Value Based Contracting Office Hours RAE Prime Office Hours September 25, 2018 Section - Title

Agenda Prime Topics: Year 3 & 4 – Current program status Year 5 MLR Metrics – Patrick Gordon Year 5 Value Based Performance Payment Criteria – Patrick Gordon/ Lori Stephenson CQM Reporting – Kim Brown/Lori Stephenson Year 6 Payment model changes  

Medicaid Prime – Program Status Section - Title

Key Timeline – Prime Now CY 2017 “Year 3” Shared Savings Distribution Practice Performance Period Underway January 2018 CY 2019 “Year 5” Practice Performance Period Starts July 2019 New Prime Agreements & Tiered Participation Structure August 2019 Shared Savings Distribution* January 2020 CY 2020 “Year 6” Practice Performance Period Starts *Contingent upon overall plan performance on total cost and quality

Year 3 – Shared Savings Distribution Four (4) core components: Did the practice meet transformation and quality measurement targets? What is the practice’s share of attribution? What is the practice’s relative risk score? How far above or below average was the total cost of care for the practice’s attributed member months? *Contingent upon overall plan performance on total cost and quality

Year 3 – Shared Savings Distribution

Looking Ahead Year 4 (PY 2018) and Year 5 (PY 2019) – Prime payment methodology unchanged. Value-based performance payment (“PBIB”) criteria evolves. Community Integration Agreements & enhanced services follow RAE tiering criteria. Year 6 (PY 2020) Further evolution of value-based performance payment (“PBIB”) criteria. Prime payment methodology changed, per revised 7/1/19 provider contracts, to reflect practice tiering levels. *Contingent upon overall plan performance on total cost and quality

Components of Prime Reimbursement Base rate or fee-for-service equivalent. Enhancement multiplier (currently +25%). Advanced practice enhancement (currently $4 pmpm). Shared savings or value-based performance payment bonus (“PBIB”). ------------------------ (Base Rate X 1.25) + $4 pmpm)) x (risk adjustment))) + (value-based payment bonus)))) = Total Prime Payment

Year 5 MLR Metric & Value-Based Performance Payment Criteria

Year 5 MLR Metrics/Targets for RMHP Depression Screening and Follow-Up = 64% NQF 0418/CMS 2 HgbA1c Poor Control > 9.0 = 23.5% NQF 0059/CMS 122 Emergency Room Utilization for Substance Use Disorder = 25.10 per 1,000 per year SUD ER Utilization What has changed? Year 4 to Year 5 CQM Diabetes Hemoglobin A1c measure replacing HEDIS CDC measure Performance focus on Prime practices participating in SIM, and Advancing the number of Prime practices reporting Diabetes A1c Poor Control Step toward moving to CQMs as opposed to HEDIS Step toward measure alignment across programs Performance Targets Depression Screening and Follow Up: Increase of about 9% PAM: Expanded re-assessment criteria to include Levels 1, 2 and 3. Also, increase target by 11%. Patient Activation Measure Levels 1, 2, & 3 Re-assessment = 41% Patient Activation Measure Roadmap Report Section - Title

Align your Internal Practice Targets Aligning MLR Metrics and Value-Based Performance Measures MLR/Value-Based Performance Measures RMHP MLR Targets Align your Internal Practice Targets Depression Screening and Follow Up 64% Diabetes HgbA1c Poor Control 23.5% ED Utilization for Substance Use Disorder 25.10/1000 per year Report NQF 0004/CMS 137 PAM Re-Assessment 41% *Aligning your internal practice targets with the RMHP MLR Targets creates a greater potential for the overall Prime region to meet the established MLR metrics* Section - Title

Year 5 Value-Based Performance Payment Criteria Quarterly submission to RMHP and annual submission to SPLIT via EHR on the following eCQMs: NQF 0059 = Diabetes Hemoglobin A1c poor control NCF 0418 = Screening for Depression and Follow-up plan NQF 0004 = Initiation and Engagement of Alcohol and other drug dependence treatment PAM Re-assessment of Level 1, 2 and 3 Risk adjusted attribution Note:  These measures can also be a part of the 6 measures required for the RAE Tiering if practices choose.  We will not require meeting a target but will provide feedback reports that emphasize the plan targets as benchmarks for the measures. CQM Reporting – Required New CQM: Initiation & Engagement of Alcohol and Other Drug Dependence Treatment (link to MLR metric – not identical but processes overlap) Reporting only however all measures are required 2 for Pediatric Practices 3 for Adult Practices PAM & CfA - Required Utilization Continue to focus on re-assessment to include Level 3 Section - Title

More on Practice Reported CQMs Required Annual Reporting All RMHP Prime practices will be given access to the SPLIT tool by December 2018. Training webinars will be held in November, December and January. RMHP Prime practices MUST report Prime CQMs into SPLIT to remain eligible for value-based performance payment (“PBIB”) Year 4 and Year 5 requirement Required Quarterly Reporting Due the 3rd Friday of the month following the end of the quarter. Links emailed out 3 weeks in advance. Quarterly feedback reports allowing meaningful comparison Opportunity to trouble shoot reporting issues before the annual SPLIT reporting requirement. Opportunity to trouble shoot performance issues before program deadline Section - Title

More on the Patient Activation Measure Required – all Patients previously assessed at Level 1, Level 2 or Level 3 are re-assessed by 12/31/2019 RMHP to monitor monthly for re-assessments and ongoing growth of utilization of both PAM and CFA Section - Title

Looking Ahead Prime Year 6 (2020) Continuous evolution of value-based performance payment (“PBIB”) criteria Alignment with RAE tiering

Questions?

Contact Lori Stephenson Patrick Gordon Nicole Konkoly Director of Clinical Program Development and Evaluation lori.stephenson@rmhp.org Patrick Gordon Associate Vice President patrick.gordon@rmhp.org Nicole Konkoly RAE Network Relations Manager Nicole.konkoly@rmhp.org Section - Title