Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual

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1 Arkansas Blue Cross and Blue Shield Patient Centered Medical Home Provider Manual 2016 This document is a guide to the 2016 Arkansas Blue Cross and Blue Shield Patient-Centered Medical Home program (Arkansas Blue Cross PCMH). This document does not guarantee clinic participation in the Arkansas Blue Cross PCMH program. This document is subject to change without notice.

2 ARKANSAS BLUE CROSS AND BLUE SHIELD PATIENT-CENTERED MEDICAL HOME (PCMH) 1. DEFINITIONS 2. ENROLLMENT AND ATTRIBUTION 2a Enrollment Eligibility 2b Clinic Enrollment and Clinic Withdrawal 2c Attribution of Members (Patient Panel) 3. CARE COORDINATION PAYMENTS 3a Care Coordination Payment Eligibility 3b Care Coordination Payment Amount 3c NCQA 4. SHARED SAVINGS 5. METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a Practice Transformation Activities Tracked 5b Metrics Tracked 5c Accountability 5d Provider Reports 6. COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE CLINIC PARTICIPATION IN THE PCMH PROGRAM 7. CONTACT US 1 DEFINITIONS AHIN (Advanced Health Information Network) Attributed Members (Patient Panel) Care Coordination Care Coordination Payments AHIN is a web-based portal that provides the Arkansas provider community real-time access to the information needed to efficiently manage a practice. AHIN s functionality includes eligibility, claim information, remittance information, and access to the State PCMH, Episode Reporting and ABCBS PCMH programs. A patient panel is a list of patients assigned (or attributed) to a Primary Care team in a practice. The team is responsible for managing the overall care for the attributed patient panel. Examples of the types of care that the team will be responsible for overseeing include: preventive care, chronic disease management, follow-up from any ED or in-patient hospital visit as well as any acute care needs. Activities focused on population management and patient engagement that aim in helping the patient/member navigate the healthcare system and improve their overall health. These activities may be carried out by an individual or spread across the care team. Per member per month (pmpm) payments made to participating Primary Care Physician practices. The payment amount is based on the number of members 1

3 CPC (Comprehensive Primary Care) Fully Insured Interoperability Medical Neighborhood Medical Neighborhood Barriers Participating Clinic Patient Alignment Patient-Centered Medical Home (PCMH) Performance Period attributed through either member selection or the attribution processed outlined in the PCMH amendment. The Comprehensive Primary Care Initiative is a multipayer program which promotes collaboration between public and private health care payers to strengthen primary care. The goal is to improve overall patient health while lowering costs. An arrangement by which a licensed insurance company gives its employer-group customers financial protection against claim loss in exchange for a monthly premium. The term fully insured member is used throughout this document. The ability of the component parts of an application (e.g. multiple EHRs communicating, hospital systems communication with clinics, or TeleVox) to operate successfully together. Involves the PCMH serving as the core provider plus any supporting entities, including but not limited to: specialists, behavioral health, pharmacists, home health, community resources and services, and other associated services. Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. A physician clinic that is enrolled in the PCMH program, which must be one of the following: A. An individual primary care physician (Provider Type: Family Medicine, General Practice, Geriatrics, Internal Medicine, Pediatrics) B. A physician group of primary care providers who are affiliated, with a common group identification number C. A Rural Health Clinic D. An Area Health Education Center E. Federally Qualified Health Center (FQHC) The process of aligning our members with a Primary Care Provider based on recent claims data, member selection, and in some cases, geographic considerations. A Primary Care Provider will then manage the patients/members that have been assigned/attributed. Participating clinics may receive care coordination payments to support population health management activities for the attributed members. The term member refers to patients. A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage patients health needs with an emphasis on health care quality and value. The period of time over which performance is aggregated and assessed. 2

