1. Value Based Contracting Office Hours
Regional Accountable Entity
February 19, 2019

2. Open Forum
Send your questions, comments, concerns or general feedback on any RMHP Value Based Contract to:

3. Agenda Key Performance Indicators (KPIs) –
Potentially Avoidable Costs (PAC) – Molly Siegel
Care Compacts – Chelsea Watkins
Attribution in the RAE – Nicole Konkoly
Billing for Behavioral Health Services – Nicole Konkoly
Truven/IBM Data Analytics Update – Nicole Konkoly
RAE and the Medicaid APM – Chelsea Watkins
What to expect in 2019 – Lori Stephenson 
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4. Key Performance Indicators (KPIs) –Potentially Avoidable Costs (PAC) & Care Compacts

5. Potentially Avoidable Costs (PAC) – Molly Siegel

6. What is PAC?
Algorithm that uses historical claims to identify complications that are potentially avoidable
Based on an “Episode of Care”
Event driven: Knee Surgery or Pregnancy
Chronic Conditions: SUD or Diabetes
Costs are divided into “typical” and PAC
Based on NDC, Procedure, and Diagnostic Codes
Developed by a panel of clinical experts

7. Making PAC Actionable
Pick three episodes and submit interventions to HCPF by March 1st
Soliciting feedback and recommendations

8. SUD PAC Data
Substance Use Disorder (SUD) accounts nearly 9 million in PAC
Alcohol Abuse and Dependence accounts for 982% more PAC than Opioid Abuse and Dependence
Seventy percent of all SUD PAC in Region 1 is attributed to Inpatient and Emergency Room Categories of Services

9. SUD Care Coordination
Create a custom workflow in that identifies and triages Members with a primary diagnosis code using real-time ED ADT alerts,
Coordinate efforts and reduce duplication of follow up/outreach activities.
Implement care coordination activities to follow up with Members who are identified through ADT alerts.
Revise the RMHP care coordination assessment to include an assessment for SUD.

10. SUD Practice Engagement
Include SBIRT Screening as a break out session at the March 2019 SIM Learning Collaborative.
Include Treating Substance Use Disorders in Primary Care as an break out session at the April 2019 Behavioral Health Skills Training.
Review, gather stakeholder feedback, and revise RMHP’s Initiation and Engagement of Alcohol & Other Drug Dependence Treatment Toolkit.
Send at least three columns in our provider newsletters discussing the importance of screening for SUD.

11. Diabetes PAC Data
Inpatient stays and DME account for just under $3 million in PAC and account for 52% of all Diabetes PAC

12. Diabetes Care Coordination
Revise screening to include General Anxiety Disorder (GAD – 7) and SUD screening
Develop list of self management and health living resources (such as Cooking Matters)
Members who are identified in the diabetes program and are in a community with a participating recreation center will be able to receive a recreation center referral
RMHP will explore and develop a plan for text reminder programs 

13. Diabetes Practice Transformation
Develop evaluation reports for PCMPs with Member level PAC data and other clinical data.
RMHP Clinical Informaticists available to review and discuss data.
Conduct regional analysis to identify outlying practices and offer practice transformation engagement
Review the RMHP Diabetes: Hemoglobin A1c Poor Control toolkit and provide to practices:
Quality Improvement Advisors to help with implementation of toolbox and PDSA cycles

14. Depression and Anxiety PAC Data

15. Depression and Anxiety Interventions
Revised Care Management Assessment to include GAD-7
Meet with healthy communities to review PAC data and discuss opportunities for improving access for Members
Streamlined referral channels for PCMPs making referrals to CMHCs
Build close loop referral processes
Expand access with the deployment of telehealth solutions

