2018 Hospital Pay For Performance (P4P) Program Guide. Contact:

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1 2018 Hospital Pay For Performance (P4P) Program Guide Contact: Published: December 1, 2017

2 Program Overview Inland Empire Health Plan (IEHP) is pleased to announce its Hospital Pay For Performance Program (Hospital P4P) for IEHP Medi-Cal contracted Hospitals within Riverside and San Bernardino Counties. The goal of the Hospital P4P Program is to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate high quality care to IEHP membership. The 2018 Hospital P4P Program is structured as a prospective program, with quarterly performance measurement and payment. Payment scales to the volume of IEHP Member admissions per hospital. The 2018 Program includes five measures and are listed below. All measures are based on 2018 calendar year performance and are assessed on a quarterly schedule that is outlined in the Payment Methodology section below. All-Cause Readmissions Post Discharge Follow-up within 7 Days of Discharge for High-Risk Members Nulliparous Term Singleton Vertex (NTSV) Cesarean Delivery Rate Manifest Med Ex (MX) Active Participation Physicians Order for Life Sustaining Treatment (POLST) Registry Utilization Participation Requirements Hospitals with an active IEHP Contract for Medi-Cal Adults and Pediatric populations at the beginning of the measurement year, and who are located within Riverside and San Bernardino Counties are eligible for program participation. Other program requirements include: Hospitals with Maternity Service lines must actively participate in the California Maternal Quality Care Collaborative (CMQCC) Maternal Data Center Reporting and sign a CMQCC authorization release to share Hospital-level results with IEHP by February 15, 2018 Hospitals with no Maternity Service lines are not eligible to receive incentive dollars for the NTSV Cesarean Delivery Rate measure Page 2 of 14

3 Financial Overview The annual budget for the 2018 Hospital P4P is $30,000,000 in total possible payouts to qualifying hospitals who meet quality performance targets. The table below summarizes the Hospital P4P budget for the year, by quarter and by measure dollars that are available. P4P Program Budget Total Dollars Available $ 30,000, Quarterly Dollars Available $ 7,500, Measure Allocation P4P Dollars Available per Measure Measures Allocation % All-Cause Readmissions 20% $1,500,000 7 Day Post Discharge Follow Up 20% $1,500,000 NTSV C-section Rate 20% $1,500,000 MX Participation 20% $1,500,000 POLST Registry Utilization 20% $1,500,000 Total Quarterly Budget 100% $7,500,000 Page 3 of 14

4 Payment Methodology Eligible hospitals are evaluated quarterly on their performance in each of the P4P measures. Each measure is calculated following the measure guidelines listed in Summary of Measures Section of this Guide. Hospital performance is assessed against the established performance goals. Below is a list of the Hospital P4P Program measures and their performance goals. For measures that have 2 Tier performance goals, 50% of the available measure dollars are rewarded for reaching Tier 1 level performance and 100% of the available measure dollars are rewarded for reaching Tier 2 level performance. For measures that have only one performance goal, 100% of the available measure dollars are rewarded for meeting the goal rate. Measure Name Data Source 2018 Performance Goals All Cause Readmissions (ACR) Post Discharge Follow Up within 7 Days for High-Risk Members IEHP Claims IEHP Claims & Encounters Tier 1: 10% Improvement over hospitalspecific baseline performance ( ) Tier 2: 11.9% or below (90th Percentile Performance for CA Medi-Cal Managed Care) Tier 1: 10% Improvement over hospitalspecific baseline performance ( ) Tier 2: 47.0% or above (90th Percentile Performance for IEHP network) NTSV Cesarean Delivery Rate CMQCC* Less than or equal to 23.9% Manifest MedEX Active Participation Manifest MedEx POLST Registry Utilization POLST Registry *California Maternal Quality Care Collaborative Both conditions must be met: 1) Hospital subscribed to and receiving MX events 2) Hospital actively querying MX portal: Hospital queries at least 60 unique patients per quarter Large Hospitals (>400 Quarterly IEHP Discharges): > 300 unique patients queried per quarter Small Hospitals (<400 IEHP Discharges): > 50% of total IEHP discharges queried per quarter Page 4 of 14

