must include a note indicating a bilateral mastectomy.) If there is evidence of two unilateral mastectomies, this patient may be excluded from the measure. The bilateral mastectomy must have occurred by the end of the measurement year. Patient Exclusion via Medical Records Records indicate evidence that patient had a bilateral mastectomy or two unilateral mastectomies. Measure Status National Quality Form (NQF) # 0031 NQF Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): National Committee for Quality Assurance (NCQA) * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 34 Appendix

36 Cervical Cancer Screening The percentage of women years of age who had appropriate screening for cervical cancer. This measure follows the USPSTF Guideline for cervical cancer screening ( Code Type CPT-4 Codes 51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, , 58548, , , 58951, 58953, 58954, 58956, Numerator Patients who had one or more Pap tests during the measurement period or the two prior measurement periods. This measure will use the billing codes from submitted claims to identify cervical cancer screening. The following codes* identify services that satisfy the measure: Code Type Codes CPT , 88147, 88148, 88150, , , 88174, HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 ICD-9-CM Procedure UB Revenue 0923 Denominator Women years of age during the measurement period. Exclusion Women who had a hysterectomy and who have no residual cervix and for whom the data do not indicate that a Pap test was performed. Look for evidence of a hysterectomy as far back as possible in the patient s history through either administrative data or medical record review. ICD-9-CM Diagnosis ICD-9-CM Procedure 618.5, V67.01, V76.47, V88.01, V Supplemental Data Option Documentation Requirements Identify Cervical Cancer Screening from Medical Records One or more Pap tests during the measurement period, or the two prior measurement periods, as documented through either administrative data or medical record review. Documentation in the medical record must include: A note indicating the date on which the test was performed, and The result or finding. Count any cervical cancer screening method that includes collection and microscopic analysis of cervical cells. Do not count lab results that explicitly state the sample was inadequate or that no cervical cells were present ; this is not considered appropriate screening. Do not count biopsies because they are diagnostic and therapeutic only and are not valid for primary cervical cancer screening. Note: Lab results that indicate the sample contained no endocervical cells may be used if a valid result was reported for the test. (Exclusionary evidence in the medical record must include a note indicating a hysterectomy with no residual cervix. Documentation of complete hysterectomy, total hysterectomy, total abdominal hysterectomy, or radical hysterectomy meets the criteria for hysterectomy with no residual cervix. Documentation of hysterectomy alone does not meet the criteria because it does not indicate the cervix has been removed.) The hysterectomy must have occurred by the end of the measurement period. Patient Exclusion via Medical Records Exclusionary evidence in the medical record must include a note indicating a hysterectomy with no residual cervix. The hysterectomy must have occurred by the end of the measurement year. Documentation of complete, total, or radical abdominal or vaginal hysterectomy meets the criteria for hysterectomy with no residual cervix. Documentation of a vaginal Pap smear in conjunction with documentation of hysterectomy meets exclusion criteria, but documentation of hysterectomy alone does not meet the criteria because it does not indicate that the cervix has been removed. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 35

37 Measure Status NQF # 0032 Original Endorsement Date: Aug. 10, 2009 Status: Endorsed Steward(s): NCQA Colorectal Cancer Screening Percentage of adults years of age who had appropriate screening for colorectal cancer. The colorectal cancer screening measures follow the USPSTF guidelines ( servicestaskforce.org/uspstf/uspscolo.htm). Numerator Patients who had one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the three criteria below: Fecal occult blood test (FOBT) during the measurement period. Flexible sigmoidoscopy during the measurement period or the four prior measurement periods. Colonoscopy during the measurement period or the nine prior measurement periods. This measure will use the billing codes from submitted claims to identify colorectal cancer screening. The following codes* identify services that satisfy the measure: CPT-4 Code Type Codes 82270, 82274, , , 45345, , 44397, 45355, , 45391, HCPCS G0104, G0105, G0121, G0328 ICD-9-CM Procedure 45.22, 45.23, 45.24, 45.25, 45.42, Denominator Patients years of age during the measurement period. the medical record must include a note indicating a diagnosis of colorectal cancer or total colectomy, which must have occurred by the end of the measurement period. Use the following codes* to identify allowable exclusions: Code Type Codes CPT , , HCPCS G0213-G0215, G0231 ICD-9-CM Diagnosis 153, 154.0, 154.1, 197.5, V10.05 ICD-9-CM Procedure 45.8 Measure Status NQF # 0034 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Chlamydia Screening for Women Percentage of eligible women years of age who were identified as sexually active and had at least one test for chlamydia during the measurement period. The chlamydia screening measures follow the USPSTF guidelines ( Numerator Documentation in the medical record of at least one chlamydia test during the measurement period. A woman is counted in the numerator if there is documentation of a chlamydia trachomatis or species test with a service date during the measurement period. This measure will use the billing codes from submitted claims to identify chlamydia screening. The following codes* identify services that satisfy the measure: Code Type Codes CPT , 87270, 87320, , Exclusion Patients with a diagnosis of colorectal cancer or total colectomy. Look for evidence of colorectal cancer or total colectomy as far back as possible in the patient s history through either administrative data or medical record review. Exclusionary evidence in Denominator Women years of age as of the end of the measurement period who are sexually active. Two methods are provided to identify sexually active women: pharmacy data and claims/ encounter data. Use both methods to identify the eligible * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 36 Appendix

38 population, although a patient must appear in only one method to be eligible for the measure. Patients who were dispensed prescription contraceptives (including diaphragm and spermicide) during the measurement period qualify for this measure. Any patient claims containing the codes* listed in the table below also identify a patient for the denominator of this measure: Exclusion Exclude patients who had a pregnancy test during the measurement year followed within seven days (inclusive) by either a prescription for Accutane (isotretinoin) or an X-ray. This exclusion does not apply to patients who qualify for the denominator based on services other than the pregnancy test alone. The following codes* and descriptions of codes are provided to identify these services: Code Type CPT-4 HCPCS ICD-9-CM Diagnosis Codes , 57022, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58970, 58974, 58976, 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, , , 59866, 59870, 59871, 59897, 59898, 59899, 76801, 76805, 76811, 76813, , , 76941, , 80055, 81025, 82105, 82106, 82143, 82731, 83632, , 84163, , 86592, 86593, , 87110, 87164, 87166, 87270, 87320, , , , 87660, 87808, 87810, 87850, , 88147, 88148, 88150, , , , 88235, 88267, G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, H1000, H1001, H1003-H1005, P3000, P3001, Q0091, S0199, S4981, S , , , , , , , 079.4, , , , , 098.0, , , , 098.2, , , , 099, 131, , 614, 615, 622.3, 623.4, 626.7, 628, , 795.0, 795.1, 796.7, , V01.6, V02.7, V02.8, V08, V15.7, V22-V25, V26.0-V26.4, V26.51, V26.8, V26.9, V27, V28, V45.5, V61.5-V61.7, V69.2, V72.3, V72.4, V73.81, V73.88, V73.98, V74.5, V76.2 CPT Pregnancy test 81025, 84702, WITH Diagnostic radiology x Retinoid Measure Status NQF # 0033 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Prescription isotretinoin Comprehensive Diabetes Care Eye Exam UB Revenue Percentage of diabetes patients years of age who received a dilated eye exam, seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist, or imaging validated to match diagnosis from these photos during the measurement period (or the prior measurement period if patient is at low risk for retinopathy). Patient is considered low-risk if there is no evidence of retinopathy in the prior measurement period. The eye exam measure is approved by the National Quality Forum ( and follows American Diabetes Association Guidelines ( Supplement_1/S11.full.pdf). * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 37