16. Questions and Recommendations?

17. Care Compacts – Chelsea Watkins

18. Care Compact KPI Update
The Medical Neighborhood KPI goal:
Meaningful and thorough care compacts
Focus on appropriate referrals
Communicate more effectively across the medical neighborhood to improve health outcomes
Care Compact Criteria:
Page 30 of the RAE Orientation Guide
Each webinar we are going to focus on KPIs that you can take immediate action on. This webinar, we are going to focus on the care compact KPI. This KPI success is directly impacted by the work that each practice does. For Quarter 1 (July-October 2018), RMHP submitted a care compact report to the State. This Q1 goal was: at least 25% Primary Care Medical Practices (PCMPs) must have at least one care compact. As you can see on the screen, 71 care compacts met the KPI criteria for an acceptable care compact out of 198 PCMP sites. Therefore, Region 1 had 35.8% which exceeds the goal for Q1.
As many of you experienced via the RAE verification process, care compacts were collected. In fact, we collected 225 care compacts from 79 different or unique practices. BUT, not all that was submitted meets the criteria. As we reviewed each care compact, we saw several themes that need to be improved upon. This includes:
Practice Information includes phone numbers, addresses, etc.
Mechanisms for renewal.
Not meeting the intent of the care compact (MOUs, template). We received several facility agreement, cost agreements, etc. which do not meet the intent of care compacts.
Defining service line transitions of care (i.e. primary care to primary care with dental health). For example, if a PCP had a care compact with an FQHC, is it for ALL service lines? BH? DH? Etc.
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19. Care Compact KPI Update
Quarter
Measures & Target
Evaluation Period:
Submit By:
Current Performance
Final Submission 1
25%+ of PCMP network has 1 or more executed care compacts in place
July 1, 2018 – September 30, 2018
October 15, 2018
N/A
71/198 = 35.8% 2
50%+ of PCMP network has 1 +
October 1, 2018 – Dec 31, 2018
January 15, 2019
102 / 198 = 51.5% 3
75%+ of PCMP network has 1 +
Jan 1, 2019 – March 31, 2019
April 15, 2019
105/198 = 53% (need 44 unique PCMPs) 4
50%+ of PCMP network has 2+ (1 w/ BH)
April 1, 2019 – June 30, 2019
July 15, 2019
43/198 = 21.7% (need 56 unique PCMPs)
Resources/Submission of Care Compact(s):
Contact your QIA or Mary Beckner
Each webinar we are going to focus on KPIs that you can take immediate action on. This webinar, we are going to focus on the care compact KPI. This KPI success is directly impacted by the work that each practice does. For Quarter 1 (July-October 2018), RMHP submitted a care compact report to the State. This Q1 goal was: at least 25% Primary Care Medical Practices (PCMPs) must have at least one care compact. As you can see on the screen, 71 care compacts met the KPI criteria for an acceptable care compact out of 198 PCMP sites. Therefore, Region 1 had 35.8% which exceeds the goal for Q1.
As many of you experienced via the RAE verification process, care compacts were collected. In fact, we collected 225 care compacts from 79 different or unique practices. BUT, not all that was submitted meets the criteria. As we reviewed each care compact, we saw several themes that need to be improved upon. This includes:
Practice Information includes phone numbers, addresses, etc.
Mechanisms for renewal.
Not meeting the intent of the care compact (MOUs, template). We received several facility agreement, cost agreements, etc. which do not meet the intent of care compacts.
Defining service line transitions of care (i.e. primary care to primary care with dental health). For example, if a PCP had a care compact with an FQHC, is it for ALL service lines? BH? DH? Etc.
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20. RAE Attribution – Nicole Konkoly

21. Attribution Methodology
Attribution: Attribution is the method used to link RAE members to their medical home, or PCMP.
PCMP: Primary Care Medical Provider
Auto-attribution: Process by which a RAE member is systematically assigned to a PCMP.
Member choice attribution: Process by which a RAE member contacts the enrollment broker, Health First Colorado Enrollment, to change their PCMP.
Reattribution: Process by which a RAE member who has a stronger claims history with a different provider becomes attributed to the new provider whom they have been seeing.
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22. Auto-Attribution
Utilization: A RAE member that has a claims history with a PCMP over the last 18 months is automatically attributed to that practice. Specifically, the member will be attributed to the practice location associated with the billing address on the claims.
Family Connection: A member that has no history with a PCMP will be attributed to a practice where someone in their household has a history, if the practice is appropriate. For example, an adult will not be attributed to a pediatric practice.
Proximity: If an ACC member cannot be attributed based on either utilization or family connection, the member will be attributed to the closest appropriate PCMP in the member’s region.
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23. PCMP to PCMP Reattribution
If a member develops a stronger relationship with another provider, the member will be attributed to that PCMP. If the member requested a provider by calling the Health First Colorado enrollment broker within the past 18 months, the member will continue to be attributed to that provider.
Typically done every six months.
Two reattribution processes have been done since July 2018.  These occurred in September/October and in December/January. 
HCPF is currently planning to run the reattribution process again in June/July, but the RAEs have indicated they may want this process to occur more frequently (quarterly, for instance), in which case it could happen as early as March/April. 
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24. Role of Health First CO Enrollment
The Health First Colorado enrollment broker, called Health First Colorado Enrollment, sends Health First Colorado members a letter to notify them of their PCMP attribution and RAE enrollment.
Note: PCMP’s physical location determines member’s RAE enrollment.
Members may call the Health First Colorado enrollment broker to choose a different PCMP at any time.
(outside of Denver). Hours: Monday-Friday, 8:00 a.m. to 5:00 p.m. (closed state holidays). 
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25. Attribution & Member Access to Care
RAE members are not locked in to any provider and can continue to see any Medicaid provider they choose.
Providers with multiple sites should note that patient attribution will be to the site they most frequently utilize for primary care but the patient is not required to only receive care from their attributed site.

