1. CCO Quality Pool Methodology February 7, 2014 Lori Coyner, Accountability and Quality Director 1

2. Quality Pool A bridge strategy in moving from capitation to paying for outcomes Quality pool awards depend on CCO performance on the 17 CCO Incentive Measures. CCOs must meet either the benchmark OR the improvement target for each measure to qualify. Benchmarks and improvement targets online at: www.oregon.gov/oha/Pages/CCO-Baseline-Data.aspx www.oregon.gov/oha/Pages/CCO-Baseline-Data.aspx Quality Pool methodology online at: http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf 2

3. Overall Pool Parameters 2013 quality pool = 2% of aggregate CCO payments made to all CCOs for CY 2013 services. –Payments made through March 31, 2014 for 2013 services are included in calculation Entire pool disbursed by June 30, 2014 Aggregate amount expected to increase annually OHA required to issue parameters of 2014 pool (for 2015 distribution) by December 1, 2014 3

4. CCO Eligibility for Pool Funds Two stage process –Stage 1: All CCOs eligible for up to 2% of a CCO’s actual paid amounts in 2013 –Stage 2: All CCOs eligible to participate in a challenge pool for any remaining funds $1m minimum payment if targets are met –Pro-rated if a CCO was only in place a portion of the year Revised DRAFT estimates for potential CCO incentive payments (based on 2% of CCO payments) are posted at: http://www.oregon.gov/oha/CCOData/Quality%20Pool%20Es timates%20by%20CCO.pdf http://www.oregon.gov/oha/CCOData/Quality%20Pool%20Es timates%20by%20CCO.pdf Final estimates will be posted by April 30 to reflect actual payments for 2013 (through March 31, 2014) 4

5. Stage 1 Distribution Overview Based on performance on 17 Incentive Measures All measures treated as pass/fail and independent of each other –For 13 of the measures, success based on whether a CCO meets the benchmark or improvement target –For PCPCH, measured according to a tiered formula –For 3 clinical measures, success based on submitting a technology plan and proof of concept data for those measures As a CCO meets more benchmarks or improvement targets, it receives a higher payment. 5

6. Stage 1 Distribution Overview (cont.) A CCO would receive 100% of the pool funds for which it is eligible if: –Meets or exceeds the benchmark, improvement target, or the measurement and reporting requirements for the clinical measures, on at least 75 percent of the incentive measures (12 of 16 measures); and –Meets or exceeds the benchmark or improvement target for the Electronic Health Record (EHR) adoption measure as one of the 12 measures above; and –Scores at least 0.6 on the PCPCH enrollment measure using the tiered formula; If the EHR measure is not met, the maximum payment a CCO could receive = the second tier (90% of the maximum). 6

7. Number of targets met (benchmark or improvement, or measurement and reporting) Percent of quality pool payment for which the CCO is eligible At least 12.6 (including EHR adoption) 100% At least 12.6 (not including EHR adoption) 90% At least 11.680% At least10.670% At least 8.660% At least 6.650% At least 4.640% At least 3.630% At least 2.620% At least 1.610% At least 0.65% Fewer than 0.6No quality pool payment Stage 1 Distribution: Payment Thresholds 7

8. Goal = all CCO members enrolled in a Tier 3 PCPCH. CCO performance measured using tiered formula: (# of members in Tier 1*1) + (# of members in Tier 2*2) + (# of members in Tier 3*3) -------------------------------------------------------------------------------------- Total number of members enrolled in the CCO * 3 Stage 1 Distribution: Patient Centered Primary Care Home (PCPCH) Enrollment 8

9. Stage 1 Distribution: PCPCH Enrollment Example of Tiered Formula CCOResults of Tiered Formula CCO A0.4 CCO B0.6 CCO C0.7 CCO D0.9 Increasing number of members enrolled in Tier 3 PCPCHs Results of the tiered formula are added to the number of measures on which a CCO meets the benchmark or improvement target. Example CCO C has met 11 of the 16 measures and scored 0.7 on the PCPCH measure. CCO C’s score = 11.7, qualifying it for 80% of its possible Stage 1 funds (see next slide). 9