39 Numerator This measure will use the billing codes from submitted claims to identify eye exams. The following codes* identify services that satisfy the measure. Code Type CPT-4 HCPCS ICD-9-CM Procedure Codes 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , , 2022F, 2024F, 2026F S0620, S0621, S0625**, S , 14.9, , 95.11, 95.12, ** Code is not limited to optometrist or ophthalmologist. Eye exams provided by eye care professionals are a proxy for dilated eye examinations because there is no administrative way to determine that a dilated exam was performed. Denominator Patients years of age as of the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2). Patients with diabetes can be identified during the measurement period or the prior measurement period through: Pharmacy data: Patients who were prescribed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis. Prescriptions to identify patients with diabetes include insulin prescriptions (drug list is available) and oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available). Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. A diagnosis of diabetes on the problem list or at least two visits with diabetes listed as a diagnosis. Code Type ICD-9-CM Diagnosis Codes 250, 357.2, 362.0, , Exclusion Blindness is not an exclusion for a diabetic eye exam because it is difficult to distinguish between individuals who are legally blind but require a retinal exam and those who are completely blind and therefore do not require an exam. Exclude patients with a diagnosis of polycystic ovaries on the problem list who did not also have a diagnosis of diabetes on the problem list during the measurement period or prior measurement period. Exclude patients with a diagnosis of gestational diabetes or steroid-induced diabetes on the problem list during the measurement period. Code Type ICD-9-CM Diagnosis Measure Status NQF # 0055 Status: Endorsed Original Endorsement Date: Aug.10, 2009 Steward(s): NCQA Codes 249, 251.8, 256.4, 648.8, Comprehensive Diabetes Care LDL-C Screening Percentage of adult diabetes patients years of age who received at least one lipid profile (or all component tests) during the measurement period. The LDL-C screening measure is approved by the National Quality Forum ( and follows American Diabetes Association Guidelines ( care.diabetesjournals.org/content/33/supplement_1/s11.full.pdf). Numerator This measure will use the billing codes from submitted claims to identify LDL-C screening. The following codes* identify services that satisfy the measure: Code Type Codes CPT , 83700, 83701, 83704, CPT Cat II 3048F-3050F Denominator Patients years of age as of the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2). * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 38 Appendix

40 Patients with diabetes can be identified during the measurement period or the prior measurement period through: Pharmacy data: Patients who were prescribed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis. Prescriptions to identify patients with diabetes include insulin prescriptions (drug list is available) and oral hypoglycemics/antihyperglycemics prescriptions (drug list is available). Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. A diagnosis of diabetes on the problem list or at least two visits with diabetes listed as a diagnosis. Code Type ICD-9-CM Diagnosis Exclusion Codes 250, 357.2, 362.0, , Exclude patients with a diagnosis of polycystic ovaries on the problem list who did not also have a diagnosis of diabetes on the problem list during the measurement period or the prior measurement period. Exclude patients with a diagnosis of gestational diabetes or steroid-induced diabetes on the problem list during the measurement period. Code Type Codes Numerator This measure will use the billing codes from submitted claims to identify HbA1c tests. The following codes* identify services that satisfy the measure: Code Type CPT , CPT Cat II Denominator 3044F-3046F Codes Patients years of age as of the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2). Patients with diabetes can be identified during the measurement period or the prior measurement period through: Pharmacy data: Patients who were prescribed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis. Prescriptions to identify patients with diabetes include insulin prescriptions (drug list is available) and oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available). Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. A diagnosis of diabetes on the problem list or at least two visits with diabetes listed as a diagnosis. ICD-9-CM Diagnosis 249, 251.8, 256.4, 648.8, Code Type Codes Measure Status NQF # 0063 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Comprehensive Diabetes Care HbA1c Testing Percentage of diabetes patients years of age who receive one or more HbA1c test(s) per measurement period. The HbA1c testing measure is approved by the National Quality Forum ( and follows American Diabetic Association Guidelines ( Supplement_1/S11.full.pdf). ICD-9-CM Diagnosis 250, 357.2, 362.0, , Exclusion Exclude patients with a diagnosis of polycystic ovaries on the problem list who did not also have a diagnosis of diabetes on the problem list during the measurement period or the prior measurement period. Exclude patients with a diagnosis of gestational diabetes or steroid-induced diabetes on the problem list during the measurement period. Code Type Codes ICD-9-CM Diagnosis 249, 251.8, 256.4, 648.8, Measure Status NQF # 0057 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 39

41 Comprehensive Diabetes Care Medical Attention for Nephropathy Percentage of diabetes patients years of age with at least one test for microalbumin during the measurement period or evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria). This measure is approved by the National Quality Forum ( and follows American Diabetic Association Guidelines ( Supplement_1/S11.full.pdf). Numerator Patients who had any one of the following: Screening for nephropathy. Evidence of nephropathy. Evidence of ACE inhibitor/arb therapy. This measure will use pharmacy claims data to identify evidence of ACE inhibitor or ARB therapy. This measure will also use the billing codes from submitted claims to identify screening for nephropathy and evidence of nephropathy. The following codes* identify services that satisfy the measure: Code Type CPT-4 CPT Cat ll HCPCS ICD-9-CM Diagnosis Codes , 84156, , 81005, 36145, 36147, 36800, 36810, 36815, 36818, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, F-3062F, 3066F, 4009F G0257, G0392, G0393, S , 403, 404, , , , , 753.0, 753.1, 791.0, V42.0, V45.1 Denominator Patients years of age as of the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2). Patients with diabetes can be identified during the measurement period or the prior measurement period through: Pharmacy data: Patients who were prescribed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis. Prescriptions to identify patients with diabetes include insulin prescriptions (drug list is available) and oral hypoglycemics/ antihyperglycemics prescriptions (drug list is available). Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; members with diabetes on these medications are identified through diagnosis codes only. A diagnosis of diabetes on the problem list or at least two visits with diabetes listed as a diagnosis. Code Type ICD-9-CM Diagnosis Exclusion Codes 250, 357.2, 362.0, , Exclude patients with a diagnosis of polycystic ovaries on the problem list who did not also have a diagnosis of diabetes on the problem list during the measurement period or the prior measurement period. Exclude patients with a diagnosis of gestational diabetes or steroid-induced diabetes on the problem list during the measurement period. Code Type ICD-9-CM Diagnosis Measure Status Codes 249, 251.8, 256.4, 648.8, NQF # 0062 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA ICD-9-CM Procedure 38.95, 39.27, 39.42, 39.43, 39.53, , 54.98, * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 40 Appendix

