Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2017 This document is a guide to the 2017 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas Blue Cross PCMH). This document does not guarantee clinic participation in the Arkansas Blue Cross PCMH program. This document is subject to change without notice.
ARKANSAS BLUE CROSS AND BLUE SHIELD PATIENT-CENTERED MEDICAL HOME (PCMH) 1. DEFINITIONS 2. ENROLLMENT AND ATTRIBUTION 2a Enrollment Eligibility 2b Clinic Enrollment and Clinic Withdrawal 2c Attribution of Members (Patient Panel) 3. CARE COORDINATION PAYMENTS 3a Care Coordination Payment Eligibility 3b Care Coordination Payment Amount 3c NCQA 4. SHARED SAVINGS 5. METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a Practice Transformation Activities Tracked 5b Metrics Tracked 5c Accountability 5d Provider Reports 6. COMPREHENSIVE PRIMARY CARE PLUS (CPC+) CLINIC PARTICIPATION IN THE PCMH PROGRAM 7. CONTACT US 1 DEFINITIONS AHIN (Advanced Health Information Network) Attributed Members (Patient Panel) Care Coordination Care Coordination Payments AHIN is a web-based portal that provides the Arkansas provider community real-time access to the information needed to efficiently manage a practice. AHIN s functionality includes eligibility, claim information, remittance information, and access to the State PCMH, Episode Reporting and ABCBS PCMH programs. A patient panel is a list of patients assigned (or attributed) to a Primary Care team in a practice. The team is responsible for managing the overall care for the attributed patient panel. Examples of the types of care that the team will be responsible for overseeing include: preventive care, chronic disease management, follow-up from any ED or in-patient hospital visit as well as any acute care needs. Activities focused on population management and patient engagement that aim in helping the patient/member navigate the healthcare system and improve their overall health. These activities may be carried out by an individual or spread across the care team. Per member per month (pmpm) payments made to participating Primary Care Physician practices. The payment amount is based on the number of members 1
CPC + (Comprehensive Primary Care Plus) Fully Insured Interoperability Medical Neighborhood Medical Neighborhood Barriers Participating Clinic Patient Alignment Patient-Centered Medical Home (PCMH) Performance Period attributed through either member selection or the attribution processed outlined in the PCMH amendment. Comprehensive Primary Care Plus is a multi-payer program which promotes collaboration between public and private health care payers to strengthen primary care. The goal is to improve overall patient health while supporting care delivery transformation. An arrangement by which a licensed insurance company gives its employer-group customers financial protection against claim loss in exchange for a monthly premium. The term fully insured member is used throughout this document. The ability of the component parts of an application (e.g. multiple EHRs communicating, hospital systems communication with clinics, or TeleVox) to operate successfully together. Involves the PCMH serving as the core provider plus any supporting entities, including but not limited to: specialists, behavioral health, pharmacists, home health, community resources and services, and other associated services. Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. A physician clinic that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type: Family Medicine, General Practice, Geriatrics, Internal Medicine, Pediatrics) B. A physician group of primary care providers who are affiliated, with a common group identification number C. A Rural Health Clinic D. An Area Health Education Center E. Federally Qualified Health Center (FQHC) The process of aligning our members with a Primary Care Provider based on recent claims data, member selection, and in some cases, geographic considerations. A Primary Care Provider will then manage the patients/members that have been assigned/attributed. Participating clinics may receive care coordination payments to support population health management activities for the attributed members. The term member refers to patients. A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage patients health needs with an emphasis on health care quality and value. The period of time over which performance is aggregated and assessed. 2
