Quality Incentive Payment System

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2 Quality Incentive Payment System QIPS background... 1 Practice and member eligibility prerequisites in order to participate in QIPS (QIPS prerequisites)...1 System overview...2 Monthly capitation... 2 Quality Performance Measure score program... 3 Practice and member eligibility requirements for the QPM score program...3 Quality performance measures...3 Practice score calculations...4 QPM score program payment...4 Practice-specific reports...5 Patient-Centered Medical Home TM incentive program... 5 Practice and member eligibility requirements for PCMH incentive program...6 Payment of PCMH incentive...6 Special payment provisions for the PCMH incentive program...6 Medical Cost Management incentive program... 7 Practice and member eligibility requirements for Medical Cost Management incentive program...7 Professional & Outpatient Cost Management measure...7 Generic Drug Prescribing measure...8 Payment of Medical Cost Management incentives...9 Special payment provisions for the Medical Cost Management incentive program...10 Medical Cost Management incentive program reporting...10 Other important terms and conditions regarding QIPS Appeals process Appendix A: Quality performance measures for measurement year Appendix B: Guidelines for combining practices Appendix C: How changes to your practice composition affect QIPS /2012 QIPS i

3 QIPS background The Quality Incentive Payment System (QIPS) is a reimbursement system developed by Keystone Health Plan East (KHPE) for participating Pennsylvania primary care physicians (PCPs). The QIPS program offers incentives for high-quality, accessible, and cost-effective care. As meaningful measures of quality and cost continue to be developed and improved, the measures contained in QIPS may be refined. QIPS is a living system that will continue to evolve. It is intended to be a fair and open system that provides incentives to continually improve the quality of medical care and patient service to our members. We reserve the right to make changes to the QIPS program upon prior written notice to PCP practices. Practice and member eligibility prerequisites in order to participate in QIPS (QIPS prerequisites) A practice must meet certain prerequisites in order to be eligible for participation in the QIPS program: PCP practices located in Pennsylvania and reimbursed on a capitated basis. Practice specialty type of family/general practice, internal medicine, or pediatrics. Electronic connectivity and transaction procedures for payments beginning July 1, 2013: Practices must be NaviNet-enabled at each practice site and utilize the NaviNet web portal as the primary mechanism for claims status inquiries, adjustment requests, referrals, and initiation of applicable preauthorizations. Practices must also register for electronic funds transfer for non-capitated reimbursement and complete the following transactions electronically: member eligibility, claims submissions, and encounters. Compliance with the electronic connectivity and transaction prerequisite will be monitored on a quarterly basis. Practices that are not in compliance will be notified and provided 60 days to bring their practice into compliance. It is understood that due to technical issues and/or unforeseen circumstances, certain transactions may periodically default back to telephone, facsimile, or other paper-based mechanisms. Accounting for these periodic issues and barring extraordinary circumstances beyond the control of the practice, electronic connectivity and transactions as defined above will be required as a prerequisite for participation in QIPS. Pennsylvania PCPs employed by a hospital or health system are eligible only if the physician s employer returns an executed practice attestation that addresses the following requirements: All practice PCPs are made aware of all of the requirements for participation in the QIPS program. All practice PCPs are made aware of the program design and associated payments annually. QIPS performance reports are reviewed directly with practice PCPs. QIPS performance results are incorporated into the PCPs compensation plan as a variable component of total compensation. If there is a signed attestation on record by the hospital or health system, this document will be retained and kept on file for future contract years. Therefore, an annual signature will not be required. If there is not a signed attestation on file, an attestation will be sent to the appropriate parties for signature. Failure to complete and return the attestation within the stated time period will result in exclusion from QIPS for all affiliated practices. Note: KHPE will continue to contact applicable hospitals and health systems each year to remind them of the terms and conditions of the above prerequisite. Practices that are not accepting new KHPE members and/or existing patients who may change their insurance to KHPE are not eligible for QIPS. These offices are referred herein as frozen offices. 6/2012 QIPS 1

