1. Value Based Contracting Office Hours
RAE Prime Office Hours
December 18, 2018
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2. What questions do you have regarding RMHP Prime?

3. Agenda Prime Topics: Year 3 Performance & Payment – Patrick Gordon
Year 3 Practice Performance Review – Patrick Gordon
Year 4 Incentive Pool Estimate – Patrick Gordon
Closing out Year 4 - Lori Stephenson
Year 5 MLR Metrics and Value Based Performance Payment Criteria – Lori Stephenson
Year 6 Strategy – Patrick Gordon  
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4. Key Timeline – Prime Now CY 2017 “Year 3” Shared Savings Distribution
Practice Performance Period Underway
January 2019
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 (SFY 2016-17) Performance & Payment Discussion
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6. Year 3 – Incentive Payment Outcomes
This is paid RMHP dollars for incurred months, not reflecting Medicare Part A or encounter equivalent info. It is only for the attributed months, not those prior to attribution. Nothing offline has been counted.
Based on % of members only
Amount to Pay
Total Shared Savings Pool:
$850,000
Total to be distributed to CMHCs:
$283,330
Total to be distributed to PCMPs:
$566,670
Prime Practice
Avg Risk Score
Payment Multiplier #1 for Risk Score
Global Caps Paid
Global Cap PMPM
Total Claim Costs
Claim PMPM
Claim + Cap PMPM
Cost Normalized on Risk Score
Payment Multiplier #2 for TCR
Shared Savings Multiplier #1 = 75% #2 = 25%
Attributed Member Months
% of Total Attribution
Unadjusted Portion of Pool
Adjusted Final Payment
Impact of TCR Adjustment
Dr Lu Family Medicine Prof LLC
2.4547
1.1129
$9,556
$31.75
$186,470
$619.50
$651.25
$585.19
0.9067
301
0.21%
$1,211
$1,287
$76
Etcheverry, Aurelio
2.0268
0.9189
$6,716
$28.82
$131,927
$566.21
$595.03
$647.56
0.7902
233
0.17%
$937
$832
-$105
Foresight Family Practice
2.4136
1.0942
$252,548
$31.46
$3,400,876
$423.68
$455.14
$415.94
1.2229
8,027
5.70%
$32,287
$36,432
$4,145
Grand Junction Family Medicine PC
1.9990
0.9063
$55,111
$28.64
$622,855
$323.73
$352.37
$388.81
1.2736
1,924
1.37%
$7,739
$7,738
-$1
Gunnison Valley Family Physicians
1.2738
0.5775
$74,892
$20.57
$1,230,352
$337.92
$358.49
$620.74
0.8403
3,641
2.58%
$14,645
$9,436
-$5,209
Juniper Family Medicine PLLC
2.1221
0.9621
$74,898
$29.48
$930,455
$366.18
$395.65
$411.23
1.2317
2,541
1.80%
$10,221
$10,541
$320
Marillac Clinic
2.2632
1.0261
$1,565,436
$70.78
$15,380,619
$695.42
$766.20
$746.73
0.6049
22,117
15.70%
$88,961
$82,057
-$6,904
MidValley Family
2.2638
1.0263
$15,734
$26.40
$229,894
$385.73
$412.13
$401.55
1.2498
596
0.42%
$2,397
$2,599
$202
Mindy Miller MD PC
2.4746
1.1219
$27,344
$32.98
$417,082
$503.11
$536.10
$477.84
1.1073
829
0.59%
$3,334
$3,735
$401
Mountain Medical Center
1.3732
0.6226
$4,315
$25.23
$97,393
$569.55
$594.78
$955.35
0.2151
171
0.12%
$688
$359
-$329
Ouray Family Medicine
$30,674
$31.59
$534,161
$550.11
$581.70
$566.78
0.9411
971
0.69%
$3,906
$3,932
$26
Peach Valley Family Medical Center
2.1430
0.9716
$68,853
$29.63
$843,015
$362.74
$392.37
$403.84
1.2455
2,324
1.65%
$9,348
$9,739
$391
Peak Family Medicine
2.1636
0.9809
$147,606
$30.78
$2,487,873
$518.85
$549.63
$560.32
0.9532
4,795
3.40%
$19,287
$18,818
-$469
Pediatric Associates
4.0294
1.8268
$25,805
$43.89
$723,186
$1,229.91
$1,273.79
$697.27
0.6973
588
$2,365
$3,659
$1,294
Peterson, Linda M
1.9084
0.8652
$9,017
$28.99
$197,716
$635.74
$664.74
$768.27
0.5646
311
0.22%
$1,251
$990
-$261
Primary Care Partners
2.0615
0.9346
$1,207,236
$29.07
$16,620,356
$400.20
$429.27
$459.31
1.1419
41,530
29.48%
$167,046
$165,066
-$1,980
River Valley Family Health Centers
1.7446
0.7910
$749,760
$96.00
$3,950,742
$505.86
$601.86
$760.93
0.5784
7,810
5.54%
$31,414
$23,218
-$8,196
Roaring Fork Family Practice
1.3678
0.6201
$65,583
$21.11
$1,092,679
$351.80
$372.91
$601.34
0.8765
3,106
2.20%
$12,493
$8,563
-$3,930
San Juan Family Medicine
2.2025
0.9985
$117,322
$31.08
$1,856,446
$491.77
$522.85
$523.62
1.0217
3,775
2.68%
$15,184
$15,276
$92
SMH Family Medicine
2.8363
1.2859
$600,397
$34.33
$10,790,824
$617.04
$651.37
$506.55
1.0536
17,488
12.41%
$70,342
$86,518
$16,176
Uncompahgre Medical Center
1.7714
0.8031 $0
$0.00
$483,485
$547.55
$681.77
0.7262
883
0.63%
$3,552
$2,789
-$763
Western Medical Associates
2.1205
0.9614
$157,312
$2,436,296
$456.49
$485.97
$505.49
1.0556
5,337
3.79%
$21,467
$21,181
-$286
Western Valley Family Practice
2.3991
1.0877
$363,401
$31.37
$5,132,447
$443.06
$474.43
$436.18
1.1851
11,584
8.22%
$46,594
$51,905
$5,311
Total
2.2057
1.0000
$5,629,516
$39.96
$69,777,149
$495.29
$535.25
140,882
100.00%