42 Use of Appropriate Medications for People with Asthma Percentage of patients who were identified as having persistent asthma during the measurement period and the prior measurement period and who were dispensed a prescription for either an inhaled corticosteroid or acceptable alternative medication during the measurement period. This measure is largely consistent with the National Heart, Lung, and Blood Institute s National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007 ( Numerator Eligible patients dispensed at least one of the following prescriptions for a preferred therapy during the measurement period: Antiasthmatic combinations. Antibody inhibitor. Inhaled steroid combinations. Inhaled corticosteroids. Leukotriene modifiers. Mast cell stabilizers. Methylxanthines. This measure will use pharmacy claims data to identify evidence of prescription for a preferred therapy. Denominator All patients 5-64 years of age as of the end of the measurement period with persistent asthma. Patients are identified as having persistent asthma when they have one or more of the following: At least one ED visit or acute inpatient visit with asthma as the principal diagnosis. At least four outpatient visits with asthma diagnosis and at least two asthma medications. At least four asthma medication dispensing events. Exclusion Exclude from the eligible population all patients diagnosed with emphysema, cystic fibrosis, acute respiratory failure, and chronic obstructive pulmonary disease (COPD) at any time on or prior to the end of the measurement year as identified by the following codes*: Code Type ICD-9-CM Diagnosis Measure Status NQF # 0036 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Codes 277.0, 491.2, 492, 493.2, 496, 518.1, 518.2, Cholesterol Management for Patients with Cardiovascular Conditions LDL-C Screening Percentage of members years of age who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) between the 1st and 305th days of the prior measurement period, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement period and the prior measurement period, who had an LDL-C screening during the measurement period. Numerator LDL-C screening: Patients who had an LDL-C test performed any time during the measurement period as identified by claims/encounter or automated laboratory data. This measure will use the billing codes from submitted claims to identify LDL-C screening. The following codes* identify services that satisfy the measure: Code Type Codes CPT , 83700, 83701, 83704, CPT Cat II Denominator 3048F-3050F Patients are identified for the eligible population by event or diagnosis. Both event and diagnosis are used to identify the eligible population, but a patient only needs to be identified by one to be included in the measure. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 41

43 Event: Discharged alive for AMI, CABG, or PCI on or between the 1st and 305th days of the prior measurement period. All cases of PCI should be included, regardless of setting (e.g., inpatient, outpatient, ED). Measure Status NQF # 0075 Endorsed (undergoing endorsement maintenance) Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Use of Spirometry Testing in the Assessment and Diagnosis of COPD This measure assesses the percentage of members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. Numerator Patients in the denominator who had a spirometry test between 730 days (two years) before to six months after the service date when the diagnosis of COPD was made. The following codes* identify services that satisfy this measure. Spirometry Denominator CPT 94010, , 94060, 94070, 94375, All patients 42 years of age or older with a new diagnosis of COPD or newly active COPD between the 183rd day of the previous measurement period and the 182nd day of the current measurement period. The following codes* identify services that satisfy this measure. ICD-9-CM Diagnosis Chronic bronchitis 491 Emphysema 492 COPD 496 Exclusions Anyone who had an acute inpatient, outpatient, or ED visit with a diagnosis of COPD in the 730 days (two years) preceding the episode date. Measure Status NQF # 0571 Status: Endorsed Original Endorsement Date: Dec. 4, 2009 Steward(s): NCQA Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Percentage of adult patients years of age who were diagnosed with acute bronchitis and were not dispensed an antibiotic prescription. The measure is reported as an inverted rate [1-(numerator/denominator)]. A higher rate indicates appropriate treatment (i.e., the proportion for whom antibiotics were not prescribed). Numerator Patients in the denominator who were prescribed an antibiotic on or within three days after the date of service. Denominator All patients 18 years of age as of the first day of the prior measurement period to 64 years of age as of the last day of the current measurement period who had an outpatient or ED visit with a diagnosis of acute bronchitis on or between the first and the 348th day of the measurement period. This measure examines the earliest eligible episode per patient. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 42 Appendix

44 The earliest date of service is any outpatient or ED visit with a diagnosis of acute bronchitis between the first day of the measurement period and seven days before the end of the measurement period that was not excluded in 1 through 3. Exclusions 1. Any date of service if in the 12 months prior to and including the date of service the patient had a claim/encounter that contained either a principal or secondary diagnosis for a comorbid condition (see table). 2. Any date of service that meets the following criteria: Patient had no pharmacy claims for either new or refill prescriptions for a listed antibiotic drug in the 30-day period prior to the date of service. No prescriptions were filled more than 30 days before and were not active on the date of service. A prescription is considered active if the days supply indicated on the date when the patient filled the prescription is the number of days or more between that date and the relevant service date. The 30-day look back period for pharmacy data includes the 30 days before the time between the first day of the measurement year and seven days before the end of the measurement year. 3. Any dates of service with any competing diagnosis during the period 30 days prior to the date of service through seven days after the date of service (inclusive). The following codes* identify dates of service that satisfy this measure. ICD-9-CM Diagnosis Acute bronchitis Outpatient CPT , , , , 99385, 99386, 99395, 99396, , 99411, 99412, 99420, UB Revenue 051x, , , 0982, 0983 ED** x, 0981 **Do not include ED visits that result in an inpatient admission. ICD-9-CM Diagnosis HIV disease; asymptomatic HIV 042, V08 Cystic fibrosis Disorders of the immune system 279 Malignancy neoplasms Chronic bronchitis 491 Emphysema 492 Bronchiectasis 494 Extrinsic allergic alveolitis 495 Chronic airway obstruction, chronic obstructive asthma 493.2, 496 Pneumoconiosis and other lung disease due to external agents Other diseases of the respiratory system Tuberculosis * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 43

45 Antibiotic Medications Aminoglycosides Aminopenicillins Antipseudomonal penicillins Beta-lactamase inhibitors First-generation cephalosporins Fourth-generation cephalosporins Ketolides Lincomycin derivatives Macrolides Miscellaneous antibiotics Natural penicillins Penicillinase resistant penicillins Quinolones Rifamycin derivatives Second generation cephalosporins Sulfonamides Tetracyclines Third generation cephalosporins Urinary anti-infectives Prescription Amikacin, Gentamicin, Kanamycin, Streptomycin, Tobramycin Amoxicillin, Ampicillin Piperacillin, Ticarcillin Amoxicillin-clavulanate, Ampicillin-sulbactam, Piperacillin-tazobactam, Ticarcillin-clavulanate Cefadroxil, Cefazolin Cephalexin Cefepime Telithromycin Clindamycin, Lincomycin Azithromycin, Clarithromycin, Erythromycin, Erythromycin ethylsuccinate, Erythromycin lactobionate, Erythromycin stearate Aztreonam, Chloramphenicol, Dalfopristin-quinupristin, Daptomycin, Erythromycin-sulfisoxazole, Linezolid, Metronidazole, Vancomycin Penicillin G benzathine-procaine, Penicillin G potassium, Penicillin G procaine, Penicillin G sodium, Penicillin V potassium, Penicillin G benzathine Dicloxacillin, Nafcillin, Oxacillin Ciprofloxacin, Gatifloxacin, Gemifloxacin, Levofloxacin, Lomefloxacin, Moxifloxacin, Norfloxacin, Ofloxacin, Sparfloxacin Rifampin Cefaclor, Cefotetan, Cefoxitin, Cefprozil, Cefuroxime, Loracarbef Sulfadiazine, Sulfamethoxazole-trimethoprim, Sulfisoxazole Doxycycline, Minocycline, Tetracycline Cefdinir, Cefditoren, Cefixime, Cefotaxime, Cefpodoxime, Ceftazidime, Ceftibuten, Ceftriaxone Fosfomycin, Nitrofurantoin, Nitrofurantoin macrocrystals, Nitrofurantoin macrocrystals-monohydrate, Trimethoprim Measure Status NQF # 0058 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 44 Appendix