5 Payment Schedule IEHP will adhere to the following payment schedule for all Hospital P4P measures 2018 Hospital P4P Payment Schedule Measurement Period Payment Date Q July 2018 Q October 2018 Q Jan 2019 Q April 2019 Reporting Timeline Measure Name Data Source(s) Measurement Period Data Freeze Date All Cause Readmissions (ACR) IEHP Claims Quarter 1: Jan - March Quarter 2: April - June Quarter 3: July - Sept Quarter 4: Oct - Dec Quarter 1: June 15, 2018 Quarter 2: Sept 15, 2018 Quarter 3: Dec 15, 2018 Quarter 4: Mar 15, 2019 Post Discharge Follow Up within 7 Days for High-Risk Members IEHP Claims & Encounters Quarter 1: Jan - March Quarter 2: April - June Quarter 3: July - Sept Quarter 4: Oct - Dec Quarter 1: June 15, 2018 Quarter 2: Sept 15, 2018 Quarter 3: Dec 15, 2018 Quarter 4: Mar 15, 2019 NTSV Cesarean Delivery Rate CMQCC Maternal Data Center Reporting Quarter 1: Jan - March Quarter 2: April - June Quarter 3: July - Sept Quarter 4: Oct - Dec Quarter 1: June 15, 2018 Quarter 2: Sept 15, 2018 Quarter 3: Dec 15, 2018 Quarter 4: Mar 15, 2019 Manifest MedEx Active Participation Manifest MedEx Quarter 1: Jan - March Quarter 2: April - June Quarter 3: July - Sept Quarter 4: Oct - Dec Quarter 1: June 15, 2018 Quarter 2: Sept 15, 2018 Quarter 3: Dec 15, 2018 Quarter 4: Mar 15, 2019 POLST Registry Utilization POLST Registry Quarter 1: Jan - March Quarter 2: April - June Quarter 3: July - Sept Quarter 4: Oct - Dec Quarter 1: June 15, 2018 Quarter 2: Sept 15, 2018 Quarter 3: Dec 15, 2018 Quarter 4: Mar 15, 2019 Payment Calculation Payments to Hospitals are scaled to IEHP Member admissions by hospital based on the following formula: Page 5 of 14

6 Step 1: Determine the Percent of Total Admissions per Hospital [Total IEHP Admissions for Hospital in the Quarter] [Total l IEHP Admissions for All Eligible Hospitals in the Quarter] = % of Total Admissions Step 2: Determine the Amount of P4P Dollars Available per Hospital [% of Total Admissions] X [Total Quarterly P4P Dollars Available] = Total P4P Dollars Available per Hospital Per Quarter Example: Hospital X: Step 1: Determine the Percent of Total Admissions per Hospital IEHP Admissions for Hospital X for Quarter = 3,000 Total IEHP Admissions for All Hospitals for Quarter = 16,000 3,000 16,000 = Step 2: Determine to Amount of P4P Dollars Available per Hospital X $1,500, = $281, Available for Hospital X per Measure per Quarter Page 6 of 14

7 Summary of Measures The following section describes each of the Hospital P4P Program measures. Measure Name: All Cause Readmissions (ACR) For IEHP Members 21 years of age and older, the number of acute inpatient stays during the measurement period that are followed by an unplanned acute readmission for any diagnosis within 30 days. Description: The Healthcare Effectiveness Data and Information Set (HEDIS ) modified measure Plan All-Cause Readmissions (PCR-CA) is utilized to determine the 30 day readmission rate for IEHP members. The measure includes acute discharges from any type of facility (including behavioral healthcare facilities) Exclusions The following discharges are excluded from the measure: Principal diagnosis of pregnancy Principal diagnosis of a condition originating in the perinatal period. Member died during the stay Non-acute inpatient stays Hospice Care One day discharge Principal diagnosis of maintenance chemotherapy Principal diagnosis of rehabilitation Organ transplant Potentially planned procedure To be eligible for this measure, Members must be enrolled with IEHP 365 days prior to the index discharge date through 30 days after the index discharge date. No more than one gap in enrollment of up to 45 days during the 365 days prior to the Index Discharge Date and no gap during the 30 days following the Index Discharge date is allowed. Denominator Minimum Denominator Requirement Numerator All acute inpatient discharges during the measurement year for IEHP members. Denominator must be 30 or greater for this measure to be eligible for payment At least one acute readmission for any diagnosis within 30 days of the index discharge date. Page 7 of 14

