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 2015 This document is a guide to the 2015 Arkansas Blue Cross and Blue Shield Patient- Centered Medical Home program (Arkansas Blue Cross PCMH). This document does not ensure 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 2c Attribution of Members 3. PRACTICE SUPPORT 3a Practice Support Eligibility 3b Care Coordination Payment Amount 4. SHARED SAVINGS 5. METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a Activities Tracked 5b Metrics Tracked 5c Accountability 5d Provider Reports 6. COMPREHENSIVE PRIMARY CARE (CPC) INITIATIVE CLINIC PARTICIPATION IN THE PCMH PROGRAM 1 DEFINITIONS AHIN (Advanced Health Information Network) Attributed members Attribution Care coordination Care coordination payment/practice Support CPC (Comprehensive Primary Care) A website used to deliver current patient information and claims clearinghouse services for Arkansas Blue Cross and Blue Shield, Health Advantage, Blue Advantage Administrators of Arkansas and a variety of other payers. The patients for whom primary care physicians and participating clinics have accountability under the Arkansas Blue Cross and Blue Shield PCMH program. The methodology by which Arkansas Blue Cross and Blue Shield and its family of companies align members for whom a participating clinic is responsible and may receive practice support incentive payments. The ongoing work of engaging members and organizing their care needs across providers and care settings. Payments made to participating clinics to support practice transformation and care coordination services. Payment amount is calculated per attributed member, per month and paid quarterly. 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. 1

3 Medical neighborhood barriers NYU Algorithm Participating Clinic Obstacles to the delivery of coordinated care that exist in areas of the health system external to PCMH. Method developed by the New York University Center for Health and Public Service Research to help classify ED utilization into four categories: 1) Non-emergent, 2) Emergent/Primary Care Treatable, 3) Emergent ED Care Needed Preventable/Avoidable, or 4) Emergent ED Care Needed Not Preventable/Avoidable. 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: General Practice, Family Medicine, internal Medicine, Pediatrics, Geriatrics) 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 Patient-Centered Medical Home (PCMH) Performance period Practice transformation Primary Care Physician (PCP) Provider portal Remediation time A team-based care delivery model led by Primary Care Physicians (PCPs) who comprehensively manage members health needs with an emphasis on health care value. The period of time over which performance is aggregated and assessed. 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 website that participating clinics use for purposes of enrollment, reporting to Arkansas Blue Cross and Blue Shield and its family of companies, and receiving information from Arkansas Blue Cross and Blue Shield and its family of companies. The Provider Portal is located on AHIN. The period during which participating clinics that fail to meet deadlines, targets or both on relevant activities and metrics tracked for practice support may continue to receive care coordination payments while improving performance. Same-day appointment A member request to be seen by a clinician within 24 hours. Shared savings program State Health Alliance for Records Exchange (SHARE) A separate program to reward cost-efficient and quality care. This program is under development. The Arkansas Health Information Exchange. For more information, go to 2

4 2 ENROLLMENT AND ATTRIBUTION 2a. Enrollment Eligibility To be eligible to enroll in the Arkansas Blue Cross and Blue Shield PCMH Program initially: A. A clinic must be a recognized PCMH by Arkansas Medicaid AND B. The clinic must include PCPs enrolled in all of the following networks; Arkansas Blue Cross and Blue Shield, Health Advantage, or True Blue. AND C. The practice must return contract amendments signed by each PCP who provides primary care to patients at the PCMH clinic location. 2b. Clinic Enrollment Enrollment in the PCMH program is voluntary. Initial enrollment will be open to clinics identified by the State of Arkansas as a PCMH. True Blue, Health Advantage and Preferred Provider Contract amendments will be sent to those clinics. Each network amendment must be signed by the person in the clinic with administrative authority. Each provider 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 withdraws; B. The clinic or provider becomes ineligible, is suspended or terminated from network participation or the PCMH program; C. Arkansas Blue Cross and Blue Shield terminates the PCMH program; or D. The clinic becomes ineligible for the State PCMH program. A participating clinic must update Provider Network Operations on changes to the list of physicians who practice at the clinic. This update must be submitted in writing within 30 days of the effective date of the change. Provider may terminate the PCMH agreement and be removed from the PCMH program by providing 30 days prior written notice of termination to Provider Network Operations P.O. Box 2181 Little Rock, AR c. Attribution of Members A participating clinic is expected to manage its caseload of attributed members. Attribution is based on claims data, following the methodology below: A. Identify Active Members B. Identify Claims for above members: i. Evaluation and Management (E & M) services (Procedure Codes: ) ii. iii. Office place of service Active Arkansas Primary Care Physicians of specialty: i. General Practice ii. Family Medicine iii. Internal Medicine iv. Pediatrics v. Geriatrics iv. Two years of Claims data v. Clinic s status is active vi. No VA or LRAFB providers 3

