Federally Qualified Health Centers Rural Health Clinics. February Interim. Pay for. Quality

Transcription

1 Federally Qualified Health Centers Rural Health Clinics February Interim Pay for Quality P R O G R A M G U I D E

2

3 Table of Contents Introduction to the 2018 Primary Care Pay-for-Quality Program....2 Summary of Changes....2 Program Eligibility and Enrollment...4 Program Summary...5 Quality Measures Data Sources and Data Audit...6 Inquiries and Requests for Reconsideration...7 Patient Population and Member Eligibility....8 Payment Details....9 Quality Measure Scoring...10 Appendix A - Clinical Quality Measure Scoring Examples Appendix B - Measure Detail Engagement Measures Clinical Quality Measures Appendix C - Patient Attribution Process

4 Introduction Thank you for your dedication to providing high quality care to HMSA members. Your hard work has improved the quality of health care and enhanced the patient experience. Together, we ve made important gains in clinical quality, patient safety, cost management, and well-being improvement. At the end of 2017, HMSA s primary care pay for quality (P4Q) and patient-centered medical home (PCMH) programs ended. Most HMSA primary care providers (PCPs) and provider organizations (POs) now participate in HMSA s new primary care payment transformation model (PTM), which incorporates performance and engagement measures that carry on the tenets of the P4Q and PCMH programs. HMSA recognizes that the new primary care PTM does not fully align with care delivery of Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). HMSA plans to work collaboratively with FQHCs/RHCs and other stakeholders in Hawaii to develop new quality incentive models that appropriately account for the variety of services and support that FQHCs/RHCs provide to their patients and the communities they serve. The 2018 P4Q program for FQHCs/RHCs intends to better align clinical quality metrics for these providers. The 2018 program also includes new engagement measures that aim to advance collaboration on data sharing and evaluation of interventions that focus on social determinants of health and well-being. Scoring Period The 2018 program will have an annual (12-month) measurement period. MEASUREMENT PERIOD BASELINE PERIOD January 1 to December 31, 2018 January 1 to December 31, 2017 Data Sources Scoring of the clinical quality measures will rely on data that participating FQHCs/RHCs submit to HMSA. Providers are required to submit quarterly performance data files with HMSA memberlevel data for each of the clinical quality measures. The data files must be extracted from the FQHC s/rhc s Uniform Data System (UDS) reporting source. The data must be electronically submitted via secure or secure FTP site (if available) to HMSA. Quality Measures Data submission deadlines Quarter 1 (January 1 to March 31, 2018) April 30, 2018 Quarter 2 (January 1 to June 30, 2018) July 31, 2018 Quarter 3 (January 1 to September 30, 2018) October 31, 2018 Quarter 4 (January 1 to December 31, 2018) February 28, 2019 Summary of Changes Provider Eligibility Primary care providers (PCP) who primarily practice at an FQHC/ RHC will be eligible to participate in the program. A PCP is considered to primarily practice at an FQHC/RHC if the majority of a PCP s payments are made to that FQHC/RHC. If a provider is contracted with HMSA as a non-pcp marketing specialty type at a non-fqhc/rhc location, that provider may still be eligible for program participation if the provider also practices at an FQHC/RHC as a PCP. Payment Conditions Engagement payments will be made monthly based on the following calculation: Engagement PMPM x # of attributed members per LOB for that month Quality payments will be made annually (following the end of the measurement period) based on the calculations outlined in Appendix A (Scoring Examples) Rates LINE OF BUSINESS (LOB) ENGAGEMENT PMPM Commercial $3.00 $4.25 QUEST Integration $2.00 $2.75 Medicare Advantage N/A $3.00 QUALITY PMPM 2