8 Measure Name: Post Discharge Follow-up within 7 Days of Discharge for High Risk Members For High-Risk Medi-Cal Members, 18 years of age and older, the number of discharges during the measurement period that are followed by an outpatient visit with a physician within 7 days. To identify high-risk members, IEHP uses the John Hopkins ACG System, that uses data from the prior twelve months to generate predictive risk scores for the next twelve months. The ACG System measures the morbidity burden of patient populations based on disease patterns, age and gender. A key strength of the ACG System rests in its ability to capture the interrelationships between co-occurring morbidities that are the hallmark of the very chronically ill populations that pose the greatest demands for health care resources. The clinical and statistical algorithms by which billions of potential disease combinations are distilled down to a fixed number of health status categories is the essence of the ACG System. IEHP uses the ACG System to harness the power of the ambulatory and inpatient diagnostic information as well as pharmaceutical information to risk stratify the entire IEHP membership. For the purpose of high-risk member stratification, IEHP uses the ACG predictive marker called Probability of Total High Cost. This marker predicts the probability of a member being in the top 5% of total high cost for IEHP in the next twelve months. Because of the robust algorithms used by the ACG System, individuals with short acute episodic utilization of the healthcare system are not part of Top 5% total high cost population. The Top 5% total high cost population include individuals with multiple chronic conditions and co-morbidity who often require extensive utilization of the healthcare system, demonstrating the need for timely post-discharge follow-up with their primary care provider. For purposes of this measure, IEHP considers Members who have probability score of >0.5 for being in top 5% of total cost as High-Risk Members. Denominator All Acute and Nonacute inpatient discharges during the measurement period for high-risk Members. IEHP utilizes the HEDIS measure denominator specifications for: MRP (Medication Reconciliation Post Discharge) to determine the initial denominator. Once these Members and discharges have been identified, the denominator is further refined to only include those Members who meet the High-Risk criteria of a Probability Risk Score value > 0.5 on the date of discharge. Page 8 of 14

9 To be eligible for this measure, IEHP Members must be enrolled with IEHP date of discharge through 30 days after discharge (31 total days). Note If the discharge is followed by a readmission or direct transfer to an acute or nonacute inpatient care setting on the date of discharge through 30 days after discharge (31 total days), count only the last discharge. Minimum Denominator Requirement Numerator Denominator must be 10 or above for this measure. High risk members who had follow-up visit with a practitioner within 7 days of discharge. To view an IEHP Member s current Probability of High Total Cost Risk Score, Hospitals can access this by logging into the IEHP Provider Portal and follow these steps: 1) From the Home Screen, click on Eligibility 2) Enter the Member ID and Click Search Page 9 of 14

10 3) Click on the Chart icon 4) View Member Risk Score: Probability of High Total Cost Page 10 of 14

11 Measure Name: NTSV Cesarean Delivery Rate Background California Maternal Quality Care Collaborative (CMQCC) calculates a standardized measure that assesses the rate of cesarean births, focusing on the all-important first birth. This measure is known as the Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate, which identifies the proportion of live babies born at or beyond 37.0 weeks gestation to women in their first pregnancy, that are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions), via cesarean birth. The US Department of Health and Human Services in its Healthy People 2020 project simplified the name for non-obstetric audiences as Low Risk Cesarean Birth among First Time Pregnant Women. This is a bit imprecise as there are certainly some higher risk patients that remain in the denominator but have very little impact. The Joint Commission subsequently adopted this metric in 2010 and now requires all hospitals with more than 300 births report their results as part of the Perinatal Core Measure Set. The metric has also been adopted by the Leapfrog Group and Centers for Medicare and Medicaid Services. Several states also require hospital reporting as part of their Medicaid quality initiatives. The NTSV Cesarean Birth measure was re-endorsed as one of NQF s Perinatal and Reproductive Health measures in 2016, and The Joint Commission is now the steward of the measure. Methodology Hospitals with Maternity Service lines must actively participate in the California Maternal Quality Care Collaborative (CMQCC) Maternal Data Center Reporting and sign a CMQCC authorization release to share Hospital-level results with IEHP by February 15, Hospitals with no Maternity Service lines are not eligible to receive incentive dollars for this measure. All hospitals who participate in the Hospital P4P Program must report their rates following the CMQCC reporting guidelines and timeframes and must provide authorization to CMQCC to allow IEHP to have access to the hospital reported rates. IEHP will receive hospital specific rates from CMQCC following the Reporting Timeline noted in the Payment Methodology Section above. Page 11 of 14