46 Annual Monitoring for Patients on Persistent Medications ACE/ARB The percentage of patients 18 years of age and older who received at least 180 treatment days of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and at least one monitoring event for the therapeutic agent during the measurement period. Numerator Patients in the denominator who received at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement period. Patients must meet one of the three criteria below: Lab panel test during the measurement period. One serum potassium and a serum creatinine during the measurement period. One serum potassium and a blood urea nitrogen during the measurement period. Note: Tests do not need to occur on the same date of service, only within the measurement period. The following codes* identify services that satisfy this measure: CPT Lab panel 80047, 80048, 80050, 80053, Serum potassium (K+) 80051, Serum creatinine (SCr) 82565, Blood urea nitrogen (BUN) 84520, Denominator All patients 18 years or older as of the last day of the measurement period who received at least 180 treatment days of ACE inhibitors or ARBs during the measurement period. Exclusions Patients who had an inpatient (acute or nonacute) claim/encounter during the measurement period. The following table identifies therapeutic agents that qualify a patient for this measure. Prescription Angiotensin converting enzyme inhibitor Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Angiotensin II inhibitors Azilsartan Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan Antihypertensive combinations Aliskiren-valsartan Aliskiren-hydrochlorothiazide-amlodipine Amlodipine-benazepril Amlodipine-hydrochlorothiazide-valsartan Amlodipine-hydrochlorothiazide-olmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Benazepril-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil Note: Patients may switch therapy with any medication listed during the measurement period and have the days supply for those medications count toward the total 180 treatment days. Measure Status NQF # 0021 Status: Endorsed Original Endorsement Date: Dec. 4, 2009 Steward(s): NCQA * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 45

47 Annual Monitoring for Patients on Persistent Medications Diuretics The percentage of patients 18 years of age and older who received at least 180 treatment days of diuretics and at least one monitoring event for the therapeutic agent during the measurement period. Numerator Patients in the denominator who received at least one diuretic in the measurement period. Patients must meet one of the three criteria below: Lab panel test during the measurement period. One serum potassium and a serum creatinine during the measurement period. One serum potassium and a blood urea nitrogen during the measurement period. Note: Tests do not need to occur on the same date of service, only within the measurement period. The following codes* identify services that satisfy this measure: CPT Lab panel 80047, 80048, 80050, 80053, Serum potassium (K+) 80051, Serum creatinine (SCr) 82565, Blood urea nitrogen (BUN) 84520, Denominator All patients 18 years or older as of the last day of the measurement period who received at least 180 treatment days of diuretics during the measurement period. The following table identifies therapeutic agents that qualify a patient for this measure: Antihypertensive combinations Prescription Aliskiren-hydrochlorothiazide Aliskiren-hydrochlorothiazide-amlodipine Amiloride-hydrochlorothiazide Amlodipine-hydrochlorothiazide-olmesartan Amlodipine-hydrochlorothiazide-valsartan Atenolol-chlorthalidone Benazepril-hydrochlorothiazide Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Chlorthalidone-clonidine Enalapril-hydrochlorothiazide Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-methyldopa Hydrochlorothiazide-metoprolol Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-propranolol Hydrochlorothiazide-quinapril Hydrochlorothiazide-spironolactone Hydrochlorothiazide-telmisartan Hydrochlorothiazide-timolol Hydrochlorothiazide-triamterene Hydrochlorothiazide-valsartan Loop diuretics Bumetanide, Ethacrynic acid Furosemide, Torsemide Potassium-sparing diuretics Amiloride, Eplerenone Spironolactone, Triamterene Thiazide diuretics Chlorothiazide, Chlorthalidone, Hydrochlorothiazide Indapamide, Methyclothiazide, Metolazone Note: Patients may switch therapy with any medication listed during the measurement period and have the days supply for those medications count toward the total 180 treatment days. Exclusions Patients who had an inpatient (acute or nonacute) claim/encounter during the measurement period. Measure Status NQF # 0021 Status: Endorsed Original Endorsement Date: Dec. 4, 2009 Steward(s): NCQA * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 46 Appendix

48 Pediatric Primary Care Measures Well-Child Visits in the First 15 Months of Life Percentage of patients who turned 15 months old during the measurement period and who had six or more well-child visits with a PCP during their first 15 months of life. This measure is based on the Centers for Medicare & Medicaid Service (CMS) and American Academy of Pediatrics guidelines for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) visits. Refer to the American Academy of Pediatrics Guidelines for Health Supervision at and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (published by the National Center for Education in Maternal and Child Health) at for more detailed information on what constitutes a well-child visit. Numerator The six well-child visits must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child. This measure will use the billing codes from submitted claims to identify well-child visits. The following codes* identify services that satisfy the measure: Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Percentage of patients 3 6 years of age as of the end of the measurement period who received one or more well-child visits with a PCP during the measurement period. This measure is based on the CMS and American Academy of Pediatrics guidelines for EPSDT visits. Refer to the American Academy of Pediatrics Guidelines for Health Supervision at and Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (published by the National Center for Education in Maternal and Child Health) at for more detailed information on what constitutes a well-child visit. Numerator Children 3-6 years of age who received at least one well-child visit with a PCP during the measurement year. The well-child visit must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child. This measure will use the billing codes from submitted claims to identify well-child visits. The following codes* identify services that satisfy the measure: Code Type Codes CPT , 99383, 99392, HCPCS G0438, G0439 Code Type Codes CPT , 99382, 99391, 99392, 99432, ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 HCPCS ICD-9-CM Diagnosis G0438, G0439 V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Denominator Patients at least 3 years old and not more than 6 years old as of the end of the measurement period. Denominator Children who turned 15 months old during the measurement period. In accordance with HEDIS definitions, the 15th month birth date will be calculated as the patient s first birthday plus 90 days. NOTE: The annual well-child visit is generally scheduled every 12 months. HMSA recognizes that families and providers need flexibility in scheduling well-child visits and will cover well-child visits that are at least nine months apart. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 47

