1. Value Based Contracting Office Hours
RAE Prime Office Hours
September 25, 2018
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2. 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

3. Medicaid Prime – Program Status
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4. 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

5. 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

6. Year 3 – Shared Savings Distribution

7. 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

8. 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

9. Year 5 MLR Metric & Value-Based Performance Payment Criteria

10. 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 = 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
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11. 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*
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12. 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
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13. 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 ed 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
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14. 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
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15. Looking Ahead Prime Year 6 (2020)
Continuous evolution of value-based performance payment (“PBIB”) criteria
Alignment with RAE tiering

16. Questions?

17. Contact Lori Stephenson Patrick Gordon Nicole Konkoly
Director of Clinical Program Development and Evaluation
Patrick Gordon
Associate Vice President
Nicole Konkoly
RAE Network Relations Manager
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