4 System overview PCP reimbursement is based on capitation, capitation billaboves paid on a fee-for-service basis, and QIPS incentives. Under the QIPS program, incentive payments are based on the performance of your practice and not on individual practitioner performance unless you are a solo practitioner. Payments begin at a fixed level (capitation), with the ability to enhance reimbursement with the following quality and Medical Cost Management incentives: Eligible incentives Quality of care per member per month Quality performance measures Patient-Centered Medical Home TM Medical Cost Management per member per month Professional & Outpatient costs Generic drug prescribing Eligible incentives grand total Commercial HMO/POS Medicare Advantage HMO $0 - $4.60 $0 - $3.00 $0 - $4.60 $0 - $1.20 $0 - $13.40 $0 - $8.60 $0 - $3.00 $0 - $8.60 N/A $0 - $20.20 Monthly capitation Monthly capitation is paid according to the age, sex, and product breakdown of a PCP s panel of members in accordance with the provider participation agreement. Capitation is paid monthly on or about the tenth day of each month. It includes all covered services provided by the PCP and his or her staff with the exception of services paid above capitation (capitation billaboves). To view a list of PCP capitation billaboves, complete the following steps: 1. Visit 2. Select Accept and Go to Medical Policy Online. 3. Select the Commercial and Other Medicare Advantage Policies link. 4. Search for policy # in the search field at the top of the page. You can also search by entering the policy name: Services Paid Above Capitation for Health Maintenance Organization (HMO) Primary Care Physicians. The capitation billaboves for Pennsylvania PCPs are listed in Attachment C of the online policy. 6/2012 QIPS 2

5 Quality Performance Measure score program The Quality Performance Measure (QPM) score program (previously known as the high-quality capitation premium) is based on how well a PCP office performs relative to other qualifying KHPE-participating PCP offices of the same specialty type (family/general practice, internal medicine, or pediatrics). The score is then compared to all participating practices of the same specialty type to determine the practice rank. Practice and member eligibility requirements for the QPM score program In addition to the QIPS prerequisites, the QPM score program applies to primary care practices whose panel size is on average a combined total of 150 or more members (commercial HMO/POS and Medicare Advantage HMO combined membership) during the measurement year. Practices must also be participating with KHPE for the entire measurement year to be eligible for the QPM score program. Quality performance measures* The quality performance measures for the QPM score program are based on the Healthcare Effectiveness Data and Information Set (HEDIS ), a well-established and tested set of standard measures. The measures are predicated on KHPE s Member Wellness Guidelines and other established clinical guidelines. Performance relative to peer practices will account for your final ranking. These measures are based on services rendered during the reporting period (January through December of the measurement year, unless otherwise noted). Accurate encounter and claims submissions are important to document services rendered. During measurement year 2012, the following quality performance measures will be used for scoring: childhood immunization adolescent immunization well-child visits in the first 15 months of life well-child visits in the third, fourth, fifth, and sixth years of life adolescent well-care visits breast cancer screening cervical cancer screening colorectal cancer screening cholesterol management (LDL-C) for patients with cardiovascular conditions persistent asthma care diabetic care use of spirometry testing in the assessment and diagnosis of COPD disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis persistence of beta-blocker treatment after a heart attack osteoporosis management in women who had a fracture Please refer to Appendix A: Quality performance measures for measurement year 2012 for the specific details of the measures listed above. *Quality performance measures are based on HEDIS and are used as the baseline measurement for performance measure frequency of preventive health services. Note, however, that members benefits vary based on product line, group, or contract. Preventive health services benefits coverage for members for most of the performance measures may be more frequent than HEDIS measurement requirements. Individual member benefits should be verified. 6/2012 QIPS 3

6 Practice score calculations Results will be calculated for each of the performance measures for each primary care practice and then will be aggregated. Practice scores will be calculated as the ratio of members who received the services as evidenced by information provided by the physician s office or through claims and encounter information (numerator) to the members in the practice s panel who were eligible to receive these services based on the definitions (denominator). Each practice will then be ranked based on its performance relative to other practices within its specialty peer group. Once a practice is given a QPM score or rank, it stays in effect for one year until the entire scoring is repeated with new information from the most recent year. QPM score program payment The QPM score program is paid on or about the 15th of each month for PCP offices that qualify. This is paid on a fixed per member per month (PMPM) basis, based on the membership on record as of the first day of the month during which the QPM score program is paid. There is no adjustment for age/sex of the member. Payment for the QPM score program for commercial HMO/POS and Medicare Advantage HMO members is as follows: PCP office percentile rank within specialty QPM score program incentive payments* Commercial HMO/POS Open office (PMPM) Current patients only (PMPM) Medicare Advantage HMO Open office (PMPM) Current patients only (PMPM) % $4.60 $2.30 $8.60 $ % $4.30 $2.15 $7.80 $ % $4.00 $2.00 $7.00 $ % $3.70 $1.85 $6.60 $ % $3.40 $1.70 $6.20 $ % $3.10 $1.55 $5.80 $ % $2.80 $1.40 $5.40 $ % $2.50 $1.25 $5.00 $ % $2.20 $1.10 $4.60 $ % $2.00 $1.00 $4.20 $ % $1.80 $0.90 $3.80 $ % $1.60 $0.80 $3.40 $ % $1.40 $0.70 $3.00 $1.50 < 25% $0 $0 $0 $0 Minimum average monthly panel size 150+ *Frozen offices are not eligible for QPM score program payments. 6/2012 QIPS 4