49 Childhood Immunization Status Percentage of children 2 years of age who had four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV); one measles, mumps, and rubella (MMR); three Haemophilus influenzae type b (Hib); two hepatitis B (HepB); one chicken pox (VZV); and four pneumococcal conjugate (PCV) vaccines by their second birthday. Numerator For all antigens, count any of the following: Evidence of the antigen or combination vaccine. Documented history of the illness. A seropositive test result. This measure will use the billing codes from submitted claims data to identify immunizations. This measure follows the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices (ACIP) guidelines for immunizations. The measure implements changes to the guidelines (e.g., new vaccine recommendations) after three years to account for the measure s retrospective period and to allow the industry time to adapt to new guidelines. Immunization CPT hcpcs icd-9-cm diagnosis ICD-9-cm procedure DTaP 90698, 90700, 90721, IPV 90698, 90713, MMR 90707, Measles and rubella Measles Mumps Rubella Hib , 90698, 90721, HepB 90723, 90740, 90744, 90747, G , 070.3, V02.61 VZV 90710, , 053 Pneumococcal conjugate 90669, G0009 Note: The ACIP recommends at least three HepB vaccinations with different dates of service on or before the child s second birthday. Providers must validate that the first HepB vaccination was administered at birth and, if administered, documented in the medical record. If a vaccination was administered, then a minimum of two office visit claims for HepB vaccines with different dates of service on or before the child s second birthday are required for this measure. If not administered at birth, the provider is required to vaccinate the child three times for HepB (three HepB vaccinations should be documented in the medical records as per ACIP recommendations for audit purposes). * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 48 Appendix

50 Denominator Children who turn 2 years of age during the measurement period. Exclusion Children who had a contraindication for a specific vaccine will be excluded. Providers may exclude patients for contraindication only if the administrative data do not indicate that the contraindicated immunization was rendered. The exclusion must have occurred by the second birthday. Immunization Any particular vaccine DTaP IPV MMR, VZV, and influenza Hepatitis B Measure Status Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis with E948.4, Encephalopathy E948.5, or E948.6 Progressive neurologic disorder, including infantile spasm, uncontrolled epilepsy Anaphylactic reaction to streptomycin, polymyxin B, or neomycin Immunodeficiency, including genetic (congenital) immunodeficiency syndromes 279 HIV disease; asymptomatic 042, V08 HIV Cancer of lymphoreticular or histiocytic tissue Multiple myeloma 203 Leukemia Anaphylactic reaction to neomycin Anaphylactic reaction to common baker s yeast NQF # 0038 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Appropriate Testing for Children with Pharyngitis Percentage of patients 2-18 years of age who were diagnosed with pharyngitis, prescribed an antibiotic, and received a group A streptococcus test for the episode. This measure is largely consistent with the Institute for Clinical Systems Improvement s Respiratory Illness in Children and Adults, Diagnosis and Treatment of (Guideline), released in February 2008 ( guidelines_and_more/gl_os_prot/respiratory_illness_in_ children_and_adults guideline_/respiratory_illness_in_children_ and_adults guideline html). Numerator A strep test administered in the seven-day period from three days prior through three days after the first eligible episode date. Codes to identify group A streptococcus tests antigen detection: Code Type CPT-4 Denominator Codes 87070, 87071, 87081, 87430, , Children 2 years of age as of the 183rd day of the prior measurement period to 18 years of age as of the 182nd day of the measurement period who had an outpatient or ER visit with only a diagnosis of pharyngitis. Code Type ICD-9-CM Diagnosis 034.0, 462, 463 Measure Status NQF # 0002 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Codes Appropriate Treatment for Children with Upper Respiratory Infection Percentage of children 3 months to 18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription on or three days after the episode date. This * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 49

51 measure is largely consistent with the Institute for Clinical Systems Improvement s Respiratory Illness in Children and Adults, Diagnosis and Treatment of (Guideline), released in February 2008 ( illness_in_children_and_adults guideline_/respiratory_illness_ in_children_and_adults guideline html). Numerator Patients dispensed a prescription for antibiotic medication on or within three days after the episode date. The measure examines one eligible episode per patient. The measure will use pharmacy claims data to identify evidence for dispensed antibiotics. Denominator All children age 3 months as of the 183rd day of the prior measurement preriod to 18 years as of the 182nd day of the measurement period who had an outpatient visit with only a diagnosis of nonspecific upper respiratory infection (URI) and an outpatient visit code. Code Type ICD-9-CM Diagnosis 460, 465 description Outpatient cpt Codes , , , , , , , 99411, 99412, 99420, ub revenue 051x, , , 0982, 0983 ED** x, 0981 **Do not include ED visits that result in an inpatient admission. Exclusion Exclude episode dates where the patient had a claim/encounter with a competing diagnosis (Table URI-C) on or three days after the episode date. Code Type ICD-9-CM Diagnosis Measure Status NQF # 0069 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Codes ,033, 034.0, 041.9, , , , 088, , 131, 382, 383, , , 473, 474, , , , , 478.9, , 590, 595, 599.0, 601, , , 686, 706.0, 706.1, 730, V01.6, V02.7, V02.8 Use of Appropriate Medications for Children with Asthma Percentage of patients who were identified as having persistent asthma during the measurement period and the prior measurement period and who were dispensed a prescription for either an inhaled corticosteroid or acceptable alternative medication during the measurement year. This measure is largely consistent with the National Heart, Lung, and Blood Institute s National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007 ( Numerator Eligible patients dispensed at least one of the following prescriptions for a preferred therapy during the measurement year: Antiasthmatic combinations. Antibody inhibitor. Inhaled steroid combinations. Inhaled corticosteroids. Leukotriene modifiers. Mast cell stabilizers. Methylxanthines. This measure will use pharmacy claims data to identify evidence of prescription for a preferred therapy. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 50 Appendix

52 Denominator All patients 5-64 years of age as of the end of the measurement period with persistent asthma. Patients are identified as having persistent asthma when they have one or more of the following: At least one ED visit or acute inpatient visit with asthma as the principal diagnosis. At least four outpatient visits with asthma diagnosis and at least two asthma medications. At least four asthma medication dispensing events. Exclusion Exclude from the eligible population all patients diagnosed with emphysema, cystic fibrosis, acute respiratory failure, and chronic obstructive pulmonary disease (COPD) at any time on or prior to the end of the measurement year as identified by the following codes: Immunization CPT ICD-9-CM Procedure Meningococcal 90733, Tdap Td 90714, Tetanus Diphtheria Denominator Adolescents who turn 13 years of age during the measurement period. Exclusions Adolescents who have a contraindication for one of these specific vaccines. Exclusion must have occured before adolescents 13th birthday. Code Type ICD-9-CM Diagnosis Codes 277.0, 491.2, 492, 493.2, 496, 518.1, 518.2, Immunization Any particular vaccine Anaphylactic reaction to the vaccine or its components ICD-9-CM Diagnosis Measure Status NQF # 0036 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Immunizations for Adolescents The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine and one tetanus, diphtheria, and acellular pertussis vaccine (Tdap) or one tetanus and diphtheria toxoids vaccine (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate. Numerator Adolescents who receive both: One meningococcal conjugate or meningococcal polysaccharide vaccine on or between their 11th and 13th birthday. One Tdap or one Td on or between their 10th and 13th birthday. Measure Status NQF # 1407 Status: Endorsed Original Endorsement Date: Aug. 15, 2011 Steward(s): NCQA Chlamydia Screening for Women Percentage of eligible women years of age who were identified as sexually active and had at least one test for chlamydia during the measurement year. The chlamydia screening measures follow the USPSTF guidelines ( taskforce.org/uspstf/uspschlm.htm). Numerator Documentation in the medical record of at least one chlamydia test during the measurement year. A woman is counted in the numerator if there is documentation of a chlamydia trachomatis or species test with a service date during the measurement year. This measure will use the billing codes from submitted claims to identify chlamydia screening. * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. Appendix 51