5 C. Attribute patients to Clinic: i. If a member received E & M care at only one PCP clinic, the member is attributed to that clinic. ii. If the member was treated at more than one clinic, we look at the plurality of care, than apply tiebreakers to determine attribution occur in this order: i. Clinic with the highest number of visits is given that member s attribution. ii. If the visit count is equal, the member is attributed to the clinic with the most recent date of service. iii. If still tied, highest allowed dollars iv. If still tied, highest paid dollars v. If still tied, the most recent process date D. Attribute patients to single Provider: i. If a member received E & M care by only one PCP within the attributed clinic, the member is attributed to that provider. ii. If more than one PCP, we look at the plurality of care, than apply tiebreakers for attributing that member to a single provider are in the same order: i. Highest number of visits ii. Most recent visit iii. Highest allowed dollars iv. Highest paid dollars v. Most recent process date E. Members are attributed to clinic/provider combinations that have been selected to participate in the Arkansas Blue Cross and Blue Shield PCMH. F. Attribution will be updated quarterly. Attributed members can be found on the PCMH Provider Portal via AHIN. 3 PRACTICE SUPPORT 3a. Practice Support Eligibility In addition to the enrollment eligibility requirements listed in Section 2a, participating clinics must meet the performance 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 quarterly. Care Coordination payments support practice transformation and care coordination services. In order to begin receiving care coordination payments for the second quarter of 2015, a clinic must submit a complete PCMH Provider Participation Agreement on or before February 15, SHARED SAVINGS 4a. Shared Savings There will be Shared Savings opportunities for all Primary Care providers under a separate program still under development. More details will be provided once the program is finalized. 4

6 5 METRICS AND ACCOUNTABILITY FOR PAYMENT INCENTIVES 5a. 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 the first day of the first calendar year in which the participating clinic is enrolled in the Arkansas Blue Cross and Blue Shield PCMH program. Activity 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 OR 2. The clinic s patient-centered assessment to determine which members on this list are highpriority. Submit this list to the PCMH Provider Portal. B. Assess operations of clinic and opportunities to improve and submit the assessment via the PCMH Provider Portal. C. Develop and record strategies to implement care coordination and practice transformation. Submit the strategies via the PCMH Provider Portal. D. Identify and reduce medical neighborhood barriers to coordinated care at the clinic level. Describe barriers and approaches to overcome local challenges for coordinated care. Submit these descriptions of barriers and approaches via the PCMH Provider Portal. E. Make available 24/7 access to care. Provide telephone 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: Deadline May 31, 2015 (If such list is not submitted by this deadline, Arkansas Blue Cross and Blue Shield and its family of companies will identify a default list of high-priority members for the clinic, based on risk scores). 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 beneficiaries; posting the 5

7 after-hours 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. Clinics must document completion of this activity by written report via the provider portal. F. Track same-day appointment requests by: 1. On a daily basis, use a tool to measure and monitor same-day appointment requests and fulfillment of requests Clinics must document compliance by written report via the provider portal. G. Establish processes that result in contact with members who have not received preventive care. Clinics must document compliance by written report submitted via the provider portal. H. Complete a short survey related to members ability to receive timely care, appointments and information from specialists, including Behavioral Health (BH) specialists. I. Invest in health care technology or tools that support practice transformation. Clinics must document health care technology investments by written report submitted via the provider portal. J. Join SHARE and be able to access inpatient discharge and transfer information. Clinics must document compliance by written report submitted via the provider portal. K. Incorporate e-prescribing into clinic workflows. Clinics must document compliance by written report via the provider portal. L. Use Electronic Health Record (EHR) for care coordination. The EHR adopted must be one that is certified by Office of the National Coordinator for Health Information Technology and is used to store care plans. Clinics are to document completion of this activity via the provider portal. M. Clinics must demonstrate the ability to extract clinical quality data from EHRs. At a minimum, this data must include: a. Collection of HbA1c levels for patients with diabetes to calculate rates of glucose control b. Collection of blood pressure readings for patients 6

8 with hypertension to enable calculation of rates of blood pressure control Clinics are to document completion of this activity via the provider portal. Arkansas Blue Cross and Blue Shield and its family of companies may add, remove, or adjust these metrics or deadlines, including additions beyond, 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 Provider manual. 5b. Metrics Tracked Arkansas Blue Cross and Blue Shield and its family of companies assesses clinics on the following metrics tracked for clinic support 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. To receive practice support, participating clinics must meet a majority of targets listed below. Metric A. Percentage of high-priority members(identified in Section 5a) whose care plan as contained in the medical record includes: Target for Calendar Year Beginning January 1, 2015 At least 80% 1. Documentation of a member s current problems; 2. Plan of care integrating contributions from health care team (including behavioral health professionals) and from the member; 3. Instructions for follow-up and 4. Assessment of progress to date. The care plan must be updated at least once a year. B. Percentage of a clinic s high priority members seen by their attributed PCP at least twice in the past C. Percentage of members who had an acute inpatient hospital stay and were seen by health care provider within 10 days of discharge D. Percentage of emergency visits categorized as nonemergent by the NYU ED algorithm At least 75% At least 40% Less than or equal to 33% 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 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. 7

9 5c. Accountability If a clinic does not meet deadlines and targets for A) activities tracked and B) metrics tracked as described in Sections 5a and 5b, then the clinic must remediate its performance to avoid suspension or termination. Clinics must submit an improvement plan within 1 month of the date that a report provides notice that the clinic failed to perform on the activities or metrics indicated above. A. With respect to activities tracked, clinics must remediate performance before the end of the first full calendar quarter after the date the clinic receives notice via the provider report that target(s) have not been met, except for activity A in Section 5a where no such remediation time will be provided. B. With respect to metrics tracked, clinics must remediate performance 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. 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 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 Arkansas Blue Cross and Blue Shield and its family of companies provide participating clinics quarterly 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 Practices in the Comprehensive Primary Care initiative may join the Arkansas Blue Cross and Blue Shield PCMH upon completion of the CPC program. 8