26. How Can Providers Identify Attribution?
In the Health First Colorado Provider Web Portal, providers can see a RAE member’s attributed PCMP and RAE enrollment under the “Managed Care Assignment Details” panel.
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27. PCMP Panel Size & Configuration
PCMPs may limit their panel size at any time by contacting their RAE network representative, Nicole Konkoly.
Once a panel limit is reached, no further attributions will be made, even if a member requests a practice by calling Health First Colorado Enrollment.
PCMPs may turn auto-assignment (geographically based attributions) on or off at any time by contacting their RAE network representative.
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28. Attribution Resources for PCMPs
PCMPs receive a monthly attribution report from RMHP, via the Box secure file sharing site.
This report allows PCMPs to see which RAE members are attributed to them, and whether they are a claims or choice based attribution, or geographic assignment (no claims history).
Member telephone and address information is included so that PCMPs can do outreach.
PCMPs can also view their attributed membership – and KPI performance - via the Truven/IBM Data Analytics Portal. Access must be granted and can be arranged by contacting Nicole Konkoly.
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29. Billing for Short-Term Behavioral Health Services in the Primary Care Setting – Nicole Konkoly

30. Background & Overview
Starting July 1, 2018, the Department increased access to short-term behavioral health (mental health and substance use disorder) services within the primary care setting.
Health First Colorado members are now able to receive short-term behavioral health services (STBHS) provided by a licensed behavioral health clinician working as part of a member’s Primary Care Medical Provider (PCMP).
The intent of this change is to provide additional access to behavioral health services for short-term episodes of care of low-acuity conditions. This may include grief and adjustment conditions, as well as medical conditions where behavioral interventions can support treatment adherence and wellness (such as obesity and diabetes).
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31. Short-term Behavioral Health Services
The PCMP may be reimbursed FFS for up to 6 visits per state fiscal year (defined as July 1-June 30).
A visit is defined as a single date of service. These visits will not require a diagnosis covered by the capitated behavioral health benefit. That said, PCMPs must use the most appropriate diagnosis that supports medical necessity.
The following procedure codes are included as STBHS:
• Diagnostic evaluation without medical services (90791)
• Psychotherapy – 30 minutes (90832)
• Psychotherapy – 45 minutes (90834)
• Psychotherapy – 60 minutes (90837)
• Family psychotherapy without patient (90846)
• Family psychotherapy with patient (90847)
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32. How to Bill for STBHS
PCMPs may submit claims for FFS reimbursement of STBHS if they have a Medicaid-enrolled, licensed behavioral health clinician on site. The billing provider must also be contracted with a RAE as a PCMP.
The rendering provider on the claim must be a Medicaid-enrolled, licensed behavioral health clinician.
The STBHS are billed just like any other service provided by the PCMP. Billing providers must follow all standard and Department billing practices and policies, as well as the rules of the Colorado Board of Registered Psychotherapists. In addition, the services must be documented in accordance with the Department’s most current Uniform Service Coding Standards Manual.
Licensed behavioral health clinicians includes licensed clinical social workers, licensed professional counselors, licensed addiction counselors, licensed psychologists, and licensed marriage and family therapists. At this time, the first six visits of the procedure codes included in the STBHS policy delivered by a PCMP’s licensed behavioral health clinician must be submitted to Colorado interChange for FFS reimbursement each state fiscal year. This is regardless of whether the services were provided for a low-acuity or chronic behavioral health condition. The Department is continuing to develop an automated methodology to identify and process low-acuity episodes of care to more precisely achieve the policy intention. Federally Qualified Health Centers, RHC, and IHS providers must list the eligible procedure code on the encounter claim using Revenue Code 0900 and must bill in accordance with FQHC rule ( ) or RHC rule ( A). If physical health services are delivered on the same day as any of the STBHS, the FQHC, RHC, or IHS must submit two (2) separate claims: one for behavioral health services and one for physical health services.
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33. Billing for Additional Visits
A Medicaid enrolled, licensed behavioral health clinician in a PCMP clinic may be able to deliver more than six (6) STBHS visits during a fiscal year if all of the following requirements are met:
The behavioral health clinician is contracted with and credentialed by the RAE;
The additional services are medically necessary;
The clinician has followed RAE utilization management policies and procedures; and
The visits are billed to the RAE for reimbursement under the capitated behavioral health benefit.
RMHP does not require a prior authorization for short-term behavioral health services in the primary care setting beyond the initial six visits during the state fiscal year.  We do require that the behavioral health clinician providing those services be contracted with and credentialed by RMHP (in addition to being contracted and credentialed with Health First Colorado). 
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34. How to View Member Utilization of STBHS
Providers are able to view how many STBHS a member has received, if any, in the Eligibility Verification response on the State’s Provider Portal. If the member has utilization history for any of the STBHS, then the utilization will be reported in the Limit Details panel.
For instructions on performing eligibility verification and accessing the Limit Details panel, see the Verifying Member Eligibility and Co-Pay Quick Guide.
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35. Resources / Reference Materials
HCPF fact sheet, updated January 2019:
RMHP’s Behavioral Health Provider Manual, updated January 2019:

36. Truven/IBM Data Analytics Portal – Nicole Konkoly

37. Overview & Recent Updates
This data analytics tool for PCMPs and RAEs includes population and performance information. The portal allows for drill downs and drill ups, data exports, and provider-level comparisons.
Enhancements to the tool are coming soon. Trainings will be offered by IBM Watson Health, and we will share that information broadly when available.
In the meantime if you do not yet have access to the portal and would like to, contact Nicole Konkoly.
Fact sheet and user guide available at:

38. RAE and the Medicaid APM – Chelsea Watkins

39. Chelsea Watkins – RMHP Clinical Informaticist Chelsea.Watkins@rmhp.org
Questions?
Chelsea Watkins – RMHP Clinical Informaticist
Nicole Konkoly – RAE Network Relations Manager
Talk about RMHP roles in each of these
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40. What to Expect in 2019 – Lori Stephenson
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41. Ongoing Demonstration Criteria
In order to stay in Attested Tier, practice must demonstrate ALL of the following:
 Achieve ≥80% on appropriate assessment
o Tier 4 Assessment – none
o Tier 3 Assessment – semi-annually
o Tier 2 Assessment – quarterly
o Tier 1 Assessment – quarterly
 Achieve Medicaid APM scoring thresholds
o Tier 4 – Medicaid APM score of 0-25%
o Tier 3 – Medicaid APM score of 26-50%
o Tier 2 – Medicaid APM score of 51-75%
o Tier 1 – Medicaid APM score of %
 Submit 6 CQMs quarterly AND annually meet or exceed the 70th percentile CMS benchmarks (January 2019 reporting is baseline based on 2018 performance)
o Tier 4 – none
o Tier 3 – 2/6 eCQMs must meet or exceed the 70th percentile of the current CMS benchmarks
o Tier 2 – 4/6 eCQMs must meet or exceed the 70th percentile of the current CMS benchmarks
o Tier 1 – 6/6 eCQMs must meet or exceed the 70th percentile of the current CMS benchmarks
 Be open to Medicaid
o Tier 4 – Not open to new Medicaid.
o Tier 3 – Limited, intermittent availability for new Medicaid patients
o Tier 2 – Open with equitable panel management processes and tools applied in order to maintain current Medicaid attribution numbers (at a minimum). Attach processes and tools.
o Tier 1 – Open to new Medicaid
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42. Questions?