4 Practice Transformation Primary Care Physician (PCP) PCMH Provider Portal Remediation Time Self-insured Plan Same-day appointment Shared Savings program The adoption, implementation and maintenance of approaches, activities, capabilities and tools that enable a participating clinic to serve as a PCMH. A physician providing primary care services whose sole or primary specialty is General Practice, Family Medicine, Internal Medicine, Pediatric Medicine, Geriatric Medicine. The provider portal will be used for the 2016 ABCBS and its family of companies PCMH enrollment process, submitting required reporting activities and/or metrics as well as receiving any information/reports shared by the plan. The provider portal is available on AHIN. The period during which participating clinics that fail to meet deadlines, targets or both on relevant activities tracked for practice transformation may continue to receive care coordination payments while improving performance. A health plan through which an employer or other group sponsor, rather than an insurance company, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a selffunded plan. Accommodating a patient s request to be seen by a clinician within 24 hours. A separate program to reward cost-efficient and quality care. A shared savings program will not be available for the 2016 program year. 2 ENROLLMENT AND ATTRIBUTION 2a. Enrollment Eligibility The Arkansas Blue Cross and Blue Shield PCMH Program eligibility requirements are: A. The practice must include primary care physicians (Family Medicine, General Practice, Geriatrics, Internal Medicine, or Pediatrics) enrolled in the following networks: Arkansas Blue Cross and Blue Shield (Preferred Provider Participant), Health Advantage and True Blue. AND B. The practice must complete the PCMH enrollment application located on the AHIN portal during the designated PCMH enrollment period. The enrollment period is announced annually on AHIN. AND C. The practice must return contract amendments signed by each primary care physician who provides primary care to patients at the PCMH clinic location. 2b. Clinic Enrollment and Clinic Withdrawal Enrollment in the PCMH program is voluntary. Enrollment is open to physicians providing primary care to patients. A clinic representative must complete the PCMH application available on the AHIN PCMH portal. True Blue, Health Advantage and Preferred Provider Participant contract amendments must be signed by the person in the clinic with administrative authority. 3

5 Each physician participant will only need to sign Exhibit B. Upon receipt of the signed amendment, the clinic and its eligible physicians will be enrolled in the PCMH program. Clinics are expected to re-enroll annually. A PCMH will remain in good standing until: A. The clinic or physician withdraws; B. The clinic or physician becomes ineligible, is suspended or terminated from network participation or the PCMH program; C. Arkansas Blue Cross and Blue Shield terminates the PCMH program A participating clinic must update the Primary Care department on changes to the list of physicians who practice at the clinic. To add or withdraw a physician from the PCMH program, send an to primarycare@arkbluecross.com. Include the name and NPI number for the physician in the . Withdrawing from the PCMH program will not impact clinic/physician participation in any other existing contract(s) or program with Arkansas Blue Cross and Blue Shield and its family of companies. Physician(s) may terminate the PCMH agreement and be removed from the PCMH program by providing 30 days prior written notice of termination to: Arkansas Blue Cross and Blue Shield Primary Care, 4S 601 S. Gaines Little Rock, AR Questions regarding the termination process should be directed to the Arkansas Blue Cross and Blue Shield Primary Care Department by calling or via primarycare@arkbluecross.com. 2c. Attribution of Patients (Patient Panel) Fully insured members will be assigned to a physician based on an attribution methodology that will include but not be limited to factors such as claims containing specific evaluation and management CPT codes ( ), assignment through recent dates of service, the total allowed amount of the paid claims and a member PCP selection process. If a member cannot be assigned based on paid claims or the member declines to select a PCP that member may be assigned to a participating clinic based on geographic proximity to the participating clinic. Members assigned to participating clinics but who have not established care at that clinic (no paid claims for E&M codes ) will not be included in the patient panel of attributed members until the participating clinic is paid for an eligible E&M service code ( ). For those members, care coordination payments will not be begin until the member has established care and the participating clinic has been paid for an eligible E&M service code ( ). Self-insured employers will independently choose to participate or not participate in the PCMH program. They will also choose the Care Coordination Payment amount for their members. 4

6 3 CARE COORDINATION PAYMENTS 3a. Care Coordination Payment Eligibility In addition to the enrollment eligibility requirements listed in Section 2a, participating clinics must meet the practice transformation activities and metrics identified in sections 5a and 5b to receive care coordination payments. 3b. Care Coordination Payment Amount Care Coordination payments are calculated per attributed member, per month and paid monthly. Care Coordination payments support practice transformation and care coordination services. In order to begin receiving care coordination payments for the first quarter of 2016, a clinic must submit a complete PCMH Provider Participation Agreement on or before December 15, Members assigned to participating clinics but who have not established care at that clinic (no previous paid claims for E&M codes ) will not be included in the care coordination payment until an eligible claim is submitted and paid. 3c. NCQA Practice(s) that hold NCQA PCMH recognition during the enrollment period 10/1/15-12/1/15 will receive an increased care management fee per member per month for their patients with a fullyinsured policy based on the level of recognition during the time of enrollment. If the practice(s) NCQA PCMH recognition expires prior to December 31, 2016 the PMPM payments will revert back to the base level the month following the expiration unless an updated recognition has been submitted to primarycare@arkbluecross.com. 4 SHARED SAVINGS 4a. Shared Savings A Shared Savings program will not be available for the 2016 program year. 5 METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a. Practice Transformation Activities Tracked Using the PCMH Provider Portal, participating clinics must complete and document the activities as described in the table below by the deadline indicated in the table. The reference point for the deadlines is January 1, Month Activities Deadline A. Identify top 10% of Arkansas Blue Cross and Blue Shield high-priority members using: 1. Arkansas Blue Cross and Blue Shield and its family of companies patient panel data that ranks members by risk at beginning of performance period. March 31, UPDATE: Due date has been extended to April 30, 2016 (If such list is not submitted by this deadline, Arkansas Blue Cross and Blue Shield and its family of 5