7 Practice-specific reports The following QPM score program reports are sent to each eligible practice in a phased approach: Report 1 Opportunity. An initial report is sent during the third quarter of the measurement year to PCP practices. This report provides a summary of the practice s total number of eligible members for each quality performance measure and the number of members who have already received the specified services. Also included is a list of members for whom we have no record of having received specific services. Practices may use this information as an opportunity to contact these members, discuss the services indicated as missing, and assist them in obtaining the necessary services. Report 2 Feedback. The second report is sent to each practice in the first quarter following the measurement year. This report provides a summary of the practice s total number of eligible members for each quality performance measure and the number of members who have already received the specified services. It also includes instructions and feedback forms that can be used to document that the indicated services were received by the listed members, using information from the members clinical office records. A Clinical Issues Detail Report is also provided for practices to document the details of any clinical issues preventing members from receiving the specified services. The completed feedback forms must be reviewed and certified by a participating network physician in the practice, as indicated by the physician s signature on the first page of the reporting forms. In order for credit to be given, the information must: meet the standard for the measure; be submitted in the requested format; be signed by the physician who provided the service or another participating network physician in your practice; be submitted by the required return date. A completed Informed Decision Making Form, which was developed to promote patient awareness of and compliance with recommended screening tests or vaccinations, can be submitted for patients who refuse to have recommended services. The form is available through the Pennsylvania Medical Society s website: RunningaPractice/Informed-Decision-Making.html. Report 3 Final. The third report provides the overall performance for each practice, how the practice performed compared to the average of its peers, and the practice rank. This report, along with the first payment, is sent to the practice in July of the year following the measurement year. Feedback audit KHPE will perform audits of office records based upon feedback submitted by providers. Where material inaccuracies are discovered between the office records and the data submitted by the provider, (upon prior written notice) the provider will receive written notification of our findings and how the audit results affect his or her QPM score and QIPS payments. Any historical QIPS payments made based on submission of inaccurate data will be recaptured from future payments made to the provider. Patient-Centered Medical Home TM incentive program The Patient-Centered Medical Home (PCMH) incentive program rewards offices that have been recognized by the National Committee for Quality Assurance (NCQA) for achieving the Physician Practice Connections (PPC)-PCMH standards of health care delivery. These standards, endorsed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, require enhanced access and communication, patient tracking, care management, patient self-management support, electronic prescribing, test tracking, performance reporting and improvement, and advanced electronic communication. More information on PCMH recognition and the PPC-PCMH standards are available on NCQA s website at 6/2012 QIPS 5

8 Practice and member eligibility requirements for PCMH incentive program All practices that have met the QIPS prerequisites are eligible for the PCMH incentive program. There are no minimum membership or quality performance thresholds. Payment of PCMH incentive Once each month, KHPE will receive notification from NCQA of practices that have received PCMH recognition. Practices will be eligible for payment 30 days following KHPE s receipt of notification from NCQA, not the date on the certificate. This incentive is paid on a fixed PMPM basis, based on the membership on record as of the first day of the month during which the incentive is paid. PCMH incentive payments* NCQA level of recognition Commercial HMO/POS and Medicare Advantage HMO PMPM Level III $3.00 Level II $2.00 Level I $1.25 Minimum monthly average panel size Not applicable *Frozen offices are not eligible for PCMH incentive payments. Special payment provisions for the PCMH incentive program Payment to practices participating in Phase Two of Pennsylvania Chronic Care Initiative program. Providers who are participating in Phase Two of Pennsylvania Chronic Care Initiative program and receive separate funding from KHPE for implementing PCMH standards are not eligible until after the pilot program and/or separate funding have ended. KHPE shall notify such practices of this special payment provision prior to the effective date of the PCMH incentive. Retroactivity. KHPE payment for PCMH recognition will be made on a prospective basis only. To the extent there is a lag in notification to KHPE from NCQA and/or recognition is provided retroactively, KHPE will not make retroactive payment to the applicable practice. Notwithstanding the above and recognizing that from time to time NCQA may not complete the review process within 60 days of a submitted application, the following will apply: If there is a delay greater than 60 days from the date NCQA accepts a completed application to the date that NCQA approves the PCMH designation, and if the practice would have qualified for an earlier payment if this time were 60 days, then the provider must submit a request to consider a retroactive payment to QIPS@ibx.com along with supporting documentation from NCQA identifying when the completed application was received. The maximum retroactive payment that a provider can receive is up to two months based on the QIPS effective date that would have been assigned had there been no extraordinary delay in the NCQA process. 6/2012 QIPS 6

