PERFORMANCE TARGET MEASURES FORMULARY ADHERENCE This measure seeks to maintain quality of care while reducing costs of prescription drugs. The CBI Program encourages PCPs to reduce the number of costly prescriptions paid by the plan when safe and effective alternatives are available for lower cost through the Alliance s formulary. ELIGIBLE POPULATION: MEASURE DESCRIPTION: The percentage of generic, and some specified allowed formulary prescriptions filled, over all prescriptions filled during the measurement period. A higher percentage represents a drug prescribing method That adheres more closely to Alliance policy. MEMBER REQUIREMENT: None. Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members. Age: All ages. Continuous Enrollment: N/A. Eligible Member Event/Diagnosis: None. Exclusions: Claims for the following drugs: Estazolam, Flurazepam, Lorazepam HCL, Strattera, Temazepam, Triazolam, Alprazolam, St. John s Wort Administrative Members on date of service Members with other health coverage on date of service Medicare D on date of service California Children s Services (CCS) Members on date of service DENOMINATOR: Total eligible prescriptions filled, for eligible population as defined above, from one of the therapeutic classes below, during the measurement period where the member was linked to the PCP on the fill date. NUMERATOR: The number of generic and some specified allowed formulary prescriptions filled. P a g e 49 of 72 Version 2018.5
SERVICING PCP SITE REQUIREMENTS: Prescribing history is attributed to the PCP site the member is linked to on the date of the prescription, regardless of the prescribing provider. DATA SOURCE: Claims, Pharmacy Data THERAPEUTIC CLASS Antidepressants and Sedatives Anti-ulcer agents Diabetes Anticoagulants Attention Deficit /Hyperactivity Disorder (ADHD) Antihyperlipidemic CALCULATION FORMULA: # of generic prescriptions filled / total eligible prescriptions filled PAYMENT FREQUENCY: Annually, following the end of quarter 4. Note, measurement period for this measure is year to date, not rolling 12 months like the Care Coordination and Quality of Care Measures. RESOURCES: 2018 Programmatic Measure Benchmarks CODE SET LINKS: Formulary Adherence Codes SSRIs and SNRIs and Benzodiazepines Proton pump inhibitors (PPIs) Oral and self-injected antidiabetic agents DESCRIPTION Warifan and Novel Oral Anticoagulants (NOACs) Stimulants and non-stimulant (atomoxetine) HMG COA Reductase Inhibitors P a g e 50 of 72 Version 2018.5
PERFORMANCE IMPROVEMENT MEASURE Performance improvement is at the heart of the CBI program and the Alliance recognizes the investments PCP site s make toward improving their scores. The Performance Improvement measures awards CBI points for site s who improve their CBI scores year over year, or sites who meet and maintain top performance benchmarks. MEASURE DESCRIPTION: PCPs shall be awarded Performance Improvement points for every measure they qualify for by either: Meeting the Plan Goal (see the 2018 Performance Improvement Plan Goals for this year s Plan Goals for each measure), or Achieve a 5% (Care Coordination- Hospital Measures) or five percentage point (Care Coordination- Access Measures and Quality of Care measures) improvement compared to the prior year. REGARDING NEW MEASURES: New measures and measures that were formerly scored Fee For Service, do not have quality scores from prior years. For this reason, it is only possible to receive Performance Improvement points for these measures by meeting the Plan Goal. If providers do not meet the Plan Goal for the measures indicated below, their points will be redistributed among the other measures their site qualifies for. Measure s which qualify for Performance Improvement points via Plan Goal only include: 30 Day Readmissions Initial Health Assessments Post Discharge Care Screening, Brief Intervention and Referral to Treatment Annual Monitoring for Patients on Persistent Medications Childhood Immunizations (combo 3) Diabetic Retinal Exam Diabetic Testing for HbA1c Maternity Care: Post-Partum Measures which qualify for Performance Improvement points via Plan Goal and Performance Improvement over the prior year include: Ambulatory Care Sensitive Admissions Preventable Emergency Visits Asthma Medication Ratio Cervical Cancer Screening Diabetic HbA1c Good Control <8.0%* Well Adolescent Visit (12-21) Well Child Visit (3-6) P a g e 51 of 72 Version 2018.5
MEMBER REQUIREMENT: The Performance Improvement measure is worth a total of 10 potential CBI points, divided among all measures for which the PCP qualifies. PCPs qualify for measures by meeting the applicable member requirements set out by the measure: 5 eligible member for all Quality of Care measures and the Care Coordination- Access Measures. 100 eligible members for the Care Coordination- Hospital Measures For measures without comparative prior year data, as listed above, the provider can qualify for Performance Improvement points by meeting the plan goal. If the Plan goal is not met, the points for that measure will be redistributed among the other measures the provider qualifies for. See grid below. The total number of Performance Improvement points each measure is worth is determined by the total number of measures for which the PCP qualifies (see explanation of qualifications above). See grid below. PERFORMANCE IMPROVEMENT POINTS Number of Qualifying Maximum Points per Measures Measure 1 10.00 2 5.00 3 3.33 4 2.50 5 2.00 6 1.67 7 1.43 8 1.25 9 1.11 10 1 11.91 12.83 13.77 14.71 15.67 16.63 P a g e 52 of 72 Version 2018.5
ELIGIBLE POPULATION: Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members. Ages: Measure specific Continuous Enrollment: Measure specific Eligible Member Event/Diagnosis: Measure specific Exclusions: Measure specific DENOMINATOR: Measures specific NUMERATOR: Measure specific SERVICING PCP SITE REQUIREMENTS: Measure specific PAYMENT FREQUENCY: Annually, following the end of quarter 4 RESOURCES: 2018 Performance Improvement Plan Goals DATA SOURCE: Measure specific P a g e 53 of 72 Version 2018.5
MEMBER REASSIGNMENT THRESHOLD Member reassignments are challenging and disruptive to the provision of healthcare to our members. The Alliance encourages provider sites to limit the number of members they reassign from their practice. This measure penalizes providers who exceed the established threshold of member reassignments in a calendar year. MEASURE DESCRIPTION: The rate of linked members a PCP Site reassigns from their practice during a calendar year. The member reassignment threshold is a maximum of 1 reassignment per 150 linked members. PCP Sites that exceed one reassignment per year per average 150 linked members are at risk of losing ½ of their CBI programmatic payments. MEMBER REQUIREMENT: PCP must have an average of 100 eligible members during the measurement period or a minimum of 100 eligible members on the last day of the measurement period. Exclusions: OHC on date of reassignment Medi-Medi on date of reassignment Administrative Members on date of reassignment California Children s Services (CCS) Members on date of service Not all member reassignments count as part of the CBI member reassignment measure. Member reassignments for the following reasons are exempt and do not count against the PCP site. Medication Management (BA) Abusive/Disruptive Behavior (AB) Fraud (FR) Aged Out (AO) Member Requested (MI) Non-Medi-Cal member reassignments SERVICING PCP SITE REQUIREMENTS: Members who are linked to provider at time of reassignment are counted toward the reassignment threshold. P a g e 54 of 72 Version 2018.5