7 OR 2. The clinic s patient-centered assessment to determine which members on this list are highpriority. Submit this list to the PCMH portal. companies will identify a default list of high-priority members for the clinic, based on risk scores). B. Report clinical quality measure data for calendar year 2015 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI). - Controlling High Blood Pressure: - Numerator: The number of patients in the denominator whose most recent BP is adequately controlled (<140/90) during the measurement year. - Denominator: Total number of patients age who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year. - Diabetes: Hemoglobin A1c Poor Control - Numerator: Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. - Denominator: Patients years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. - Weight Assessment and Counseling for Children and Adolescents - Numerator: The percentage of patients in the denominator who had evidence of Body Mass Index (BMI) percentile documentation during the measurement year. - Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB GYN during the measurement year. March 31, Month Activities Deadline C. Assess operations of practice and opportunities for improvement. D. Develop strategies to implement practice transformation and care coordination. E. Identify and address medical neighborhood barriers to coordinated care at the clinic level (including Behavioral Health professionals and facilities). June 30, 2016 June 30, 2016 June 30, 2016 F. Make available 24/7 access to care. Provide telephone June 30,

8 access to a live voice (e.g., an employee of the primary care physician or an answering service) or to an answering machine that immediately pages an on-call medical professional 24 hours per day, 7 days per week. The on-call professional must: 1. Provide information and instructions for treating emergency and non-emergency conditions, 2. Make appropriate referrals for non-emergency services and 3. Provide information regarding accessing other services and handling medical problems during hours the PCP s office is closed. 4. PCPs must make the after-hours telephone number known by all patients; posting the afterhours number on all public entries to each site; and including the after-hours phone number on answering machine greetings. 5. When employing an answering machine with recorded instructions for after-hours callers, PCPs should regularly check to ensure that the machine functions correctly and that the instructions are up to date. G. Document approach to expanding access to same-day appointments. Answer the questions listed for Activity G on the PCMH portal. June 30, Month Activities Deadline H. Childhood/Adult Vaccination Practice Strategy. Answer the questions listed for Activity H on the PCMH portal. I. Establish processes that result in contact with patients who have not received preventive care. Complete the questions listed for Activity I on the PCMH portal. J. Patients ability to receive timely care, appointments and information from specialists, including Behavioral Health (BH) specialists. K. Incorporate e-prescribing into clinic workflows. Answer the questions listed for Activity K on the PCMH portal. L. Integrate EHR into practice workflows. Answer the questions listed for Activity L on the PCMH portal. M. A minimum of 80% of high-priority members (identified in Activity A) whose care plan as contained in the medical record includes: 1. Documentation of a patient s current problems; 2. Plan of care integrating contributions from health care team (including behavioral health professionals) and from the member; December 31, 2016 December 31, 2016 December 31, 2016 December 31, 2016 December 31, 2016 December 31,

9 3. Instructions for follow-up and 4. Assessment of progress to date. The care plan must be updated at least twice a year. 13 Month Activities Deadline N. Report clinical quality measure data for calendar year 2015 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI). - Controlling High Blood Pressure: - Numerator: The number of patients in the denominator whose most recent BP is adequately controlled (<140/90) during the measurement year. - Denominator: Total number of patients age who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year. - Diabetes: Hemoglobin A1c Poor Control - Numerator: Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. - Denominator: Patients years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. - Weight Assessment and Counseling for Children and Adolescents - Numerator: The percentage of patients in the denominator who had evidence of Body Mass Index (BMI) percentile documentation during the measurement year. - Denominator: Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB GYN during the measurement year. January 31, 2017 Arkansas Blue Cross and Blue Shield and its family of companies may add, remove, or adjust these practice transformation activities or deadlines, including additions beyond 12 months, based on new research, empirical evidence or experience from initial metrics. Arkansas Blue Cross and Blue Shield and its family of companies will publish such extension, addition, removal or adjustment on AHIN and in the PCMH Provider manual. 5b. Metrics Tracked Arkansas Blue Cross and Blue Shield and its family of companies assesses participating clinics on the following metrics tracked starting on the first day of the first calendar year in which the participating clinic is enrolled in the PCMH program and continuing through the full calendar year. 8