53 The following codes identify services that satisfy the measure: Code Type Codes CPT , 87270, 87320, , Denominator Women years of age as of the end of the measurement year who are sexually active. Two methods are provided to identify sexually active women: pharmacy data and claims/encounter data. Use both methods to identify the eligible population, although a patient must appear in only one method to be eligible for the measure. Patients who were dispensed prescription contraceptives (including diaphragm, spermicide) during the measurement period qualify for this measure. Any patient claims containing the codes listed in the table below also identifies a patient for the denominator of this measure: Code Type ICD-9-CM Diagnosis Exclusion Codes 042, , , , , , , 079.4, , , , , 098.0, , , , 098.2, , , , 099, 131, , 614, 615, 622.3, 623.4, 626.7, 628, , 795.0, 795.1, 796.7, , V01.6, V02.7, V02.8, V08, V15.7, V22-V225, V26.0-V26.4, V26.51, V26.8, V26.9, V27, V28, V45.5, V61.5-V61.7, V69.2, V72.3, V72.4, V73.81, V73.88, V73.98, V74.5, V76.2 Exclude patients who had a pregnancy test during the measurement year followed within seven days (inclusive) by either a prescription for Accutane (isotretinoin) or an X-ray. This exclusion does not apply to patients who qualify for the denominator based on services other than the pregnancy test alone. Code Type CPT-4 HCPCS Codes , 57022, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58970, 58974, 58976, 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, , , 59866, 59870, 59871, 59897, 59898, 59899, 76801, 76805, 76811, 76813, , , 76941, , 80055, 81025, 82105, 82106, 82143, 82731, 83632, , 84163, , 86592, 86593, , 87110, 87164, 87166, 87270, 87320, , , , 87660, 87808, 87810, 87850, , 88147, 88148, 88150, , , , 88235, 88267, G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, H1000, H1001, H1003-H1005, P3000, P3001, Q0091, S0199, S4981, S8055 The following codes* and descriptions of codes are provided to identify these services: Codes to Identify Exclusions CPT UB Revenue Pregnancy test 81025, 84702, WITH Diagnostic radiology x Medications to Identify Exclusions Retinoid Measure Status NQF # 0033 Status: Endorsed Original Endorsement Date: Aug. 10, 2009 Steward(s): NCQA Prescription isotretinoin * Note: The codes listed under various headings in Appendix A: Measure Details are a summary set for each measure and do not comprise an exhaustive list of all codes applicable to the pay-for-quality program, which by default adheres to HEDIS specifications. 52 Appendix

54 Appendix B: Provider Toolkit for PCMH This toolkit provides sample materials to help you inform your patients about and engage them in your PCMH. Feel free to customize each document to fit the needs of your practice. (You are not required to use these materials. Make sure they reflect your practice before using them.) Included are the following: Pre-visit Contact Form. Questions your staff can ask a patient to help you prepare for a visit. Introductory Letter to Patient with Rights and Responsibilities. Announce your PCMH approach to your patient and describe how they will participate in a PCMH. Patient-Provider Partnership Agreement. A best practice used in many PCMHs, this agreement is signed by your patient to indicate an understanding of and agreement to participate in a PCMH. Patient Checklists. Help your patient prepare for the first and future appointments with you under the PCMH. These documents are available for download at hmsa.com/ providers/pcmh/toolkit.aspx. Also available is the Information for Families Brochure to help your patient s family maximize the benefits of the PCMH. The brochure is available for download at hmsa.com/providers/ assets/info-for-families-brochure.pdf. For a hard copy, contact your HMSA Provider Relations and Advocacy representative. Appendix 53

55 SAMPLE PRE-VISIT CONTACT FORM Note to Staff: Please check with scheduling to allow enough time for the visit. Date Patient s name Chart# or DOB Phone where reached Other type of contact Help us prepare for your visit. Please let us know: 1. Have you been to an emergency room (ER) or urgent care clinic since your last visit? Yes No If yes, where, when, and why? What happened? What did they tell you to do? Staff: Is there a record of the visit available? Yes No 2. Have you been in the hospital since your last visit? Yes No If yes, where, when, and why? What happened? What did they tell you to do? Staff: Is there a record of the hospital stay available? Yes No 3. Have you seen or consulted any other health care providers since your last visit? Yes No If yes, where, when, and why? What happened? What did they tell you to do? Staff: Is the specialist note in the chart? Yes No 4. Have you had any blood work or X-rays done since your last visit? Yes No If yes, where, when, and why? Staff: Is the specialist note/letter in the chart? Yes No 5. Are there any forms or letters you will need us to fill out? Yes No If yes, please describe the purpose of the forms. 6. What are your top areas of concern or topics that you want to talk about at this visit? Appendix

56 SAMPLE INTRODUCTORY LETTER TO PATIENT Re: Patient-Centered Medical Home Initiative Dear Patient: Welcome to the patient-centered medical home (PCMH) model of care. PCMH is a new way of managing your health care! PCMH is not a building, a house, or a hospital. It is a way of doing health care with a team of doctors who work together. That way, they can focus on your all-around well-being. Optional: HMSA has identified me as your potential primary care provider (PCP) based on your enrollment selection or your pattern of doctor visits. I would be happy to be your PCP and work with you on your health care needs. I invite you to continue working with me in this new model of care. I will work with other health care providers to take care of you. As your care team, we will involve you in decisions about your health and health care, and thus be able to develop a stronger relationship with you. You will also have easier access to me through: <insert as applicable: phone visits, Web visits, secure through HMSA s Online Care>. These are all elements in my PCMH approach to your care. Optional: If you are over 40 years of age or have a chronic condition for which you are being treated and have not seen me within the last year, please contact my office and schedule an appointment so we may reconnect. Attached is a list of our roles in working together to keep you healthy. If you have any questions, please call my office at <insert telephone number>. I look forward to walking with you on the path to a healthier you! Sincerely, Enclosure Appendix 55

