Aetna Better Health 2000 Market Street, Suite 850 Philadelphia, PA 19103 Quality Management Department Re: Subject line (optional) AETNA BETTER HEALTH Pay for Quality Program You may be eligible to earn more compensation with our new Pay for Quality (P4Q) program! We re introducing our 2016 P4P program for all participating primary care, dentists and OB/GYNs in Pennsylvania. We recognize your importance in providing care for our Medicaid members. In recognition of that role, Aetna Better Health Pennsylvania is implementing a Pay-for-Quality (P4Q) Program for 2016. All Participating Network Primary Care Providers who maintain a panel size of at least 50 members, OB/GYNs and dentists are eligible to participate. This program is all upside. The P4Q program will support your HealthChoices members and our quality care initiatives by: Promoting care that results in a healthier population by improving quality and outcomes. Enriching care delivery consistency and adherence to efficacy based standards of care. Promoting a continuous quality improvement orientation. Promoting care coordination between providers and the health plan, resulting in greater member engagement. The program is based on practice-specific data tied to a variety of clinical quality and utilization guidelines. We ll make payments for the P4Q program based on patient encounters from January 1, 2016 through December 31, 2016. Providers - individuals and/or group practices (defined at the Pay To TIN level) that qualify for program compensation will receive payments during 2016 and during summer 2017. How Does the Program Work? The program measurement year is the calendar year for dates of service January 1 - December 31, 2016. Maternity measures include dates of services from November 6, 2015 November 5, 2016. Credit will be given for any qualified metric related services provided throughout 2016 and included in the payout calculations. For non-rate based measures, financial awards will be paid quarterly for rendered metric related services. For rate based measures, achievement of at least the 50 th percentile of National HEDIS Medicaid 2015 benchmark is required. Performance of each metric will be calculated and rewarded individually, based on claims data. To determine your annual program performance and associated financial award, at the end of the performance year (2016), and allowing for a 90 days claim lag, the cumulative annual performance will be calculated for
each measure for each eligible provider. Providers will be rewarded for each metric related service for which they meet or exceed the established the established target. Annual performance payments are expected to be paid during summer 2017. Refer to the attached document for more information about measures, thresholds and dollar amounts. We re here to help and answer your questions Our goal is to help support your patients with access to the highest quality medical care. If you have questions, call us at 1-866-638-1232. Sincerely, Jason Rottman CEO Patricia Guerra-Garcia, MD Chief Medical Officer Enclosure: P4P Program measures *Payment for the P4P program is dependent on the funding that the Pennsylvania Department of Public Welfare provides. Aetna Better Health reserves the right to end the P4P program if funding becomes unavailable.
2016 Pay for Performance Measures Adolescent well-care visits (ages 12-21 years) Targeted providers: Primary care providers This measure includes members ages 12 21 years who receive one adolescent well visit according to HEDIS Technical Specifications between January 1, 2016 and December 31, 2016 as shown through claims data. Providers are required to meet at least the 2015 HEDIS 50 th percentile of 49.15% in order to receive payment. Those who achieve no less than the 75 th percentile of 59.98% will realize greater compensation. Providers will share in a pool of approximately $500,000 as payment for this measure. Please see the below chart for specifics. Annual dental visit (ages 1 21 years) Targeted providers: Dentists participating with DentaQuest This measure includes members ages 1 21 years who receive one annual preventive dental visit according between January 1, 2015 and December 31, 2015 shown through DentaQuest claims data. Providers will receive a one-time payment of $25 for each member who receives dental care. Payment will be sent to dentists after the close of each quarter during 2016 for this measure. Comprehensive diabetes care: Hemoglobin A1c (HbA1c) poor control (>9%) Targeted providers: Primary care providers This measure includes members 18 75 years of age with diabetes (type 1 and type 2) whose most recent 2015 HbA1c level is <9mg/dL according to HEDIS Technical Specifications. This is shown through claims data by services that Quest Labs and LabCorp obtains (Aetna Better Health s lab vendors). We ll make payment once to providers after the completion of the full calendar year of 2016. If the member has more than one HbA1c test, we will use the test result performed closest to December 31, 2016 to determine compliance. Providers are required to meet no less than the 2015 HEDIS 50 th percentile of 42.22% to receive payment. Providers who achieve the 75 th percentile of 34.66% or greater will realize greater compensation. Providers will share in a pool of approximately $500,000 as payment for this measure. Please see the below chart for specifics. Controlling high blood pressure (ages 18-85) Targeted providers: Primary care providers This measure includes members 18-85 years of age whose most recent 2015 BP reading during the measurement year (as long as it occurred after the diagnosis of hypertension was made) is <140/90 according to HEDIS Technical Specifications. If multiple BP measurements occur on the same date, or are noted in the chart on the same date, the lowest systolic and lowest diastolic BP reading will be used. If there is no BP recorded during the measurement year, we will assume that the member is not controlled. PCPs will be required to send claims indicating member blood pressure reading of below 140/90 and associated diagnosis of hypertension. You may also send documentation by fax or mail, and photocopied from the member s medical record. It should indicate a diagnosis of hypertension before the date of the blood pressure reading and the member s blood pressure reading on that date. We will keep a database of all documentation we collect. We ll also use an RN to review the documentation to determine compliance. We ll make payment once to providers after the completion of the full calendar year of 2016. Since members may have more than one blood pressure reading, the most recent reading performed before