10. Stage 1 Distribution: Advance Distribution for Clinical Measures CCOs are able to access incentive pool funds earlier for measuring and reporting on 3 clinical quality measures (3/17ths of available pool funds) –Diabetes blood sugar control –Hypertension control –Depression screening CCO submits technology plan by February 1, 2014 –Qualifies to receive 75% of the 3/17ths funding early (advance) –Can submit earlier and receive 75% earlier CCO submits proof of concept data for the three measures by May 1, 2014 –Qualifies to receive remaining 25% of 3/17ths Final pool distribution will be net of any advanced funding 10

11. Stage 2 Distribution Overview Quality pool funds remaining after stage 1 distribution = “Challenge Pool” Distributed to CCOs that meet the benchmarks, improvement targets, or data submission requirements on 4 measures: Diabetes Control Depression Screening PCPCH Enrollment SBIRT 11

12. Stage 2 Distribution: Step 1 Determine the number of instances in which CCOs have achieved the improvement target or benchmark For Example Challenge Measure# of CCOs meeting targets PCPCH Enrollment16* SBIRT5 Depression Screening3 (submitted proof of concept data) Diabetes Control6 (submitted proof of concept data) Total:30 *Assume all CCOs met the PCPCH target (since using the tiered formula instead of benchmark) 12

13. Stage 2 Distribution: Step 2 Calculate the “base payment” using formula: Quality Pool funds remaining after Stage 1 ---------------------------------------------------------- # of instances CCOs met the targets For Example Assume $1,000,000 remaining after Stage 1 Payment ------------------------------------------------------------ = $33,333.33 30 instances (previous example) 13

14. Stage 2 Distribution: Step 3 Adjust the “base payment” based on average monthly CCO enrollment relative to the mean for those CCOs that met the challenge measure targets. This calculation is performed separately for each of the three measures: depression screening, SBIRT, and diabetes control. 14

15. CCO NameBase PaymentMember Months (MM) CCO’s ratio of MM to mean MM Adjusted challenge pool payment CCO A$33,333.3329,5881.459$33,333.33* 1.459 = $48,633.33 CCO B$33,333.3323,3431.151$33,333.33* 1.151 = $38,366.66 CCO C$33,333.3322,7881.124$33,333.33* 1.124 = $37,466.66 CCO D$33,333.3318,0140.889$33,333.33*.889 = $29,633.33 CCO E$33,333.3316,3940.808$33,333.33*.808 = $26,933.33 CCO F$33,333.3311,5210.568$33,333.33*.568 = $18,933.33 $200,000 (total challenge pool for the diabetes control measure) 121,648 (Total MM) $200,000 (total) 20,274.67 (Mean MM) 15

16. Stage 2 Distribution: Step 4 For the PCPCH enrollment measure, adjust the “base payment” based on average monthly CCO enrollment adjusted by the results of the tiered formula. CCO Name Base PaymentResult of Tiered Formula Member Months (MM) Adjusted Member Months Adjusted MM relative to the mean Adjusted challenge pool payment CCO A$33,3330.4 * 29,588 =11,8350.969$ 33,333 *.969= $32,299 CCO B$33,3330.5 * 23,343 =11,6710.956$ 33,333 *.956= $31,866 Repeat calculation for all 16 CCOs – all CCOs are assumed to have met the benchmark for the PCPCH measure $533,333 (total challenge pool for PCPCH measure) 73,273 (Total adjusted member months) $533,333 (total) 12,212 (Mean adjusted member months) 16

17. Questions? More information:  Quality Pool Reference Document at: http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf http://www.oregon.gov/oha/CCOData/ReferenceInstructions.pdf Lori Coyner: lori.a.coyner@state.or.uslori.a.coyner@state.or.us 17