5 Summary of New Engagement Measures MEASUREMENT DESCRIPTION REQUIREMENT Data Sharing and Integration Social Determinants of Health (SDoH) Initiatives Summary of New Quality Measures Collaborate with HMSA on development of strategy and implementation to accomplish timely and accurate bidirectional data sharing between HMSA and FQHCs/RHCs. Design outcomes reporting and evaluation for a social determinants-related initiative. Participate in collaborative discussions. Give input on technical (systems) processes and requirements. Share plans for implementation of new systems, data processing, data feeds, etc. Submit description and plans for SDoH initiative. Identify potential outcomes of success and measurement specifications for initiative. Share progress reports, data, and findings of evaluation. The 2018 program will include measures based on Health Resources and Services Administration (HRSA) Uniform Data System (UDS) specifications for calendar year MEASUREMENT DESCRIPTION Cervical Cancer Screening Percentage of women years of age who received one or more Pap tests to screen for cervical cancer. Childhood Immunization Status Colorectal Cancer Screening Controlling High Blood Pressure Diabetes Care HbA1c Poor Control (> 9.0%) Early Entry into Prenatal Care Percentage of children 2 years of age during the measurement period who received the following vaccines by their second birthday: four diphtheria, tetanus, and acellular pertussis (DTaP); three polio (IPV); one measles, mumps, and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu). Percentage of adults years of age who had appropriate screening for colorectal cancer. Percentage of patients years of age diagnosed with hypertension whose most recent blood pressure reading was less than 140/90 mmhg during the measurement period. Percentage of patients years of age with diabetes whose most recent HbA1c was greater than 9.0 percent during the measurement period. (Note: lower performance is better.) Percentage of prenatal care patients who entered prenatal care during their first trimester. New Quality Measures Improvement Targets The improvement targets for the 2018 program year will be based on the 2016 UDS-reported* national performance rates for each measure. MEASURE Cervical Cancer Screening 54.40% Childhood Immunization Status 42.80% Colorectal Cancer Screening 39.90% Controlling High Blood Pressure 62.40% Diabetes Care HbA1c Poor Control (> 9.0%) 32.10% Early Entry into Prenatal Care 68.80% TARGET *Source: HRSA Health Center Program 2016 Health Center Data ( 3

6 Program Eligibility and Enrollment Providers covered under an FQHC/RHC medical group agreement will be enrolled in the 2018 quality program if the FQHC/ RHC returned a signed Letter of Agreement for the 2018 interim quality program. Please note that some criteria apply uniquely to commercial, QUEST Integration, and Medicare Advantage P4Q programs. Note: Exceptions to eligibility criteria may be made at HMSA's sole discretion. Universal Eligibility and Enrollment Criteria The following universal eligibility criteria are applied across commercial, QUEST Integration, and Medicare Advantage pay-for-quality programs: 1. Practice in one of the following primary care specialties: Family medicine. General practice. Internal medicine. Naturopathic medicine. Advanced practice registered nurses (primary care). Physician assistants under the supervision of a program-eligible primary care provider. Pediatrics (commercial and QUEST Integration). 2. Primary care providers (PCPs) who primarily practice at an FQHC/RHC will be eligible to participate in the program. A PCP is considered to primarily practice at an FQHC/RHC if the majority of the PCP's payments are made to that FQHC/RHC. If a provider is contracted with HMSA as a non-pcp specialty type at a non-fqhc/rhc location, that provider may be eligible for program participation if the provider also practices at an FQHC/RHC as a PCP. HMSA reserves the right to exclude other non-primary care specialists in accordance with the Centers for Medicare & Medicaid Services (CMS) standards. Enrollment Conditions 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 payfor-quality award from HMSA. Providers may request reconsideration of their score and/or award, but must follow established procedures for reconsideration (see Inquiries and Requests for Reconsideration section on page 7). Providers, at their sole cost and expense, will maintain adequate records related to their obligations under the payfor-quality program. Providers agree that the Department of Health and Human Services, the comptroller general, and/or their designees will have the right of access and entry to this information and to providers facilities, including computer and other electronic systems, that pertain to any aspect of providers performance that results in payments from HMSA for the purposes of audit, evaluation, and/or inspection. 1 Additional Eligibility Criteria COMMERCIAL 1. Participation in HMSA S PPO and/or HMO plan at the end of the measurement period. QUEST INTEGRATION 1. Participation in HMSA S QUEST Integration plan at the end of the measurement period. MEDICARE ADVANTAGE 1. Participation in a Medicare Advantage plan at the end of the measurement period. 1 Required by regulations promulgated under the Affordable Care Act, 45 C.F.R

7 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. Measurement Responsibility All providers (regardless of specialty) are scored on all measures for which their patient panels are eligible. Target Dates and Deliverables COMMERCIAL QUEST INTEGRATION MEDICARE ADVANTAGE DATE January 1, 2018 March 31, 2018 April 30, 2018 July 31, 2018 August 2018 September 30, 2018 October 31, 2018 February 28, 2019 March 31, 2019 April 30, 2019 May 31, 2019 July 31, 2019 MILESTONES 2018 FQHC/RHC quality program begins. Deadline for FQHC/RHC to submit initiative descriptions and plans for SDoH engagement measure. Deadline for FQHC/RHC to submit quarter 1 data for each of the clinical quality measures. Deadline for FQHC/RHC to submit quarter 2 data for each of the clinical quality measures. Baseline performance data (CY 2017) available from HRSA. Deadline for FQHC/RHC to submit initiative measurement and outcomes specifications for SDoH engagement measure. Deadline for FQHC/RHC to submit quarter 3 data for each of the clinical quality measures. Deadline for FQHC/RHC to submit quarter 4 (year-end) data for each of the clinical quality measures. Deadline for FQHC/RHC to submit initiative progress reports, data, and findings/evaluation for SDoH engagement measure. Final quality measures performance report and payment for 2018 program year. Deadline for requests for reconsideration of final performance and payment for the 2018 program year. Notification of HMSA determination for requests for reconsideration submitted for 2018 program year. Engagement Measures Payment Schedule Payments will be issued at the end of the month listed in the Payment Date column. ATTRIBUTION PERIOD January 2018 February 2018 February 2018 March 2018 March 2018 April 2018 April 2018 May 2018 May 2018 June 2018 June 2018 July 2018 July 2018 August 2018 August 2018 September 2018 September 2018 October 2018 October 2018 November 2018 November 2018 December 2018 December 2018 January 2019 Scoring Period PAYMENT DATE COMMERCIAL QUEST INTEGRATION MEDICARE ADVANTAGE SCORING PERIOD 2018 (all clinical quality measures) MEASUREMENT PERIOD January 1 to December 31, 2018 BASELINE PERIOD January 1 to December 31,

8 Quality Measures Data Sources and Data Audit Data Sources Scoring of the clinical quality measures will rely on data that participating FQHCs/RHCs submit. Providers are required to submit quarterly performance data files with HMSA member-level data for each of the clinical quality measures. The data files must be extracted from the FQHC s/rhc s Uniform Data System (UDS) reporting source. The data must be electronically submitted via secure or secure FTP site (if available) to HMSA. Data submission deadlines Quarter 1 (January 1 to March 31, 2018) April 30, 2018 Quarter 2 (January 1 to June 30, 2018) July 31, 2018 Quarter 3 (January 1 to September 30, 2018) October 31, 2018 Quarter 4 (January 1 to December 31, 2018) February 28, 2019 Data file format requirements The quarterly data file must include all HMSA members who are eligible for each of the clinical quality measures. The data must be sent via a secure transmission method to HMSA (e.g., secure or uploaded to a secure FTP site). The data file should be in Excel format with a separate tab for each measure and must include the following information: DATA FIELD Patient Last Name Patient First Name DOB HMSA Plan Type HMSA Subscriber ID DOS DESCRIPTION Last name of patient First name of patient Patient's date of birth HMSA plan that member is enrolled in; choose from the following: commercial, QUEST Integration, Medicare Advantage Patient's HMSA subscriber ID number Date of service that satisfies measure compliance; leave blank if patient is not numeratorpositive Data Audit HMSA reserves the right to conduct an audit of patient medical records to verify that the measure data submitted by the FQHC/ RHC was accurate. HMSA will notify the FQHC/RHC in writing with details about the audit process and requirements before the audit. 6

9 Inquiries and Requests for Reconsideration Inquiries An inquiry is defined as a request for additional information about the FQHC/RHC quality program. General inquiries about the program (not specific to scores or results) will be answered at any time throughout the year. Send inquiries by: Letter. Mail to: HMSA Attn: Provider Services - POA P.O. Box 860 Honolulu, HI Send to PSInquiries@hmsa.com. Phone. Please call HMSA. For assistance identifying your contact, please call on Oahu or 1 (877) toll-free on the Neighbor Islands. Request for Reconsideration Process 1. Submit the necessary documents and information to HMSA. Fax: on Oahu PSInquiries@hmsa.com Mailing address: HMSA Attn: Provider Services - POA P.O. Box 860 Honolulu, HI HMSA will review and respond to your request within 60 business days from the date that HMSA receives the request. 3. If you re dissatisfied with HMSA s response to your request for reconsideration, additional dispute resolution remedies are available to you under your HMSA participating provider agreement. 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 payment. Requests for reconsideration will be accepted only in writing up through May 31, A request for reconsideration submitted within the criteria explained below should include supporting data. If a request is approved, the FQHC's/RHC's final quality score and payment will be adjusted accordingly. Requests for reconsideration must communicate: Measure. Patient. Clinical rationale and supporting citations for denominator exclusion or numerator credit. Medical record information to support denominator exclusion or numerator credit such as: Service/procedure. Date of service. Diagnosis. Lab result. Documentation including calculations and rationale to support adjustments to quality performance scores. 7

10 Patient Population and Member Eligibility Patient Population Identification COMMERCIAL HMSA s commercial plans (HMO and PPO) are eligible for the program. FEP members won't be included in the program. MEDICARE ADVANTAGE Members enrolled in a Medicare Advantage plan with HMSA are eligible for the program. If a member participates in another plan in addition to Medicare Advantage, the member can only be counted under one plan as follows: If a member under Medicare Advantage also has coverage under HMSA s commercial plan, the member will be counted under the commercial plan. If a member under Medicare Advantage also has coverage under HMSA QUEST Integration, the member will be counted under the Medicare Advantage plan. Note that the P4Q program in which a member is counted depends on the provider's program eligibilty. For example, if a member has coverage under both Medicare Advantage and HMSA QUEST Integration, but the provider only participates in HMSA QUEST Integration, then the member will be counted under the QUEST Integration plan. QUEST INTEGRATION HMSA QUEST Integration is eligible for the program. If a member under HMSA QUEST Integration also has coverage under HMSA's commercial plan, the member will be counted under the commercial plan. If member under HMSA QUEST Integration also has coverage under Medicare Advantage, the member will be counted under the Medicare Advantage plan. Note that the pay-for-quality program in which a member is counted depends on the provider's program eligibilty. For example, if a member has coverage under both Medicare Advantage and HMSA QUEST Integration, but the provider participates only in HMSA QUEST Integration, then the member will be counted under the QUEST Integration plan. Engagement Measures - Member Eligibility To be included in a provider's monthly engagement payment calculations, the member must be assigned to the provider for that month. Clinical Quality Measures - Member Eligibility To be included in a provider s performance rate calculations, 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 measurement period. All members eligible for a quality measure, whether or not they meet the 9-of-12 requirement, will contribute to a provider s quality payment maximum potential for each of the months they are assigned to the provider. 8

11 Payment Details Payment Conditions To be eligible, an FQHC/RHC provider must meet all of the following criteria: Participate in: HMSA s PPO and/or HMO plan at the end of the measurement period for commercial quality. An HMSA Medicare Advantage plan at the end of the measurement period for Medicare Advantage quality. HMSA QUEST Integration plan at the end of the measurement period for QUEST Integration. Practice in the state of Hawaii at the end of each measurement period. Submit claims to HMSA that indicate a face-to-face encounter, during the measurement period. See, also, details under the Program Eligibility and Enrollment sections on page 4. 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 measurement period. Providers must be participating in the 2018 FQHC/RHC quality program at the end of the measurement period to receive their quality payment earned in that program. If a provider ends FQHC/RHC quality program participation and begins participating in HMSA's Payment Transformation Performance (Quality) Measures prior to the end of the FQHC/RHC quality measurement period, the provider forgoes any FQHC/RHC quality award earned and won't receive payment for that FQHC/RHC quality measurement period. Quality Payments FQHC/RHC quality payments are based on your cumulative performance during the measurement period compared to your performance during the corresponding baseline period. See Scoring Period table on page 5. Final performance quality reports will be available on completion of the annual scoring and payment process in April For detailed program schedules, see the Target Dates and Deliverables table on page 5. Under the 2018 FQHC/RHC 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. Providers can earn up to 110% of the measure s maximum payment potential by performing above the target threshold. Payment Rates LINE OF BUSINESS (LOB) ENGAGEMENT PMPM Commercial $3.00 $4.25 QUEST Integration $2.00 $2.75 Medicare Advantage N/A $3.00 QUALITY PMPM Engagement Payments Providers will receive a monthly payment for their participation in the engagement measures. A summary report will be provided with each monthly payment. The summary report will include attributed member counts and the total engagement payment for each provider who belongs to the FQHC/RHC. The monthly payment is based on the following formula: Engagement PMPM x # of attributed members per LOB per month. See the Engagement Measures Payment Schedule on page page 5 for more details. If a provider has not sufficiently satisfied the requirements for any of the engagement measures, HMSA reserves the right to recoup these payments. 9

12 Quality Measure Scoring Measure Improvement Targets The improvement targets for the 2018 program year will be based on the 2016 UDS-reported* national performance rates for each measure. The improvement targets will be the same for all lines of business. The baseline for each FQHC will be their 2017 UDSreported performance rate for each measure. The same baseline will be applied for all lines of business. The 2017 rates will be available from the HRSA Health Center Program website around August MEASURE TARGET Cervical Cancer Screening 54.40% Childhood Immunization Status 42.80% Colorectal Cancer Screening 39.90% Controlling High Blood Pressure 62.40% Diabetes Care HbA1c Poor Control (> 9.0%) 32.10% Early Entry into Prenatal Care 68.80% Measure Weightings The weightings for the quality measures are below. MEASURE COMMERCIAL (PMPM) QUEST (PMPM) MEDICARE (PMPM) Cervical Cancer Screening $0.71 $0.46 $0.50 Childhood Immunization Status $0.71 $0.46 $0.50 Colorectal Cancer Screening $0.71 $0.46 $0.50 Controlling High Blood Pressure $0.71 $0.46 $0.50 Diabetes Care HbA1c Poor Control (> 9.0%) $0.71 $0.46 $0.50 Early Entry into Prenatal Care $0.70 $0.45 $0.50 TOTAL: $4.25 $2.75 $3.00 *Source: HRSA Health Center Program 2016 Health Center Data ( 10

13 Appendix A - Clinical Quality Measure Scoring Examples Appendix A: Scoring Examples Improvement is awarded proportionally based on the actual amount the provider has improved from the baseline relative to the improvement target. Example 1: Where More (Higher) is Better For measures where there is a direct relationship between the numerator and performance improvement (i.e., where a higher numerator makes for better performance and a lower numerator makes for worse performance), see the example below and steps in Table 1 for the measure s improvement calculation. Given the following: Improvement target: 85.20% Baseline rate: 57.60% Performance rate: 73.90% Attributed members: 6,000 Measure weight ($/PMPM): $0.30 PMPM TABLE 1: IMPROVEMENT CALCULATION WHERE MORE (HIGHER) IS BETTER a. The maximum potential dollar amount for this measure is derived by the product between the attributed members and the weight of the measure over 12 months. b. The difference between the improvement target and the baseline rate yields maximum improvement potential. 6,000 X $0.30 X 12 = $21, % 57.60% = 27.60% c. The difference between the performance and baseline rates yields actual improvement % 57.60% = 16.30% d. The quotient of the actual improvement to the maximum improvement potential is the proportion of the maximum potential dollar amount to be awarded for this measure (c divided by b). e. Apply the proportion computed above to calculate the dollars earned for this measure (d multiplied by a) % = 59.06% 27.60% 59.06% X $21,600 = $12, % (Base) (b) 27.60% 73.90% (Perf) 85.20% (Target) (c) 16.30% (d) percentage points for improvement 11

14 Example 2: Where Less (Lower) is Better For measures where there is an inverse relationship between the numerator and performance improvement (i.e., as with Diabetes Care HbA1c Poor Control (> 9.0%), where a lower numerator makes for better performance and a higher numerator makes for worse performance), see the example variables below and Table 2 for the measure s improvement calculation. Given the following: Improvement target: 68.00% Baseline rate: 88.00% Performance rate: 86.00% Attributed members: 6,000 Measure weight ($/PMPM): $0.30 PMPM TABLE 2: IMPROVEMENT CALCULATION WHERE LESS (LOWER) IS BETTER a. The maximum potential dollar amount for this measure is derived by the product between the attributed members and the weight of the measure over 12 months. b. The difference between the baseline rate and improvement target yields maximum improvement potential. 6,000 X $0.30 X 12 = $21, % 68.00% = 20.00% c. The difference between the baseline and performance rates yields actual improvement % 86.00% = 2.00% d. The quotient of the actual improvement to the maximum improvement potential is the proportion of the maximum potential dollar amount to be awarded for this measure (c divided by b). e. Apply the proportion computed above to calculate the dollars earned for this measure (d multiplied by a). 2.00% = 10.00% 20.00% 10.00% X $21,600 = $2, % (Target) (b) 20.00% 86.00% (Perf) 88.00% (Base) (e) $2, (10.00%) (d) percentage points for improvement (c) 2.00% $19, (90.00%) 12

15 Appendix B - Measure Detail Engagement Measures Engagement Measure: Data Sharing and Integration Engagement Measure: Social Determinants of Health (SDoH) Initiatives Clinical Quality Measure Find the clinical measures indexed alphabetically below. Cervical Cancer Screening...16 Childhood Immunization Status (All individual immunizations) Colorectal Cancer Screening...16 Controlling High Blood Pressure...17 Diabetes Care - HbA1c Poor Control (> 9.0%)...17 Early Entry into Prenatal Care

16 Engagement Measures Data Sharing and Integration Description Collaborate with HMSA on the development of a strategy and implementation to accomplish timely and accurate bidirectional data sharing between HMSA and FQHCs/RHCs. Requirements To fulfill this measure, FQHCs/RHCs must complete the following milestones. No specific reporting documentation is required at this time. HMSA may request feedback on topics relating to the milestones and FQHCs/RHCs are asked to respond in a timely manner to help faciliate continued collaboration and partnership. Participate in collaborative discussions and meetings, including site visits with HMSA staff. Give input on technical processes and requirements, including potential barriers to systems integration. Share plans for implementation of new systems, data processing, and data feeds, etc. Social Determinants of Health (SDoH) Initiatives Description Design outcomes reporting and evaluation for a social determinants-related initiative. The SDoH initiative can be connected to but not duplicate the projects being undertaken as part of HMSA s community grants. Initiatives and activities that have been started within the last six months can be included for measure credit. MILESTONE DEADLINE Submit description and plans for SDoH initiative. March 31, 2018 Identify potential outcomes of success and measurement specifications for initiative. September 30, 2018 Share progress reports, data, and findings of evaluation. March 31, 2019 Requirements To recieve full credit for this measure, each FQHC must submit the information outlined for each milestone to HMSA by the deadline. Please submit the information in a Word document (or other similar format) electronically via to ProviderQuality@hmsa.com. 14

17 Milestone 1: Describe the social determinants of health and plans for the initiative and activities. Due to HMSA by March 31, Provide responses to the following questions in five pages or less: 1. What s the problem that you re trying to solve? 2. Who s your target population? 3. What is your intervention or activity to address the problem? 4. What are the desired outcomes of your intervention or activity? How are you achieving these outcomes? 5. Please include a high-level plan and timeline of how your intervention or activity will be/has been implemented. Milestone 2: Identify potential outcomes and measurements of success for the initiative and activities. Due to HMSA by September 30, Provide responses to the following questions in five pages or less: 1. How are you measuring the impact of your intervention or activity? Please include a description of any products or deliverables that result from the intervention or activity. For example, an intervention targeted at patients who are unemployed might measure impact by the number of unemployed patients that complete resume writing and job interviewing classes. 2. How are you measuring the desired outcomes of your intervention or activity? Please describe specific data that's collected and how the data is used to track progress toward outcomes and performance. For example, an outcome measure for an activity that targets childhood obesity might be a 30 percent increase in the number of children that regularly engage in physical activity. Milestone 3: Share progress reports, including data and any findings from evaluation of your intervention and activities. Due to HMSA by March 31, Provide responses to the following in five pages or less: 1. Describe your experiences with implementing your intervention or activities. Did you have to modify your plan and timeline? Are there any lessons learned from this experience? 2. Please share preliminary outcomes data and progress on products or deliverables from your intervention or activities. 3. What are the next steps for your intervention or activities? Will you modify the design and/or outcomes measurement of your intervention or activities? 15

18 Clinical Quality Measures Cervical Cancer Screening Description The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women ages who had cervical cytology performed every three years. Women ages who had cervical cytology and human papillomavirus (HPV) co-testing performed every five years. Numerator Patients who were screened for cervical cancer using either of the following criteria: Patients years of age who had cervical cytology during the measurement period or the two prior measurement periods. Patients years of age who had cervical cytology and a human papillomavirus (HPV) test during the measurement period or the four prior measurement periods. Denominator Women years of age with a medical visit during the measurement period. Exclusions Evidence of a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix at any time in the patient s history. The hysterectomy must have occurred by the end of the measurement period. Measure Status NQF # 0032 Original Endorsement Date: August 10, 2009 Status: Endorsed Steward(s): NCQA Childhood Immunization Status (All individual immunizations) Description 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); four pneumococcal conjugate (PCV) one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. Numerator Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday. Denominator Children who turn 2 years of age who had a medical visit during the measurement period. Exclusions None. Measure Status NQF # 0038 Status: Endorsed Original Endorsement Date: August 10, 2009 Steward(s): NCQA Colorectal Cancer Screening Description Percentage of adults years of age who had appropriate screening for colorectal cancer. Numerator Patients who had one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the criteria below: Fecal occult blood test (FOBT), including a fecal immunochemical test (FIT), 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. Denominator Patients years of age with a medical visit during the measurement period. Exclusions 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. Measure Status NQF # 0034 Status: Endorsed Original Endorsement Date: August 10, 2009 Steward(s): NCQAControlling High Blood Pressure (<140/90) 16

19 Controlling High Blood Pressure (<140/90) Description Percentage of patients, years of age, whose blood pressure was adequately controlled (less than 140/90) during the measurement period based on the most recent blood pressure reading during the measurement period. Numerator Patients whose blood pressure is adequately controlled at the most recent visit during the measurement period. For a patient s blood pressure to be controlled, the systolic pressure must be less than 140 mmhg and diastolic pressure must be less than 90 mmhg. Denominator Patients years of age at the end of the measurement period with a medical visit during the measurement period and who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period. Exclusions Patients with evidence of end-stage renal disease (ESRD), dialysis, or renal transplant before or during the measurement period. Patients with a diagnosis of pregnancy during the measurement period. Measure Status NQF # 0061 Status: Endorsed Original Endorsement Date: August 10, 2009 Steward(s): NCQA Exclusions Patients with a diagnosis of secondary diabetes due to another condition. Measure Status NQF # 0059 Status: Endorsed Original Endorsement Date: August 10, 2009 Steward(s): NCQA Early Entry into Prenatal Care Description Percentage of prenatal care patients who entered prenatal care during their first trimester. Numerator Women beginning prenatal care at the health center, with a referral provider, or with another prenatal provider during their first trimester. Denominator Women seen for prenatal care at the health center during the measurement period. Exclusions None. Diabetes Care - HbA1c Poor Control (>9.0%) Description The percentage of patients with diabetes years of age whose most recent HbA1c level during the measurement period was greater than 9.0 percent. (Note: lower performance is better.) Numerator Patients whose most recent HbA1c test performed during the measurement period had a result greater than 9.0 percent. If the test was NOT performed, the patient is noncompliant for the measure. Denominator Patients years of age at the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2) and had a medical visit during the measurement period. 17