Practice Transformation Primary Care Physician (PCP) PCMH Provider Portal Remediation Time Self-insured Plan Same-day appointment Shared Savings program The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating clinic to serve as a PCMH. A physician providing primary care services whose sole or primary specialty is General Practice, Family Medicine, Internal Medicine, Pediatric Medicine, or Geriatric Medicine. The PCMH provider portal is used to submit reporting activities and/or metrics as well as receiving any information/reports shared by the plan. The PCMH provider portal is available on AHIN. The period during which participating clinics that fail to meet deadlines, targets or both on relevant activities tracked for practice transformation may remain enrolled in the program while improving performance. ABCBS may suspend care coordination payments during the remediation period. A health plan through which an employer or other group sponsor, rather than an insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a selffunded plan. Accommodating a patient s request to be seen by a clinician within 24 hours. A separate program to reward cost-efficient and quality care. A shared savings program will not be available for the 2017 program year. 2 ENROLLMENT AND ATTRIBUTION 2a. Enrollment Eligibility The Arkansas Blue Cross and Blue Shield PCMH Program eligibility requirements are: A. The practice must include primary care physicians (Family Medicine, General Practice, Geriatrics, Internal Medicine, or Pediatrics) enrolled in the following networks: Arkansas Blue Cross and Blue Shield (Preferred Provider Participant), Health Advantage and True Blue. AND B. The practice must complete the PCMH enrollment application located on the AHIN portal during the designated PCMH enrollment period. The enrollment period is announced annually on AHIN. AND C. The practice must return contract amendments signed by each primary care physician who provides primary care to patients at the PCMH clinic location. AND D. The practice must not be participating in the CPC+ program. 2b. Clinic Enrollment and Clinic Withdrawal 3
Enrollment in the PCMH program is voluntary. Enrollment is open to physicians providing primary care to patients. A clinic representative must complete the PCMH application available on the AHIN PCMH portal. True Blue, Health Advantage and Preferred Provider Participant contract amendments must be signed by the person in the clinic with administrative authority. Physicians new to the program will need to sign Exhibit B. A signature is not required for returning physicians. Upon receipt of the signed amendment, the clinic and its eligible physicians will be enrolled in the PCMH program. Clinics are expected to re-enroll annually. A PCMH will remain in good standing until: A. The clinic or physician withdraws; B. The clinic or physician becomes ineligible, is suspended or terminated from network participation or the PCMH program; C. Arkansas Blue Cross and Blue Shield terminates the PCMH program A participating clinic must update the Primary Care department on changes to the list of physicians who practice at the clinic. To add or withdraw a physician from the PCMH program, send an email to primarycare@arkbluecross.com. Include the name and NPI number for the physician in the email. Withdrawing from the PCMH program will not impact clinic/physician participation in any other existing contract(s) or program with Arkansas Blue Cross and Blue Shield and its family of companies. Physician(s) or clinic administrative personnel may terminate the PCMH agreement and be removed from the PCMH program by providing 30 days prior written notice of termination to: Arkansas Blue Cross and Blue Shield Primary Care, 4S 601 S. Gaines Little Rock, AR. 72201 Questions regarding the termination process should be directed to the Arkansas Blue Cross and Blue Shield Primary Care Department by calling 501-378-2370 or via email primarycare@arkbluecross.com. 2c. Attribution of Patients (Patient Panel) Fully insured members will be assigned to a physician based on an attribution methodology that will include but not be limited to factors such as claims containing specific evaluation and management CPT codes (99201-99499), assignment through recent dates of service, the total allowed amount of the paid claims and a member PCP selection process. If a member cannot be assigned based on paid claims or the member declines to select a PCP that member may be assigned to a participating clinic based on geographic proximity to the participating clinic. Members assigned to participating clinics but who have not established care at that clinic (no paid claims for E&M codes 99201-99499) will not be included in the patient panel of attributed members until the participating clinic is paid for an eligible E&M service code (99201 99499). For those members, care coordination payments will not be begin until the member has established care and the participating clinic has been paid for an eligible E&M service code (99201-99499). Self-insured employers will independently choose to participate or not participatein the PCMH program. They will also choose the Care Coordination Payment amount for their members. 4