December 31, 2016 will be used to determine compliance. Providers are required to meet at least the 2015 HEDIS 50 th percentile of 57.53% in order to receive payment. Providers who realize the 75 th percentile of 65.49% or more will realize greater compensation. Providers will share in a pool of approximately $500,000 as payment for this measure. Please see the below chart for specifics. Providers, who are submitting blood pressure information, please fax or mail a copy of the member s visit that includes the date, diagnosis of hypertension prior to the date of the blood pressure reading and the actual blood pressure reading to: ATTN: QUALITY MANAGEMENT Aetna Better Health 2000 Market Street, Suite 850 Philadelphia, PA 19103 FAX: 1-860-754-0337 Frequency of ongoing prenatal care: > 81% of expected visits This measure includes members who deliver between November 6, 2015 and November 5, 2016. And, for those members who complete 81% or more of expected prenatal visits according to HEDIS Technical Specifications shown through claims data. Providers will receive a one-time payment of $100.00 for each member who completes 81% of expected prenatal visits. Payment will be sent to providers after the close of each quarter of 2016 for this measure. Prenatal care in the first trimester This measure includes members who deliver between November 6, 2014 and November 5, 2015 who receive one prenatal visit in the first trimester or, within 42 days of enrollment according to HEDIS Technical Specifications shown through claims data. Providers will receive a one-time payment of $100.00 for each member who completes a prenatal visit in the first trimester or within 42 days of enrollment into Aetna Better Health. Payment will be sent to providers after the close of each quarter during 2016 for this measure. Postpartum care This measure includes members who deliver between November 6, 2015 and November 5, 2016 who receive one postpartum visit 21 56 days post-delivery according to according to HEDIS Technical Specifications shown through claims data. Providers will receive a one-time payment of $100.00 for each member who delivered between November 6, 2015 and November 5, 2016 who has one postpartum visit 21 to 56 days post-delivery. Payment will be sent to providers after the close of each quarter during 2016 for this measure. Well Child in the First 15 Months of Life 6 or More Visits Targeted providers: Family Practice/Pediatricians This measure includes members who turned 15 months old during 2016 and who had 6 or more visits with a PCP during their first 15 months of life according to HEDIS Technical Specifications shown through claims data. Providers will receive a one-time payment of $100.00 for each member who have at least six visits with their PCP during their first 15 months of life. Payment will be sent to providers after the close of each quarter during 2016 for this measure.
Electronic Submission of the Obstetrical Needs Assessment Form (ONAF) This includes OB/GYN and Family Practice providers who submit the ONAF through the Aetna Better Health Secure Web Portal. A payment of $50.00 will be made for the initial electronic submission of a completed ONAF and an additional $50.00 payment will be made for the electronic submission of a completed post-partum form. Please contact your Provider Services representative to learn how to register at 1-866-638-1232. HEDIS National Committee for Quality Assurance (NCQA) is a registered trademark.
2016 Pool Payment Measures Payment Methodology The following chart provides an example of the P4P pool payment methodology using a pool funding of $10,000 for the three (3) pool measures. TOTAL DOLLAR POOL - $10,000 (Two Providers) Metric Thresholds Provider Year End Rates and (Denominator Count) Provider Points Earned 50 th 75 th Prov. 1 Prov. 2 Prov. 1 Prov. 2 AWC 49.15% 59.98 50.50% (50 th = 1 point) 65% (75 th = 2 points) 100 (100X1) 100 (50X2) DENOMINATOR 100 50 CBP 57.33 65.49 48.2% (none) 58.6% (50 th = 1 point) 0 (20X0) 10 (10X1) DENOMINATOR 20 10 CDC HbA1c Poor Control 42.22 34.66 33.5% (75 th = 2 points) 40.4% (50 th = 1 point) 80 (40X2) 25 (25X1) DENOMINATOR 40 25 TOTAL POINTS EARNED 180 135 GRAND TOTAL POINTS EARNED 315 DOLLAR VALUE PER POINT $10,000/315 = $31.75 (rounded) DOLLARS EARNED $5715 (180 X $31.75) $4286.25 (135 X $31.75) 1. Points earned for hitting targets 1 point for the 50 th percentile, 2 points for the 75% and above: 2. Points earned (0, 1 or 2) are multiplied by the number of denominators for each measure. **Note The denominator is defined as each panel member for whom the measure applies. If a provider does not have panel members associated with a particular measure, no points are earned for that measure. If a provider does not achieve at least the 50 th percentile, no points are earned for that measure. 3. All points earned by each provider are summed to obtain total earned points per provider. 4. The total points earned for each provider are summed to calculate total points earned by all providers. 5. The total pool dollars are divided by the total points earned by all providers to obtain a dollar value per point 6. The total points earned by each provider are multiplied by the dollar per point value to derive the total dollars earned. 7. Payout Annually Summer 2017