7. Year 3 – Incentive Payment Outcomes

8. Year 4 (SFY 17-18) – Practice Performance Review

9. Practice Performance – Foresight Family Physicians

10. Practice Performance – Grand Valley PC

11. Practice Performance – Marillac Health

12. Practice Performance – Mountain Family

13. Practice Performance – Primary Care Partners

14. Practice Performance – River Valley

15. Practice Performance – St. Mary’s Family

16. Practice Performance – Western Valley

17. Year 4 – Incentive Pool Estimate
Total Revenue
$186,451,371
HIT $0
Risk Corridor Recoup
$483,327
Revised Revenue for MLR
$186,934,698
Total Medical
$162,163,339
Additional Medical
Total Expense
Actual MLR
86.7%
Target MLR
85.0%
MLR Recoup
Total Revenue
$189,409,119
Operating
$22,394,781
Total Medical
$165,812,647
Additional Benefit Costs
$690,828
HIT Tax $0
Risk Corridor Recoup
-$483,327
MLR Recoup
Total Expense
$188,414,929
Shared Savings Pool
$994,190
RMHP Share
$99,419
Provider Share
$894,771
Estimate only Subject to change.

18. Closing out Year 4 – CQM Reporting and PAM/CfA

19. Year 4 Shared Savings Criteria Review
Clinical Quality Measures (CQM) – All Prime participating practices will be required to report on ALL measures.
ADULT PRACTICES: All 3 measures are reported to RMHP via SPLIT by 1/31/2019.
NQF 0059: Diabetes Hemoglobin A1c Poor Control (>9.0%)
NQF 0418: Depression Screening and Follow up
NQF 0421: Adult BMI Screening and Follow up
PEDIATRIC PRACTICES: Both measures are reported to RMHP via SPLIT by 1/31/2019.
NQF 0418: Depression Screening and Follow Up
NQF 0024: Childhood BMI Screening with Nutrition and Physical Activity Counseling
Patient Activation Measure/Coaching for Activation (PAM/CfA) Utilization – Practices to continue demonstrating ongoing utilization of the PAM and CfA tools on a subset of their attributed Prime population. Further, practices will perform a re-assessment on all previously screened patients that are at a PAM Level 1 or Level 2 by 12/31/2018
Practices were NOT required to set performance targets with RMHP. Practices should work to sustain processes that support continuous data driven improvement on the measures listed on this slide.
PAM/CfA:
Any re-assessment done prior to 2018 is counted
RMHP to monitor continued utilization of CfA via monthly reports.
Please ensure all PAM surveys are entered into Flourish as soon as possible.
RMHP to begin drafting final practice and program level reports the 1st of January.
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20. Year 4 Required Annual CQM Reporting
All RMHP Prime practices will be given access to the SPLIT tool by December Practices MUST report the required Prime CQMs into SPLIT to remain eligible for value-based performance payment (“PBIB”)
Annual CQM Reporting due 1/31/2019 for performance year
2018 (1/1/18-12/31/18)
FINAL SPLIT TRAINING: January 11th at 12:00pm – Register at:
ADULT REQUIRED MEASURES
PEDS REQUIRED MEASURES
Diabetes A1c Poor Control
Depression Screening & Follow Up
Childhood BMI, Nutrition & Physical Activity Counseling
Adult BMI Screening & Follow Up
OPTIONAL MEASURE FOR ADULT AND PEDIATRIC PRACTICES
Initiation and Engagement of Alcohol & Other Drug Dependence Treatment
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21. Year 5 MLR Metric & Value-Based Performance Payment Criteria

22. 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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23. Align your Internal Practice Targets
Year 5 - 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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24. 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 is required for all practices (2 for Pediatric Practices), (3 for Adult Practices)
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
PAM & CfA - Required Utilization with Continued focus on re-assessment to include Level 3
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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25. Year 6 Prime Program Expectations

26. Year 6 Program Expectations
Prime Year 6 (2020)
Continuous evolution of value-based performance payment (“PBIB”) criteria
Alignment with RAE tiering

27. Questions?

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