3 CARE COORDINATION PAYMENTS 3a. Care Coordination Payment Eligibility In addition to the enrollment eligibility requirements listed in Section 2a, participating clinics must meet the practice transformation activities and metrics identified in sections 5a and 5b to receive care coordination payments. If a clinic fails to meet these requirements they are subject to suspension or termination. Suspension may result in a temporary interruption of the care coordination payments, while termination may result in a permanent cessation of care coordination payments. 3b. Care Coordination Payment Amount Care Coordination payments are calculated per attributed member, per month and paid monthly. Care Coordination payments support practice transformation and care coordination services. In order to begin receiving care coordination payments for the first quarter of 2017, a clinic must submit a complete PCMH Provider Participation Agreement on or before December 15, 2016. Members assigned to participating clinics but who have not established care at that clinic (no previous paid claims for E&M codes 99201-99499) will not be included in the care coordination payment until an eligible claim is submitted and paid. 3c. NCQA Practice(s) that hold NCQA PCMH recognition during the enrollment period 10/1/16-12/1/16 will receive an increased care management fee per member per monthfor their patients with a fullyinsured policy based on the level of recognition during the time of enrollment. If the practice(s) NCQA PCMH recognition expires prior to December 31, 2017 the PMPM payments will revert back to the base level the month following the expiration unlessan updated recognition has been submitted to primarycare@arkbluecross.com. 4 SHARED SAVINGS 4a. Shared Savings A Shared Savings program will not be available for the 2017 program year. 5 METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a. Practice Transformation Activities Tracked Using the PCMH Provider Portal, participating clinics must complete and document the activities as described in the table below by the deadline indicated in the table. The reference point for the deadlines is January 1, 2017 5
2017 Activities Deadline Initial Practice Assessment and Work Plan Development 3/31/2017 A. Identify/Update high-priority patients for 2017 4/30/2016 B. Provide 24/7 access to care 6/30/2017 C. Document approach to expanding access to same-day appointments 6/30/2017 D. Capacity to receive direct electronic messaging from the patients 6/30/2017 E. PCP Enrollment in the Arkansas Prescription Drug Monitoring Program (PDMP) 6/30/2017 F. Childhood/adult vaccination practice strategy 12/31/2017 G. Receiving discharge information 12/31/2017 H. Incorporate e-prescribing into practice workflows 12/31/2017 I. High-priority patients whose care plan as contained in the medical record includes: 1. Documentation of a patient s current problems 2. Assessment of the progress to date 12/31/2017 3. Plan of care as provided to the patient 4. Instructions for follow up The care plan must be updated at least twice a year. J. Patient Health Literacy Assessment Tool Administer a health literacy assessment (Single Item Literacy 12/31/2017 Screener, REALM-SF, etc.) to at least 50 patients or caregivers enrolled in the ARBCBS PCMH program. K. Ability to receive Patient Feedback 12/31/2017 L. Care Instructions for High Priority Patients (Create and share with the patient an after visit summary which include updated/reconciled medication list, vital signs, purpose of the 12/31/2017 visit, procedures and other information or instructions based on clinical discussions that took place during the visit, summary of topics covered/considered, and follow up instructions.) M. Medication Management Describe the practice s EHR reconciliation process. Document 12/31/2017 updates to active medication list in EHR for high priority patients. N. 10 day follow-up after an acute inpatient hospital stay (40% of patients with an inpatient stay had an in-person visit or followup phone call within 10 days of discharge) 12/31/2017 Report Clinical Quality Measure Data for Calendar Year 2017: Controlling High Blood Pressure Diabetes: Hemoglobin A1c Poor Control Diabetes Eye Exam 1/31/2018 Cervical Cancer Screening Colorectal Cancer Screening Breast Cancer Screening Human Papillomavirus for Female Adolescents Arkansas Blue Cross and Blue Shield and its family of companies may add, remove, or adjust these practice transformation activities or deadlines, including additions beyond 12 months, based on new research, empirical evidence or experience from initial metrics. Arkansas Blue Cross and Blue Shield and its family of companies will publish such extension, addition, removal or adjustment on AHIN and in the PCMH Provider manual. 6
5b. Metrics Tracked Arkansas Blue Cross and Blue Shield and its family of companies assesses participating clinics on the following metrics tracked starting on the first day of the first calendar year in which the participating clinic is enrolled in the PCMH program and continuing through the full calendar year. Quality Metrics 1. Percentage of patients who turned 15 months old during the performance period and who received at least five wellness visits in their first 15 months. 2. Percentage of patients 3-6 years of age who had one or more well-child visits during the measurement year. 3. Percentage of patients 12-21 years of age who had one or more well-care visits during the measurement year. 4. Percentage of patients prescribed appropriate asthma medications. 5. Percentage of children who received appropriate treatment for Upper Respiratory Infection (URI). 6. Percentage of a clinic s high-priority patients seen by a member of the PCP s care management team at least twice in the past 12 months. 7. Percentage of patients 2 years old at the end of the report period that had an MMR by their 2nd birthday. 8. Percentage of patients with uncomplicated low back pain that did not have imaging studies. 9. Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. (All payer source) 10. Percentage of patients 18-75 years of age with diabetes (type 1 or type 2) whose most recent HbA1C level during the measurement period was greater than 9.0% (poor control) or was missing the most recent result, or an HbA1C test was not done during the measurement period. (All payer source) 11. Percentage of female patients 50-75 years of age that had a screening mammogram in the past two years. (All payer source). 12. Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer. (All payer source) Target for Program Year Beginning January 1, 2017 At least 60% At least 60% At least 50% At least 85% No more than 30% At least 80% At least 92% At least 70% At least 55% Self-report No more than 35% Self-report At least 72% Self-report Informational only Self-report 7
Quality Metrics 13. Percentage of patients 18-75 years of age with a diagnosis of diabetes who had an annual dilated eye exam. (All payer source) 14. Percentage of female patients 21-64 years of age who had appropriate screening for cervical cancer. (All payer source) 15. Percentage of female patients 13 years of age at the end of the reporting period who had three HPV vaccines by their13 th birthday. (All payer source) Target for Program Year Beginning January 1, 2017 Informational only Self -report Informational only Self report Informational only Self report Arkansas Blue Cross and Blue Shield and its family of companies may add, remove, or adjust these metrics based on new research, empirical evidence or experience from initial metrics. 5c. Accountability If a participating clinic does not meet deadlines and targets for practice transformation activities and metrics as described in Sections 5a and 5b, then the clinic must submit an improvement plan to prevent a change in participation status with the program. The improvement plan should be submitted within one month of receiving their Arkansas Blue Cross and Blue Shield PCMH report notifying them of failure to meet an activity requirement. Clinics will be expected to follow the Improvement Plan policy set forth by Arkansas Blue Cross and Blue Shield. A. Activities tracked a. The participating clinic will have a full calendar quarter to complete remediation after being notified of the requirements that did not meet expectations. B. Metrics tracked a. Performance must be remediated before the end of the second full calendar quarter after the date the clinic receives notice via the provider report that target(s) have not been met. b. For purposes of remediation, performance is measured on the most recent four calendar quarters. If a clinic fails to meet the deadlines or targets for practice transformation activities and metrics tracked within this remediation time, then Arkansas Blue Cross and Blue Shield and its family of companies may suspend care coordination payments or terminate the clinic from the PCMH program. Arkansas Blue Cross and Blue Shield and its family of companies retain the right to confirm clinics performance against deadlines and targets for activities and metrics tracked. 5d. Provider Reports Arkansas Blue Cross and Blue Shield and its family of companies provide participating clinics reports containing information about their clinic performance on activities and metrics. Reports will be located on the AHIN PCMH provider portal. 8
6 COMPREHENSIVE PRIMARY CARE PLUS (CPC +) CLINIC PARTICIPATION IN THE PCMH PROGRAM 6a. CPC+ Clinic Participation Any Practice/Provider participating in CPC+ is not eligible for participation in the Arkansas Blue Cross and Blue Shield PCMH program. 7 CONTACT US 7a. Questions regarding the Arkansas Blue Cross and Blue Shield PCMH program The Arkansas Blue Cross and Blue Shield Primary Care team is available to answer questions regarding the Arkansas Blue Cross PCMH program via email or by phone Monday Friday 8:00am 4:30pm CST. Email: primarycare@arkbluecross.com Phone: 501-378-2370 9