9 Medical Cost Management incentive program Given the important role of the PCP in the overall management of health for our members, KHPE recognizes and rewards practices that deliver cost-effective care. The Medical Cost Management incentive program is comprised of the following two components: Professional & Outpatient Cost Management; Generic Drug Prescribing (not applicable to Medicare Advantage). Practice and member eligibility requirements for Medical Cost Management incentive program In addition to the QIPS prerequisites, the Medical Cost Management incentive program includes the following practice eligibility requirements calculated separately: Practices that perform below the 30th percentile in the QPM score program are not eligible for the Medical Cost Management incentives for the corresponding measurement year. Practices must have an average panel size of 250 commercial HMO/POS members to be eligible for the commercial Professional & Outpatient Cost Management incentive. Practices must have an average panel size of 150 Medicare Advantage HMO members to be eligible for the Medicare Advantage Professional & Outpatient Cost Management incentive. Practices must have an average panel size of 150 commercial HMO/POS members to be eligible for the Generic Drug Prescribing incentive. Practices must be participating with KHPE for the entire measurement year to be eligible for the Medical Cost Management incentives. Professional & Outpatient Cost Management measure The Professional & Outpatient Cost Management incentive rewards those practices that are active in the care and coordination of their members. Performance-based incentives will be paid to practices with a risk-adjusted* PMPM cost that is within predetermined medical cost targets. The medical cost targets are based on the prior year s actual medical costs for the providers specialty trended forward to the measurement year for unit cost trends. Medical cost targets will be developed annually for each PCP specialty at the product level (i.e., commercial HMO/POS vs. Medicare Advantage HMO). *The PCP Allowed PMPMs are risk-adjusted using Verisk DxCG Risk Scores and a linear regression. In the regression, the dependent variable is the Allowed PMPM and the independent variables are the average risk scores and potential polynomial terms of average risk scores for each PCP. The final functional form of independent variables are empirically tested and selected to get the best model goodness-of-fit in each PCP specialty and lines of business. The output of the linear regression produces an Expected Allowed Amount PMPM for each PCP. The risk-adjusted Allowed Amount PMPM for that PCP is the Actual Allowed Amount PMPM for that PCP divided by Expected Allowed Amount PMPM for that PCP from regression and times the average Allowed Amount PMPM for all PCPs. 6/2012 QIPS 7

10 The medical cost targets will be communicated by the second quarter of each measurement year, allowing for sufficient claims run-out. Medical costs are defined as the plan-allowed payments (i.e., inclusive of member liability) for each practice s panel with the following exclusions: Medical cost exclusions inpatient facility and professional services home health/hospice prescription drugs paid through pharmacy benefits maternity professional services (e.g., deliveries) injury/poison-related diagnosis (800.0 to 999) mental health/substance abuse, dental, and vision capitation payments preventive care screenings (mammography, Pap testing, colon cancer screening, immunization/administration) Member exclusions members younger than 2 as of the last day of the reporting year; members enrolled in the CHIP program; high-cost claimants: Family practice and internal medicine. Commercial HMO/POS members with greater than $50,000 in total annual medical costs and Medicare Advantage HMO members with greater than $100,000 in total annual medical costs; Pediatrics. Commercial HMO/POS members with greater than $20,000 in total annual medical costs; members who are not continuously enrolled with your practice for at least 11 months of the measurement year; members with end-stage renal disease identified as any member with outpatient dialysis claims for three consecutive months during the study year. Generic Drug Prescribing measure Research indicates that the vast majority of generic drugs have an efficacy equivalent to that of their brand-name equivalents. Prescribing generic drugs is cost-efficient, reduces member copayments, and lowers total drugs costs. The Generic Drug Prescribing incentive rewards practices that prescribe generic drugs when available. This incentive program compares your generic drug prescribing percentage to the average generic drug prescribing percentage of your primary care specialty (i.e., family/general practice, internal medicine, or pediatrics). Practices receive progressively higher reimbursement for superior performance relative to their peers (i.e., family/general practice, internal medicine, or pediatrics). Vitamins and fluoride that require a prescription as well as HFA-propelled inhalers without a generic alternative are excluded from generic prescribing calculations. Changes to the list of excluded drugs will be reviewed annually and when generic alternatives become available. 6/2012 QIPS 8