57 OUR ROLES IN WORKING TOGETHER As your primary care provider, I will: Learn about you, your family, life situation, and health goals and preferences. I will remember these and your health history every time you seek care and suggest treatments that make sense for you. Take care of any short-term illness, long-term chronic disease, and your all-around well-being. Keep you up-to-date on all your vaccines and screening tests. Connect you with other members of your care team (specialists, health coaches, etc.) and work with them as your health needs change. Be available to you after hours for your urgent needs. Notify you of test results in a timely manner. Communicate clearly with you so you understand your condition(s) and all your options. Listen to your questions and feelings. I will respond promptly to you and your calls in a way you understand. Help you make the best decisions for your care. Give you information about classes, support groups, or other services. This can help you learn more about your condition and stay healthy. We trust you, as our patient, to: Know that you are a full partner with us in your care. Come to each visit with any updates on medications, dietary supplements, or remedies you re using, and questions you may have. Let us know when you see other health care providers so we can help coordinate the best care for you. Keep scheduled appointments or call to reschedule or cancel as early as possible. Understand your health condition: ask questions about your care and tell us when you don t understand something. Learn about your condition(s) and what you can do to stay as healthy as possible. Follow the plan that we have agreed is best for your health. Take medications as prescribed. Call if you do not receive your test results within two weeks. Contact us after hours only if your issue cannot wait until the next work day. If possible, contact us before going to the emergency room so someone who knows your medical history can care for you. Agree that all health care providers in my care team will receive all information related to your health care. Learn about your health insurance coverage and contact HMSA if you have any questions about your benefits. Pay your share of any fees. Give us feedback to help us improve our care for you. 56 Appendix

58 SAMPLE PATIENT-PROVIDER PARTNERSHIP AGREEMENT Dear Patient, Welcome and thank you for choosing my practice. I am committed to providing you with the best medical care based on your health needs. My hope is that we can work together to keep your whole self as healthy as possible, no matter what your current state of health. Your commitment to my patient-centered medical home practice will provide you with an expanded type of care. I will work with both you and other doctors as a team to take care of you. It will be easier to contact me. You can use phone and Web visits and secure through HMSA s Online Care. As your primary care provider, I will: Learn about you, your family, life situation, and health goals and preferences. I will remember these and your health history every time you seek care and suggest treatments that make sense for you. Take care of any short-term illness, long-term chronic disease, and your all-around well-being. Keep you up-to-date on all your vaccines and screening tests. Connect you with other members of your care team (specialists, health coaches, etc.) and work together with them as your health needs change. Be available to you after hours for your urgent needs. Notify you of test results in a timely manner. Communicate clearly with you so you understand your condition(s) and all your options. Listen to your questions and feelings. I will respond promptly to you and your calls in a way you understand. Help you make the best decisions for your care. Give you information about classes, support groups, or other services. This can help you learn more about your condition and stay healthy. We trust you, as our patient, to: Know that you are a full partner with us in your care. Come to each visit with any updates on medications, dietary supplements, or remedies you re using, and questions you may have. Let us know when you see other doctors so we can help coordinate the best care for you. Keep scheduled appointments or call to reschedule or cancel as early as possible. Understand your health condition: ask questions about your care and tell us when you don t understand something. Learn about your condition(s) and what you can do to stay as healthy as possible. Follow the plan that we have agreed is best for your health. Take medications as prescribed. Call if you do not receive your test results within two weeks. Contact us after hours only if your issue cannot wait until the next work day. If possible, contact us before going to the emergency room so someone who knows your medical history can care for you. Agree that all health care providers in my care team will receive all information related to your health care. Appendix 57

59 Learn about your health insurance coverage and contact HMSA if you have any questions about your benefits. Pay your share of any fees. Give us feedback to help us improve our care for you. I look forward to working with you as your primary care provider in your patient-centered medical home. Provider Signature Printed Provider Name Date Patient Signature Printed Patient Name Date Parent/Guardian Signature Printed Parent/Guardian Name Date *Cell Phone Number * Address *By providing your cell phone number and/or address, you consent to your PCMH care team contacting you regarding your medical care via cell phone or Appendix

60 SAMPLE PATIENT CHECKLIST BEFORE APPOINTMENT A patient-centered medical home aims to give you total health care. With it, you will have a care team to support you. The team helps you make the best decisions for your health. So help us to know you better. Use this handy checklist to get ready for your appointment. Make a list of any questions you have about your health. Put the questions that are most important to you at the top of the list. Make a list of other doctors you have visited. Jot down their contact information and the reason why you visited them. Bring all of your medications, in their original containers, to your appointment. Be sure to include prescription, over-the counter, natural, and herbal medications and dietary supplements. Take your HMSA membership card and other insurance information with you. Appendix 59

61 SAMPLE PATIENT CHECKLIST DURING APPOINTMENT The patient-centered medical home is a way for you to be involved in and better understand your own health care. So during your appointment, use this handy checklist. Write down the names of the members of your care team. Let your provider know about any changes in your health and/or condition. Are there any updates on your use of medications or dietary supplements? Have you visited other health care providers? Use your list of questions. Ask your top questions first. That way, even if you can t get all the answers you need at one time, you can at least keep track. Talk with your provider about what health issue(s) you should work on first. Make sure you understand what you should do before you leave the office. Ask how you can reach your care team after hours if it becomes necessary. 60 Appendix

62 Appendix C: PCMH Care Coordination Care Coordination The joint principles of PCMH are: A personal provider. Provider-directed medical practice. Whole-person orientation. Quality and safety. Enhanced access to care. Payment structure. Care coordination. Coordination of care across the health system is a critical component for the effective delivery of HMSA s PCMH program. Care coordination is the integration of all care delivery elements in the health care system and the patient s community. The goal is to coordinate providers, technology, and operational workflows into a cohesive unit and have them work together to ensure a patient s needs are understood, shared, and met. Care Coordination: Cornerstone to PCMH Success HMSA s PCMH program is designed to incorporate care coordination into the daily workflow of provider practices and provide enhanced access to the Integrated Service Center. The service center is a central access point to care coordination support services for primary care practices. More information on the service center follows. Care coordination is a core component of a PCMH and is essential to each participating physician organization and each participating provider. While care coordination support services will differ from practice to practice, providers will focus on meeting the patient s needs (before, during, and after a visit) and implementing plans to enhance care between visits. The provider s practice may also benefit from using other health care professionals to expand the care team as needed. The following services are available to help PCPs coordinate care for their patients: 1. Care Planning Registries. 2. Support Services Catalog. 3. Central access point to the Integrated Service Center. Medical Home Personal Provider Payment Structure Enhanced Access to Care Provider & Patient Care Team Provider- Directed Medical Practice Whole-Person Orientation Quality and Safety Coordinated Care Across Health Care System Appendix 61