20 Appendix C - Patient Attribution Process Member Attribution to PCPs The goal of the attribution process is to reflect members preference for a provider as their PCP by member selection or based on their office-visit pattern. A PCP s attribution list is updated monthly and sent to Cozeva monthly. Member attribution must be verified monthly with their HMSA membership status. A PCP s panel will be based on HMSA s attribution methodology, which consists of two elements: Member selection: HMSA members are attributed to their selected PCP. Members who selected a PCP are never attributed to a PCP based on anything other than their PCP selection; claims don t change the attribution of these members. PCP selection is determined during enrollment via member attestation (see Member Attestation section) or by direct member request to HMSA. Medicare Advantage, commercial HMO, and QUEST Integration members must contact HMSA to select or change their PCP. PCPs are encouraged to help Medicare Advantage, commercial HMO, and QUEST Integration members complete and submit a member attestation form (see Member Attestation section). Claims history: In 2016 and 2017, HMSA members who didn't select a PCP were attributed to a provider based on a claims algorithm (PCP seen most often in the preceding 16 months or, in the case of a tie, PCP seen most recently). After October 2017, HMSA no longer attributes members via this claims history methodology. The PCP assignments based on historic claims-based attribution for commercial PPO members will remain until a change is requested through Cozeva. Dual members: Members with more than one HMSA plan may be attributed to only one provider. The attributed provider aligns with PCP assignments in HMSA's membership databases, which are also displayed on HHIN. To request a PCP update, the member should contact HMSA or the PCP may submit a patient attestation form on the member's behalf. Attribution to Self and Immediate Family Members HMSA plans don't provide benefit payment or cover services rendered by medical practitioners to themselves or to members of their immediate family. HMSA defines immediate family members as: Parent Child Spouse As an extension of this policy, PCPs in the HMSA Payment Transformation Program may not add themselves or their immediate family members to the PCP s own patient panel or accept patient attribution for themselves or immediate family members. That's because HMSA makes benefit payment in the form of the base PMPM payment for each attributed patient. Accepting a PMPM payment for yourself or immediate family members is a violation of this policy. PCPs should not add themselves or their immediate family members to HMSA's population management tool or select themselves as PCP or allow immediate family members to select them as their PCP when enrolling in HMSA plans. Use of Cozeva to Manage Attribution PCPs can manage their attributed panel using Cozeva. Using the Panel tab when logged in to Cozeva, PCPs can see their list of attributed members, including new and transferred members. PCPs may submit requests through Cozeva to add, transfer, or remove patients from their panel. Cozeva requests submitted for members with only a commercial PPO plan will initiate an attribution change. For members with a Medicare Advantage, commercial HMO, or QUEST Integration plan, providers need to fax a patient attestation form to HMSA to initiate an attribution change. PCP attestation/request: To attest/request that a member be attributed, a PCP must use the process in Cozeva. The provider should log in to Cozeva, click the Panel tab, and select Add Patient. This will take the PCP to an electronic request form that must be completed with the member s full name, date of birth, HMSA subscriber ID number, and gender. The PCP must also attest with an electronic signature that there s a medical need to access this member s personal health information. Lastly, PCPs must check the box, Add patient to Payment Transformation program, to request that the member be added to their attributed panel. (PCPs who don't check the box will have access to the member s Cozeva profile and care history, but won't have the member added to their PT Performance Measures; the only PCPs who shouldn't check this box are those who are covering for the member s PCP or providing specialty care). PCPs will have access to newly added patients Cozeva profiles within 24 hours. Commercial PPO members will be considered attributed to the PCP as of the month they were added. A member may only be added by one PCP each month in Cozeva. In addition to adding members on Cozeva, PCPs must collect a member attestation form from their patients to confirm the PCP-patient relationship. All attribution changes initiated via Cozeva are subject to audit. Member attestation: To confirm a member s choice to change PCP, PCPs should have all members in all lines of business complete and sign a patient attestation form when adding the member to their panel in Cozeva. The PCP should keep a copy of the form in the medical record. The form requires the member s signature to confirm that the provider is his/her PCP or the HMSA subscriber's or authorized representative's signature of a child 18 years old and under. For commercial HMO, QUEST Integration, and Medicare Advantage members, PCPs should fax the completed attestation form to HMSA Membership Services. Forms submitted via other methods won't be processed. Members will be attributed to the PCP as of the month that the form was processed by HMSA (i.e., within 10 business days of receipt). HMSA cannot assign members to a provider who is nonparticipating for a line of business that the member has an enrollment with. Cozeva is a registered trademark of Applied Research Works, Inc. Applied Research Works is an independent company that provides COZEVA, an online tool for HMSA providers to engage members on behalf of HMSA. 18

21 cs