11 Payment of Medical Cost Management incentives The Medical Cost Management incentive is paid annually in August of the year following the measurement year (i.e., 2012 performance paid in August 2013). For eligible practices, the incentive is paid on a fixed PMPM basis, based on an annualized membership on record as of August 1 of the payment year (i.e., membership multiplied by 12). As this is an annual one-time payment, the PMPM incentive amounts are also expressed as per member per year (PMPY) amounts. The Medical Cost Management incentive amounts are as follows: Professional & Outpatient Cost Management incentive payments* Medical cost target percentile Commercial HMO/POS Medicare Advantage HMO PMPM PMPY PMPM PMPY Tier 1 (85% 100%) $4.60 $55.20 $8.60 $ Tier 2 (65% 84.99%) $3.00 $36.00 $6.50 $78.00 Tier 3 (50% 64.99%) $1.50 $18.00 $3.50 $42.00 Tier 4 (< 50%) $0 $0 $0 $0 Minimum monthly average panel size Generic Drug Prescribing incentive payments* PCP office percentile rank within specialty PMPM Commercial HMO/POS PMPY Tier 1 (75 100%) $1.20 $14.40 Tier 2 ( %) $0.80 $9.60 Tier 3 ( %) $0.60 $7.20 Tier 4 ( %) $0.40 $4.80 Tier 5 ( %) $0.25 $3.00 Tier 6 ( %) $0.10 $1.20 Tier 7 (< 25%) $0 $0 Minimum monthly average panel size 150+ *Frozen offices are not eligible for Medical Cost Management incentives. Based on membership during the measurement year. 6/2012 QIPS 9

12 Special payment provisions for the Medical Cost Management incentive program Medical Cost Management incentives and practices under common ownership. Practices that do not meet the minimum monthly average panel size requirement of the Medical Cost Management program will not be eligible for incentive payments. However, practices under common ownership may submit a request to combine membership for purposes of meeting member thresholds included in the incentive components. KHPE, at its sole discretion, will evaluate such requests on a case-by-case basis. See Appendix B: Guidelines for combining practices for additional information. QIPS Medical Cost Management incentive for practices with low overall medical cost. Providers who are not rewarded under the Professional & Outpatient Cost Management measure due to high outpatient costs but whose overall risk-adjusted total medical cost PMPM is lower than other practices within its specialty peer group will be evaluated for a separate incentive payment by product level (i.e., commercial HMO/POS and Medicare Advantage HMO) under the Professional & Outpatient Cost Management measure. To qualify, practices must: perform in the top 25th percentile for the QPM score program for the corresponding measurement year; perform in the top 50th percentile for 2-year risk-adjusted total costs (i.e., lower than the median costs); have an average panel size of: 500 or more commercial HMO/POS members for the commercial HMO/POS incentive payment; 500 or more Medicare Advantage HMO members for the Medicare Advantage HMO incentive payment. Practices that meet the criteria for a separate incentive payment may be eligible as follows (refer to the Professional & Outpatient Cost Management incentive payments chart on page 9 for tier payments): If 2-year total costs fall in the percentile, practices qualify for Tier 2 payments. If 2-year total costs fall in the percentile, practices qualify for Tier 3 payments. Medical Cost Management incentive program reporting KHPE will deliver the following Medical Cost Management performance reports throughout the measurement year: Medical cost target report. The targets for measurement year 2012 will be sent in the second quarter of the measurement year. Medical Cost Management status report. This report will provide a status of how your practice is performing against the medical cost targets previously provided. The report will be based on dates of service January 2012 through July 2012 and mailed out in December. Medical Cost Management final report. This report will detail your practice s final performance, anticipated payments, and earnings potential for the measurement year versus the medical cost targets and practice generic drug prescribing performance. The report will be based on dates of service January 2012 through December 2012 and mailed out in August of the following year. Note: With the medical cost target and Medical Cost Management status reports, we will also provide, for informational purposes only, a 12-month rolling report. 6/2012 QIPS 10

13 Other important terms and conditions regarding QIPS Please make note of the following terms and conditions regarding QIPS: QIPS may be further developed, refined, and enhanced over time. Accordingly, KHPE reserves the right to modify QIPS at any time and will provide written notification of such modifications. KHPE reserves the right, in its sole discretion, to audit and/or remove any PCP or PCP practice from this program at any time due to fraud, material inaccuracies in submission of data, or when it reasonably believes that the provider is not providing Medically Necessary Covered Services in order to obtain QIPS incentives. The monthly capitation is paid for members choosing a PCP s office. If a member is retroactively terminated or added, the PCP will receive a capitation adjustment for changes effective for up to six previous months. For computational and administrative ease, no retroactive capitation adjustments will be made to QIPS payments. QIPS payments will be paid according to the membership known at the beginning of each month. There are certain HMO members (e.g., Away From Home Care members) for whom payment to the PCP is based on fee-for-service and is not capitated. These members are not eligible to be included for QIPS payments. If changes to your practice composition occur during the measurement year, please review Appendix C: How changes to your practice composition affect QIPS, which outlines various scenarios and describes how each would affect your QIPS. Appeals process Providers who choose to appeal their results must submit the appeal in writing to a network Medical Director within 90 days of receipt of the final results. All requests must specify the basis for the appeal and include the appropriate documentation (e.g., chart notes, laboratory reports, imaging reports). The appeal will be forwarded to the QIPS Oversight Committee for review and determination. The provider will be notified of the determination in writing by a network Medical Director. If you need assistance identifying your network Medical Director, please use the Network Coordinator Locator Tool found on under Contact Information. NaviNet is a registered trademark of NaviNet, Inc., an independent company. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. The AMA assumes no liability for data contained or not contained herein. The Blue Cross and Blue Shield names and symbols and Away From Home Care are registered trademarks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 6/2012 QIPS 11

14 Appendix A: Quality performance measures* for measurement year 2012 Measure Description Eligible members Childhood immunization Adolescent immunization meningococcal Adolescent immunization Tdap or Td Well-child visits in the first 15 months of life Children who turned 2 during the measurement year (2012) and who were identified as having the following: four DTaP on or before the 2nd birthday; three IPV on or before the 2nd birthday; three H influenza type B (HiB) on or before the 2nd birthday; one MMR on or before the 2nd birthday; two or three rotavirus, depending on the vaccine type, on or before the 2nd birthday: - two doses of Rotarix ; OR - one dose of Rotarix and two doses of RotaTeq ; OR - three doses of RotaTeq. Also, for DTaP, IPV, or HiB, a vaccination administered from birth to age 42 days cannot be counted. Adolescents who turned 13 during the measurement year (2012) and who were identified as receiving one dose of the meningococcal vaccine on or between the member s 11th and 13th birthdays. Adolescents who turned 13 during the measurement year (2012) and who were identified as receiving one dose of Tdap (tetanus, diphtheria toxoids, and acelluar pertussis) OR Td (tetanus and diphtheria toxoids) on or between the member s 10th and 13th birthdays. Children who were 15 months old during the measurement year (2012) and who had six well-child visits during their first 15 months of life. Each well-child visit should include the following: a health and developmental history, a physical exam, and health education/anticipatory guidance. who turned 2 during the measurement year (2012) who turned 13 during the measurement year (2012) who turned 13 during the measurement year (2012) from 31 days through 15 months who were 15 months old during the measurement year (2012) Well-child visits in the third, fourth, fifth, and sixth years of life Children who were 3 through 6 as of December 31 of the measurement year (2012) and who had one well-child visit during the measurement year (2012). The well-child visit should include the following: a health and developmental history, a physical exam, and health education/anticipatory guidance. who were 3 through 6 as of December 31 of the measurement year (2012) Adolescent well-care visits Breast cancer screening Cervical cancer screening Members who were 12 through 21 as of December 31 of the measurement year (2012) and who had one well-care visit during the measurement year (2012). The well-care visit should include the following: a health and developmental history, a physical exam, and health education/anticipatory guidance. Women 42 through 69 who had a mammogram during the measurement year (2012) or the year prior to the measurement year (2011). Women 24 through 64 who received one or more Pap tests during the measurement year (2012) or the two years prior to the measurement year (2010 and 2011). who were 12 through 21 as of December 31 of the measurement year (2012) Continuously enrolled women who were 42 through 69 during the measurement year (2012) Continuously enrolled women who were 24 through 64 during the measurement year (2012) *Quality performance measures are based on the Healthcare Effectiveness Data and Information Set (HEDIS ), a well-established and tested set of standard measures, and are used as the baseline measurement for performance measure frequency of preventive health services. Note, however, that members benefits vary based on product line, group, or contract. Preventive health services benefits coverage for members for most of the performance measures may be more frequent than HEDIS measurements. Individual member benefits should be verified. Fifteen months of life is defined as the patient s first birthday plus 90 days. A visit will count as an encounter if the documentation includes the proper CPT or ICD-9 preventive care codes. 6/2012 QIPS 12

15 Measure Description Eligible members Colorectal cancer screening Cholesterol management (LDL-C) for patients with cardiovascular conditions Persistent asthma care Members 51 through 75 who had appropriate screening for colorectal cancer using any one of the following criteria: fecal occult blood test (FOBT) or fecal immunochemical test (FIT) during the measurement year (2012); OR flexible sigmoidoscopy between measurement year (2012) or four years prior; OR colonoscopy between measurement year (2012) or nine years prior. An FOBT or FIT done during a digital rectal exam in the doctor s office is not adequate for screening. Members 18 through 75 who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous coronary interventions (PCI) from January 1 to November 1 of the year prior to the measurement year (2011) or who had a diagnosis of ischemic vascular disease (IVD) in the measurement year (2012) and the year prior to the measurement year (2011) and had evidence of LDL-C screening during the measurement year (2012). Members 5 through 64 who were identified as having persistent asthma by having a record of receiving asthma medications or receiving medical services with an asthma diagnosis in the measurement year (2012) and the year prior to the measurement year (2011) and who also received one of the following classes of long-term control medications in measurement year (2012): inhaled corticosteroids cromolyn sodium nedocromil leukotriene modifiers methylxanthines who were 51 through 75 during the measurement year (2012) Members 18 through 75 as of December 31 of the measurement year (2012) who were continuously enrolled during the measurement year (2012) and the year prior to the measurement year (2011) and had an AMI, CABG, and/or PCI hospital discharge on or between January 1 and November 1 of the year prior to the measurement year (2011) or a diagnosis of IVD in the measurement year (2012) and the year prior to the measurement year (2011) who were 5 through 64 as of December 31 of the measurement year (2012) identified as having persistent asthma in the measurement year (2012) and the year prior to the measurement year (2011) 6/2012 QIPS 13

16 Measure Description Eligible members Diabetic care Use of spirometry testing in the assessment and diagnosis of COPD Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis Members who were 18 through 75 with diabetes (type 1 or type 2) and had each of the following performed: hemoglobin A1c (HbA1c) testing in the measurement year (2012); LDL-C screening in the measurement year (2012); dilated retinal eye examination in the measurement year (2012) by an ophthalmologist or optometrist or a negative retinal exam in the year prior to the measurement year (2011); medical attention for nephropathy in the measurement year (2012) documentation of any of the following will meet this criteria: - a nephropathy screening test (urine microalbumin); OR - a visit to a nephrologist; OR - a renal transplant; OR - medical attention for any of the following: o diabetic nephropathy o renal insufficiency o proteinuria o albuminuria o end-stage renal disease o chronic kidney disease o chronic renal failure o acute renal failure o dialysis, hemodialysis, or peritoneal dialysis; OR - a positive urine macroalbumin test; OR - evidence of ACE/ARB therapy. Members who were 40 and older who were identified as having either a new diagnosis of chronic obstructive pulmonary disease (COPD) or newly active COPD through claims for outpatient, emergency room (ER), or acute inpatient visits on or between July 1 of the year prior to the measurement year (2011) and June 30 of the measurement year (2012) and who received appropriate spirometry testing to confirm the diagnosis. Members who were 18 and older who had a diagnosis of rheumatoid arthritis through claims for two different face-to-face encounters in an outpatient or non-acute inpatient setting on or between January 1 and November 30 of the measurement year (2012) and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug. who were 18 through 75 as of December 31 of the measurement year (2012) identified as diabetics through pharmacy data and claims/encounter data in the measurement year (2012) or the year prior to the measurement year (2011) who were 42 and older as of December 31 of the measurement year (2012), who had either a new diagnosis of COPD or newly active COPD in an outpatient, ER, or acute inpatient visit for two years prior and six months after the earliest date of service in the time frame for an eligible visit with a diagnosis of COPD, and who had no outpatient, ER, or acute inpatient visit with a COPD diagnosis during the two years prior to the new diagnosis who were 18 and older as of December 31 of the measurement year (2012), identified as having a diagnosis of rheumatoid arthritis in two separate encounters in an outpatient or non-acute inpatient setting, who did not have a diagnosis of pregnancy in the measurement year (2012) and who did not have a diagnosis of HIV at any time prior to December 31 of the measurement year (2012) 6/2012 QIPS 14

17 Measure Description Eligible members Persistence of beta-blocker treatment after a heart attack Osteoporosis management in women who had a fracture Members who were 18 and older who were hospitalized with a diagnosis of AMI, discharged alive on or between July 1 of the year prior to the measurement year (2011) and June 30 of the measurement year (2012), and who received persistent betablocker treatment for six months after discharge. Women who were 67 and older who had a diagnosis of a fracture on or between July 1 of the year prior to the measurement year (2011) and June 30 of the measurement year (2012) and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the 6 months after the fracture. who were 18 and older as of December 31 of the measurement year (2012) who were discharged alive from an acute inpatient setting with an AMI on or between July 1 of the year prior to the measurement year (2011) and June 30 of the measurement year (2012), through 180 days after discharge. If there is more than one episode of AMI during the time frame, only the initial episode discharge date is used. Continuously enrolled women who were 67 and older as of December 31 of the measurement year (2012), who had a diagnosis of a fracture (with the exception of fingers, toes, face, and skull) 12 months before and six months after the earliest date of service in the time frame with a diagnosis of fracture, who had no prior diagnosis of fracture in the two months prior to the eligible diagnosis date, and who did not have a BMD test or did not receive any osteoporosis treatment during the 12 months prior to the eligible diagnosis date 6/2012 QIPS 15

18 Appendix B: Guidelines for combining practices The following guidelines apply when submitting a request to combine practice membership for purposes of meeting member thresholds: A request to have your office combined is a one-time election and needs to be submitted for all owned offices via to QIPS@ibx.com by March 31 of the measurement year. If for any reason you would like to cancel your election to combine offices, this is also a one-time election and must be done by March 31 of the measurement year. The offices must be under common ownership. All practices, at the time they combine, must be under the average membership threshold; combined practices will be evaluated at a line-of-business level and must meet all other requirements. Commercial. When offices are combined, they must meet the eligibility requirement of an average panel size of 250+ members for the Professional & Outpatient Cost Management measure and 150+ members for the Generic Drug Prescribing measure. In the event the membership of the combined offices does not meet the membership threshold, they will be combined with the next lowest office under common ownership by commercial membership that meets the threshold. Medicare Advantage. When offices are combined, they must meet the eligibility requirement of an average panel size of 150+ members. This applies to only the Professional & Outpatient Cost Management measure. In the event the membership of the combined offices does not meet the membership threshold, they will be combined with the next lowest office under common ownership by Medicare Advantage membership that meets the threshold. The combining of practices applies only to the Medical Cost Management incentive program: Professional & Outpatient Cost Management (both commercial and Medicare Advantage) and Generic Drug Prescribing (commercial only), evaluated at the line-of-business level. All offices under the membership threshold and under common ownership must combine, without the ability to selectively choose which offices to combine. Offices that already qualify for the Medical Cost Management incentive program (those that meet prerequisites and membership threshold requirements) are not entitled to combine. The individual offices do not have to be large enough to qualify for the QPM score program in order to be included in the combining of practices. The membership of those offices approved for combination, whose QPM score in July of the payment year is less than 30 percent, will not be eligible for Medical Cost Management incentive payments. 6/2012 QIPS 16

19 Appendix C: How changes to your practice composition affect QIPS QIPS Provider scenario Description QPM resolution Medical Cost Management Program resolution Provider number transfer When a practice remains intact but changes only Tax ID or ownership. An intact practice is one where the membership is moved to the new provider number, and the physicians remain with the new practice. Practice is entitled to keep its QPM ranking. Practice s medical cost target percentile and rank for Generic Drug Prescribing will be transferred to the new practice. Merge When two practices merge or combine during or after a measurement period, the scores for the individual practices will be merged. If a practice merges during the study period, the information from both practices is brought together. If it is after the scoring, a weighted average is taken, resulting in the monthly payments equaling the sum of the individual payments each practice was receiving. If a score was not available to one of the two practices because that practice did not meet the eligibility requirements, the merged office will be given the rank of the scored office. The information obtained during the study period or after the study period for both practices will be combined to form a new percentile for the Professional & Outpatient Cost Management measure. The prescriptions from both practices will be combined to determine rank for the Generic Drug Prescribing incentive. If a score was not available to one of the two practices because that practice did not meet the eligibility requirements, the merged office will be given the rank of the scored office. Providers leave a practice If a physician or physicians leave a practice and join another practice, even if they take significant membership to the new practice. The original practice is still intact. QPM scores remain with the intact practice. Percentile ranking and the Generic Drug Prescribing ranking will remain with the intact practice. Provider split When there is a split in a provider composition during the measurement year or after the measurement year and the following conditions occur: the original practice tax identification is not used by either component; the membership is divided between the two components. Offices that split will retain the QPM score for which their original office would have been eligible had they not split. Since the subsequent year will have no score available, offices that meet the membership eligibility threshold will retain the most recent presplit office eligible score. Offices that split will retain the Medical Cost Management score for which their original office would have been eligible had they not split. Since the subsequent year will have no score available, offices that meet the membership eligibility threshold will retain the most recent presplit office eligible score. Provider office dissolution Providers terminate out of network; provider retires and ceases practicing immediately; provider is deceased, office dissolves. If an office is terminated, it will not qualify for QIPS. If a new office is formed, it will qualify for QIPS once it meets the eligibility requirements/prerequisites. If an office is terminated, it will not qualify for QIPS. If a new office is formed, it will qualify for QIPS once it meets the eligibility requirements/prerequisites. Note: The above situations could result in a delay of payment (eligibility requirements and prerequisites still apply). Appropriate manual adjustments will need to be calculated. 6/2012 QIPS 17