10 Quality Metrics 1. Percentage of patients who turned 15 months old during the performance period and who received at least four wellness visits in their first 15 months. 2. Percentage of patients 3-6 years of age who had one or more well-child visits during the measurement year. 3. Percentage of patients years of age who had one or more well-care visits during the measurement year. 4. Percentage of patients 6-12 years of age with an ambulatory prescription dispensed for ADHD medication that was prescribed by their PCMH, who had a follow-up visit within 30 days by any practitioner with prescribing authority. 5. Percentage of patients prescribed appropriate asthma medications. 6. Percentage of CHF patients age 18 years and over on beta blockers. 7. Percentage of children who received appropriate treatment for Upper Respiratory Infection (URI). 8. Percentage of diabetic patients who complete annual HbA1C between years of age. 9. Percentage of patients with Diabetes and CAD that are currently taking a statin. 10. Percentage of a clinic s high-priority patients seen by a member of the PCP s care management team at least twice in the past 12 months. 11. Percentage of members who had an acute inpatient hospital stay and were seen by health-care provider within 10 days of discharge. 12. Percentage of patients age 18 years and older who were prescribed chronic Alprazolam (Xanax) during the measurement year. Arkansas Blue Cross and Blue Shield will provide data when available. 13. Percentage of patients age years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period (all payer source). The PCMH clinic will self-report this metric through the PCMH portal. 14. Percentage of patients years of age with diabetes (type 1 or type 2) whose most recent HbA1C level during the measurement period was greater than 9.0% (poor control) or was missing the most recent result, or if an Target for Program Year Beginning January 1, 2016 At least 70% At least 67% At least 45% At least 36% At least 85% At least 49% No more than 65% At least 78% At least 70% At least 76% At least 40% No more than 12% At least 55% No more than 35% 9

11 Quality Metrics HbA1C test was not done during the measurement period (All payer source). The clinic will self-report this metric through the PCMH portal. 15. Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of height, weight, and body mass index (BMI) percentile documentation during the measurement period (All payer source). The clinic will self-report this metric through the PCMH portal. Target for Program Year Beginning January 1, 2016 At least 45% Arkansas Blue Cross and Blue Shield and its family of companies will publish targets for subsequent years, calibrated based on experience from targets initially set, on the AHIN PCMH portal. Such targets will escalate over time. Arkansas Blue Cross and Blue Shield and its family of companies may add, remove, or adjust these metrics based on new research, empirical evidence or experience from initial metrics. 5c. Accountability If a participating clinic does not meet deadlines and targets for practice transformation activities and metrics as described in Sections 5a and 5b, then the clinic must submit an improvement plan to prevent a change in participation status with the program. The improvement plan should be submitted within one month of receiving their Arkansas Blue Cross and Blue Shield PCMH report notifying them of failure to meet an activity requirement. Clinics will be expected to follow the Improvement Plan policy set forth by Arkansas Blue Cross and Blue Shield. A. Activities tracked a. The participating clinic will have a full calendar quarter to complete remediation after being notified of the requirements that did not meet expectations. B. Metrics tracked i. Exception: Activity B in Section 5a where no such remediation time will be provided. a. Performance must be remediated before the end of the second full calendar quarter after the date the clinic receives notice via the provider report that target(s) have not been met. b. For purposes of remediation, performance is measured on the most recent four calendar quarters. If a clinic fails to meet the deadlines or targets for practice transformation activities and metrics tracked within this remediation time, then Arkansas Blue Cross and Blue Shield and its family of companies will terminate the clinic from the PCMH program. Arkansas Blue Cross and Blue Shield and its family of companies retain the right to confirm clinics performance against deadlines and targets for activities and metrics tracked. 5d. Provider Reports 10

12 Arkansas Blue Cross and Blue Shield and its family of companies provide participating clinics reports containing information about their clinic performance on activities and metrics. Reports will be located on the AHIN PCMH provider portal. 6 COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE CLINIC PARTICIPATION IN THE PCMH PROGRAM 6a. CPC Initiative Clinic Participation Any Practice/Provider in good standing at the completion of the CPCi program may join the Arkansas Blue Cross PCMH program. Anyone with an active improvement plan in the CPCi program may apply and include the improvement plan details with their enrollment. 7 CONTACT US 7a. Questions regarding the Arkansas Blue Cross and Blue Shield PCMH program The Arkansas Blue Cross and Blue Shield Primary Care team is available to answer questions regarding the Arkansas Blue Cross PCMH program via or by phone Monday Friday 8:00am 4:30pm CST. primarycare@arkbluecross.com Phone: