Amerigroup Louisiana, Inc. 1 Agenda Introduction Behavioral - - PowerPoint PPT Presentation

Amerigroup Louisiana, Inc.

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Agenda

• Introduction
• Behavioral Health
• Member-PCP Alignment
• Clinic Days
• Provider Quality Incentive Program
• Potential Missed Care Opportunities

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• Effective December 1, 2015, all Behavioral Health

will be carved in to Bayou Health Plans

• Providers will be responsible for completing the credentialing

and contracting process directly with the Health Plans

• Please send us your updated rosters with behavioral health

providers highlighted, as well your credentialing information:

– Email your scanned PDFs to lainterpr@amerigroup.com – Fax to 1-888-375-5063: Attention: Network development – Louisiana – Mail through FedEx, UPS or U.S. Postal Service to:

Amerigroup Network Development – Louisiana 5353 Essen Lane, Suite 300 Baton Rouge, LA 70809

Behavioral health

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Member-PCP alignment

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• We know it is essential to connect and build the relationships

between our members and our PCPs

• Your relationships with our members help them make good

decisions about their care and produce better health outcomes

• Effective [June 1, 2015], PCPs will only be reimbursed for

providing services to members who are on their assigned member listing or the listing of another participating PCP in their group

• Please provide your covering provider information immediately

as claim payments may be affected

Covering Provider Information

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Clinic Day Program Guide Overview

Objective: Conduct a series of Clinic Day events at high-volume provider offices with a minimum of 10 member per Clinic Day

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A shared savings program that rewards

• ur providers for improving quality and

medical cost management

Provider Quality Incentive Program (PQIP)

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PQIP Objectives

• Improve clinical quality results

– Empower providers to reach all assigned members for preventive services and chronic condition management

• Improve medical cost management

– Provide incentives and tools so providers reduce unnecessary utilization and costs

• Enhance provider service

– Increase contact with individually assigned Amerigroup Louisiana, Inc. provider representative on provider-specific initiatives

• Promote quality, safe and effective patient care across the health care

delivery system

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Program Components

Eligibility requirements

• Minimum of 1,000 members per PCP or PCP group in total
• Participating during entire measurement year prior to the program year
• Open panel status (group level)
• Signed Letter of Agreement

PQIP model components

• Quality Scorecard
• Shared Savings
• Provider reporting

Note: PCP is defined as either a solo PCP, a PCP group or an independent practice association, whichever is the highest level of contractual relationship with Amerigroup Louisiana.

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Quality Scorecard Component

• Uses administrative-only measures attributable to PCPs
• Measurement will be at the highest contracted level
• A set of 13 HEDIS-like indicators will be measured
• The top four indicators, in terms of measured members, are

used for scoring; at least 30 measured members are required for each of the top four measures

• Points assigned for absolute score versus peers and for levels
• f improvement
• The weighted average peer comparison percentile for the top

four measures must exceed the 40th percentile to meet the Quality Threshold Level and participate in the Shared Savings component

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HEDIS-like Quality Measures

• 1. Well-child visits – during the first 15 months of life
• 2. Well-child visits – (ages 3-6)
• 3. Adolescent well-care visits (ages 12-21)
• 4. Adult access to preventive/ambulatory health services
• 5. Diabetic HbA1c testing
• 6. Diabetic eye screening
• 7. Diabetic nephropathy screening
• 8. Breast cancer screening
• 9. Cervical cancer screening
• 10. Appropriate treatment for children with upper respiratory infection
• 11. Appropriate testing for children with pharyngitis
• 12. Appropriate management of children and adults with asthma
• 13. Appropriate follow-up/management of children with newly prescribed medication for

attention deficit hyperactivity disorder

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2015 PQIP Quality Scorecard Peer Comparison Component

Example for ABC PCPs Current quality scorecard measurement period (MP) Eligible population Compliant with measure Current MP rate Current MP peer comparison percentile Peer comparison score (from table below) Measure weighting Peer comparison weighting Peer comparison earned contribution Measure number 1 Highest # of measured members 830 508 61% 70th 70% x 25% x 80% = 14% 2 Second highest 357 261 73% 55th 70% x 25% x 80% = 14% 3 Third highest 144 109 76% 94th 120% x 25% x 80% = 24% 4 Fourth highest 92 79 86% 36th 25% x 25% x 80% = 5% Weighted Average Peer Comparison Percentile 64th Total Peer Comparison Earned Contribution 57% Quality Threshold Level met (i.e., > 40th) Determination of Peer Comparison Score: 0 to 24.9th percentile = 0% 25th to 49.9th percentile = 25% 50th to 74.9th percentile = 70% 75th to 89.9th percentile = 85% 90th to 100th percentile = 120%

Peer Comparison Component is weighted at 80 percent and Quality Improvement Component is weighted at 20 percent.

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2015 PQIP Quality Scorecard Quality Improvement Component nt

Quality Improvement Baseline Rate = HEDIS Quality Compass 50th Percentile rate for that measure Quality Improvement Target Rate = the rate needed to close 20 percent of the gap between the prior-year rate and the Quality Improvement Baseline Rate Quality Improvement Score = 100 percent if the Quality Target Rate is achieved or if the current-year rate is greater than the Quality Improvement Baseline Rate

Example for ABC PCPs Current quality scorecard measurement period Eligible population Compliant with measure Current MP rate Prior MP rate Quality improvement baseline rate Quality improvement target rate Improvement target achieved? Quality improvement score Measure weighting Quality improvement weighting Quality improvement earned contribution Measure Highest # of Measured Members 830 508 61% 55% 65% 57% Y 100% x 25% x 20% = 5% Second highest 357 261 73% 72% 82% 74% N 0% x 25% x 20% = 0% Third highest 144 109 76% 71% 65% 65% Y 100% x 25% x 20% = 5% Fourth highest 92 79 86% 77% 75% 75% Y 100% x 25% x 20% = 5% Total Quality Improvement Earned Contribution 15%

Peer Comparison Component is weighted at 80 percent and Quality Improvement Component is weighted at 20 percent.

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Peer Comparison Earned Contribution is added to the Quality Improvement Earned Contribution to arrive at the Total Earned Contribution.

Example for ABC PCPs Total Peer Comparison Earned Contribution 57% Total Quality Improvement Earned Contribution 15%

Total Earned Contribution 72%

2015 PQIP Quality Scorecard Total Earned Contribution

The Total Earned Contribution drives the amount of Shared Savings that are earned.

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Enhanced Pay Component

• Must meet Quality Threshold Level to participate
• Enhanced Pay is a shared savings structure based on adjusted

medical loss ratio (MLR)

• The target MLR and shared savings rates are structured in corridors

based on the prior-year MLR

• Maximum shared savings are capped at 25 percent of a PCP’s

underlying reimbursement

Corridor Prior-year MLR Target MLR Shared savings rate 1 0%-80% 80%

• If calendar year MLR

is reduced 50%

• If calendar year MLR

is increased 30% 2 80%-85% Prior Year – 2% 50% 3 > 85% Prior Year – 2% 20%

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PQIP Earned Shared Savings Example

Example for ABC PCPs Assumptions: Calculations: Prior Year MLR 85% Unadjusted Shared Savings: Thus, MLR Target = 83% Difference in Target MLR and Program Year MLR: 5% Thus, Shared Savings Potential = 50% x Program Year Total Premium $ 2,000,000 Equals Unadjusted Shared Savings $ 100,000 Current Year MLR 78% Earned Shared Savings: Program Year Total Premium $ 2,000,000 Unadjusted Shared Savings $ 100,000 x Shared Savings Potential 50% Total Earned Contribution 72% x Total Earned Contribution 72% Equals Earned Shared Savings $ 36,000

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Total Medical Costs

Definition:

The costs incurred by Amerigroup Louisiana for payment of all covered services (including hospital, medical, pharmacy and nonhospital services) provided to each member by all providers (participating or nonparticipating, including the provider and PCPs) furnishing such services to members, adjusted for the PQIP Stop-loss Premiums and Recoveries and Value-added Benefits The calculation of Total Medical Expenses will be as follows:

• Claims and capitation paid through the defined claims run-out period
• Plus a reasonable amount for incurred but not reported costs
• Plus the PQIP Stop-loss Premium
• Minus the PQIP Stop-loss Recoveries

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Stop-loss

Definition: A methodology incorporated into the Total

Medical Expenses calculation designed to spread the risk of high-dollar claims over the entire population of PCPs. It is not

• ptional.
• Stop-loss Premium:

– Included as part of the Total Medical Expenses calculation – Will be the per-member per-month actual Program Year portion of any individual claim in excess of $50,000 for all Amerigroup Louisiana members in the PCP’s health plan, multiplied by the member months for the provider

• Stop-loss Recoveries:

– Deducted from paid claims as a part of the Total Medical Expenses calculation – Will be the portion of any individual claim in excess of $50,000

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New PCMS Reporting – Simple, Actionable and Relevant

$39.3M $14.2M $5.5M

• Enhanced functionality and ease-of-use packaging in a way

to better fit practice workflow

• Transforming from task-based, nonintegrated lists to a new

integrated solution showing a comprehensive view of the member

• Displays patient-level details affected by financial targets

with the actionable information that drives the practice’s performance management

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PCMS Population Management Component

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PCMS Population Management Component – Landing Page

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PCMS Population Management Component – Care Opportunities

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PCMS Performance Management Component Medicaid PQIP Quality Scorecard

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Home Population Management Home Home Population Management Performance Management Primary Care Practice

Scorecard Medical Cost Summary

Earned Contribution  Peer Comparison

Max

24.00% 24.00% 24.00% Earned: 5.00%

Rate = 85.87%

3.00%

4 Services

7.00%

4 Services Earned: 14.00% Rate = 73.11%

3.00%

22 Services

7.00%

14 Services

9.00%

2 Services Cervical Cancer Screening Adolescent Well-care Visit Rate = 50.00% Rate = 95.35% 4 Services Breast Cancer Screening 7 Services 4 Services 1 Services 1 Services Rate = 80.85% URI Treatment Well-child Visits – First 15 Months Well-child Visits 3-6 Years Pharyngitis Testing 72.26% 79.23% 83.00% 65.47% 64.10% 69.06% 74.00% 59.24% 87.20% 90.90% 95.12% 80.39% 60.00% 65.00% 70.00% 49.00% 85.00% 87.00% 89.00% 82.00% 78.00% 81.00% 83.00% 72.00% Provider Group: Sample Medical Group ABC Current Measurement Interval: Program: Sample PQIP Program Measurement Period: 1/1/2015– 12/31/2015

Peer Comparison

57.00%

96.00% Improvement

15.00%

20.00% Total Earned

72.00%

116.00%

Earned: 24.00%

Rate = 75.69%

24.00%

Update

Export View Perf Rates

View By: Scoring Levels My Organization My Group ‘Default Org Name’ Earned: 14.00% Rate = 61.20%

3.00%

65 Services

7.00%

59 Services 60.09% 69.00% 76.10% 52.05% Level 1 Level 2 Level 3 Level 4

0.00% 0.00% 0.00%

Level Measure Percentile Result Peer Comparison Score Measure Weighting Peer Comparison Weighting Per Measure Earned Contribution Potential 0 to < 25th Percentile = 0% X 25% X 80% =

0%

1 25th to < 50th Percentile = 25% X 25% X 80% =

5%

2 50th to < 75th Percentile = 70% X 25% X 80% =

14%

3 75th to < 90th Percentile = 85% X 25% X 80% =

17%

4 90th to 100th Percentile = 120% X 25% X 80% =

24%

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Home Population Management Home Home Population Management Performance Management Primary Care Practice

Scorecard Medical Cost Summary

Earned Contribution  Peer Comparison

Max

20.00% 20.00% 20.00% Earned: 5.00%

Rate = 85.87%

3.00%

4 Services

7.00%

4 Services Earned: 14.00% Rate = 73.11%

3.00%

22 Services

7.00%

14 Services

9.00%

2 Services Measure 5 Measure 6 Rate = 50.00% Rate = 95.35% 4 Services Measure 7 7 Services 4 Services 1 Services 1 Services Rate = 80.85% Measure 4 Measure 1 Measure 2 Measure 3 72.26% 79.23% 83.00% 65.47% 64.10% 69.06% 74.00% 59.24% 87.20% 90.90% 95.12% 80.39% 60.00% 65.00% 70.00% 49.00% 85.00% 87.00% 89.00% 82.00% 78.00% 81.00% 83.00% 72.00% Provider Group: Sample Medical Group ABC Current Measurement Interval: Program: Sample PQIP Program Measurement Period: 1/1/2015– 12/31/2015

Peer Comparison

57.00%

80.00%

Improvement

15.00%

20.00% Total Earned

72.00%

100.00%

Earned: 24.00%

Rate = 75.69%

20.00%

Update

Export View Perf Rates

View By: Scoring Levels My Organization My Group ‘Default Org Name’ Earned: 14.00% Rate = 61.20%

3.00%

65 Services

7.00%

59 Services 60.09% 69.00% 76.10% 52.05%

All Measures – Peer Comparison

Measure My Organization My Group Level Achieved

Adherent Rate Adherent Rate

Well-child Visits – First 15 Months 23/45 51.11% 508/830 61.20% Level 2 Well-child Visits 3-6 Years 30/43 69.77% 261/357 73.11% Level 2 Pharyngitis Testing 32/47 68.09% 109/144 75.69% Level 4 URI Treatment 30/43 69.77% 79/92 85.87% Level 1 Cervical Cancer Screening 0/0

• 36/72

50.00% N/A Adolescent Well-care Visit 17/19 89.47% 41/43 95.35% N/A Breast Cancer Screening 12/23 52.17% 38/47 80.85% N/A

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2015 PQIP Timeline: Shared Savings Reconciliations and Payments

• Reconciliations:

– Interim quarterly reconciliations after three months of claims run-out and 45 days to produce reconciliation

• Q1 2015 (3 months ending 3/31/2015) – delivered 8/15/2015
• Q2 2015 (6 months ending 6/30/2015) – delivered 11/15/2015
• Q3 2015 (9 months ending 9/30/2015) – delivered 2/15/2016
• Final 2015 (12 months ending 12/31/2015) – delivered 5/15/2016
• Same schedule for 2016
• Withholds:

– Applicable withholds are as follows:

• Q1 2015 – 75 percent
• Q2 2015 – 50 percent
• Q3 2015 – 25 percent
• Final 2015 – 0 percent

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Provider Reporting Tools

• Learn about the reporting tools available to

you and how to leverage these reports to maximize your potential care opportunities

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User Guide (continued)

Sample PMCO Report (continued)

Sample PMCO Report (continued)