63 Providers can most effectively use these care coordination support services by following the steps below: PCMH Care Coordination Support Services - Getting Started Know Your Panel View Your Registry Work Your Gaps Leverage the Center Access your Patient Panel Report through the reporting platform. Review and understand the Patient Panel Report. Request edits to your patient panel as needed. Access Care Planning Registry through the reporting platform. Review and understand the Care Planning Registry. Identify measures with opportunities for improvement. Find gaps in care from the Care Planning Registry. PCMH outreach campaign will automatically send out general mail and telephone reminders that services are needed based on the gaps in care. Identify which patients need additional support beyond the general reminders. Determine what additional support services are required for your patients. Review the Support Services Catalog to see if the applicable services are available via the Integrated Service Center. Contact the service center to request care coordination support services. The Care Planning Registry All PCPs participating in the pay-for-quality program will have access to monthly Care Planning Registry reports via the reporting platform. The registry reports on 14 of the 15 gaps in care for adults and five of the seven gaps in care for pediatrics, as defined by the 2012 pay-for-quality program. One adult measure (avoidance of antibiotic treatment with acute bronchitis) and two pediatric measures (appropriate testing for children with pharyngitis and appropriate treatment for children with upper respiratory infection) are excluded because the rate can only be determined after a member did not receive appropriate care. Since September 2011, providers have been submitting supplemental data to report on filled gaps in care that were not captured in their registries. 62 Appendix

64 The Support Services Catalog The Support Services Catalog is a list of the support services available to providers to help address their patients gaps in care. These services can be assessed and requested via the Integrated Service Center. The diagram below (PCMH Phase I Support Services Summary) provides a high-level view of the available services. HMSA s PCMH program will be enhanced as the support services available via the service center expand. Quality Metrics Quality Metrics Support Services (How HMSA can help) PATIENT OUTREACH CONDITION MANAGEMENT PROVIDER RESOURCES Telephone-based screening reminders/ Assessment education Education Mail-based screening reminders/education Coaching & case management Inter-appointment support & monitoring Medication adherence Care coordination Provider quick reference guides Provider office materials (brochures, posters, prescription pads) For Adults Preventive Health Screenings, Diabetes, Heart Disease, Asthma Breast cancer screening Cervical cancer screening Colorectal cancer screening Chlamydia screening (18-24 years) Asthma appropriate medication Diabetes care LDL-C screening Diabetes care HbA1C testing Diabetes care nephropathy screening or treatment Diabetes care eye examination Cholesterol management LDL-C screening For Children Access to Care, Immunizations, Appropriate Respiratory Care, Asthma Childhood immunizations Well-child visits first 15 months Well-child visits 3rd, 4th, 5th, 6th year Children with pharyngitis appropriate testing Children with upper respiratory infections appropriate use of antibiotics Asthma appropriate medication Well-Being Improvement (Whole-Person Orientation) Support Services (How HMSA can help) Patient PATIENT OUTREACH Telephone-based screening reminders/ education Mail-based screening reminders/education CONDITION MANAGEMENT Assessment Education Coaching & case management Inter-appointment support & monitoring Medication adherence Care coordination SMOKING CESSATION Readiness to quit assessment Counseling Personalized quit plans Telephonic & online support Referrals to in-person classes WELLNESS ASSESSMENT Online & paperbased health risk assessments Biometric testing (BMI, waist measurement, body fat analysis, BP, and heart rate) HEALTH COACHING FOR RISK FACTORS Nutrition Weight Exercise Stress Telephonic coaching & motivation Self-management skills education Well-being plans Connection to community resources Educational materials General Patient Chronic Disease Patient Diabetes COPD Asthma CAD CHF Hypertension Special Patient Populations Pregnancy Behavioral Health To request services: Call 1 (855) 765-PCMH (7264) Fax your request to 1 (808) on Oahu or 1 (800) on the Neighbor Islands Hours of operation Monday to Friday 8:00 a.m. 7:00 p.m. Appendix 63

65 The Integrated Service Center HMSA s PCMH program offers providers the Integrated Service Center, a single, consolidated access point to care coordination. The service center links patients with gaps in care to needed care services. Providers may access the service center using a dedicated phone line or fax to request various services within the categories of wellness, lifestyle management, collaborative care, education, community resources, hospital discharge follow-up, and improvement of quality of care. Functionalities of the service center will evolve as additional services become available. Integrated Service Center Wellness 1(855)765-PCMH (7264) (Oahu) 1(800) (NI) Improvement of Quality of Care Lifestyle Management Integrated Service Center Hospital Discharge Follow-up Collaborative Care Community Resources 12/23/2011 Education Summary The Care Planning Registry, Support Services Catalog, and Integrated Service Center are essential tools for effective delivery of quality care. Over time, these tools will mature with the PCMH program to bring more value to coordinating care across providers, technology, and operational workflows. 64 Appendix

66 Appendix D: PCMH Level Verification Request Process The following steps explain the process for PCMH level verification requests. Step 1 Review the population health management levels and requirements to determine whether a provider is eligible to move up in PCMH levels. The information on population health management levels and requirements is located on page 7 of this guide. The most recent version of this matrix was mailed to physician organization leadership on Nov. 21, The physician organization must confirm a provider has completed all requirements prior to submitting a level verification request. Step 2 Download the HMSA PCMH Level Verification Form from www. hmsa.com/providers/assets/hmsa_pcmhlevelverification.pdf. Step 3 Complete the form and compile the supporting documentation listed in the population health management levels and requirements matrix. Note: If a provider requests to move from level 1 to level 2, they must satisfy both level 1 and 2 requirements to be considered for level 2. The provider should work with their physician organization leadership to complete the form and compile the necessary documentation. For questions regarding the requirements, physician organization leadership should reach out to their HMSA Provider Relations and Advocacy manager. Step 4 Submit the required materials to HMSA. The physician organization, and not the provider, must submit the completed HMSA PCMH Level Verification Form and supporting documentation to HMSA. The physician organization is responsible for ensuring that the information is complete. The materials may be submitted at any time. However, submitting in the first week of each month increases the likelihood that PCMH level changes can take effect by the first day of the following month. The materials may be submitted by: - to PSInquiries@hmsa.com. Submitting by will expedite the administrative process. - Fax to on Oahu, attention PCMH Coordinator. - Mail to: Hawaii Medical Service Association Attn: POA, Room 503 HMSA P.O. Box 860 Honolulu, HI If additional information or clarification is needed, HMSA s PCMH coordinator will contact the provider by phone or , and send a copy to the physician organization. Step 5 The PCMH Level Verification Review Committee meets during the second and fourth weeks of every month. The committee will make a determination regarding the provider s request by the 15th of the month. If the request is approved, payments at the new level will be take effect on the first day of the following month. To verify that we have received your submitted materials and for information on the status of your request, contact HMSA s PCMH coordinator at on Oahu or at PSInquiries@hmsa.com. Step 6 Once the committee has made its determination, the decision will be communicated in writing to the physician organization and provider no later than 30 business days following the receipt of the request. HMSA will mail a letter to the physician organization and provider explaining the decision. For example, if the committee did not approve the request, the letter will specify what requirements need to be fulfilled to qualify for a PCMH level change. Providers are encouraged to submit a new request when they have fulfilled these requirements. Note: HMSA may request, through the physician organization, that a provider s PCMH level be verified. In these cases, the same steps should be followed. The HMSA PCMH Level Verification Form is located on HMSA s website at LevelVerification.pdf. Appendix 65

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