12 Measure Name: Manifest MedEx Active Participation Background Manifest MedEx (MX) supports HIE connectivity across the state of California and currently includes 30 hospitals and medical centers, medical groups, IPAs and physician practices in the Inland Empire. MX works closely with a local partner, Inland Empire Health Information Organization (IEHIO) whose leadership represents eleven hospitals and most of the physicians (2,400 unduplicated physicians) in the area who participate in organized physician groups and IPAs. The remaining physicians are largely in solo practices. MX also includes many other health care organizations, such as FQHCs and multi-specialty clinics. Baseline requirements As a baseline requirement, Hospitals must have current participation agreement with MX and meet the data contribution requirements below: IEHP has the following MX data contribution requirements for Hospitals HL7 ADT data feed that complies with MX data sharing guidelines in production HL7 ORU data feed that complies with MX data sharing guidelines in production HL7 RDE data feed that complies with MX data sharing guidelines in production Performance Measure Hospital is: 1. subscribed to and receiving MX event notifications; AND 2. actively querying the MX portal to support patient care To sign up for services, please contact sproctor@iehio.org How MX will measure 1. yes/no 2. users within the organization query at least 60 unique patients per quarter (this equates to 20 patients per month or 5 patients per week) Data sources MX will use 1. MX notification service subscription report 2. Longitudinal patient record audit report from MX technology vendor Page 12 of 14

13 Definitions Data Contribution Requirements (these are all included in the standard MX Participation Agreement) For Hospitals: HL7 ADT data feed that complies with MX data sharing guidelines in production HL7 ORU data feed that complies with MX data sharing guidelines in production HL7 RDE data feed that complies with MX data sharing guidelines in production Current Participation Agreement Participant has executed a PA with MX using MX s post-merger PA structure Acronym dictionary: PA: participation agreement DSG: data submission guidelines ADT: admission, discharge transfer message ORU: observation result message RDE: pharmacy/treatment encoded order message HL7: Health level 7 standards development organization Page 13 of 14

14 Measure Name: Physicians Order for Life Sustaining Treatment (POLST) Registry Utilization Background A POLST Registry is a repository that hosts digital POLST forms that can be accessible via various digital platforms. Providers are able to access the digital POLST on demand throughout the continuum of care without any administrative delay. Integrating the POLST Registry into a hospital s EHR will facilitate utilization of the POLST Form. The Registry will be available to hospitals, skilled nursing facilities, and the IEHIE, as well as mobile and web technologies. Access, at any given time, will ensure patient desired treatment at the end of life is being honored. IEHP has engaged California POLST Registry to connect a digital POLST Form network throughout the Inland Empire healthcare system including hospitals, skilled nursing facilities, HIE and independent physicians. Each participating hospital must enter into an Agreement with California POLST Registry for the purpose of integrating the POLST Registry into the Hospital EHR. Please contact: California POLST Registry support@capolstregistry.org Phone: (888) Hospital utilization of the POLST Registry as demonstrated by the number of queries into the Registry by the Hospital is the metric for 2018 Hospital P4P program. Rate Calculation Large Hospitals Hospitals with 400 or more IEHP discharges in a quarter Care Directives (administrator of the registry) will provide IEHP with the number of inqueries made each quarter by each hospital. This number will be used to determine if it meets the IEHP performance goal of this measure for Large Hospitals. Small Hospitals Hospitals with less than 400 IEHP discharges in a quarter Numerator Care Directives (administrator of the registry) will provide IEHP with the number of inqueries made each quarter by each hospital. Denominator IEHP will identify the total number of IEHP discharges at a hospital during the reporting period. Page 14 of 14