Gateway to Practitioner Excellence (GPE)

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Hilary Gilbert
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1 Gateway to Practitioner Excellence (GPE) 2018 Medicaid Recognizing and Rewarding Excellent Practices Improving the Health of Gateway Members

2 Practice Eligibility (see PCMH slide #15 for separate eligibility requirements) Primary Care Practices Medicaid (MA) Family Practice, Internal Medicines, Pediatrics 50 member panel size per Line of Business (LOB) (as of 12/31/2017) (PA only) No minimum panel size for NC, KY and OH Obstetrical Care Providers (OCPs) No minimum panel Dental Practices No minimum panel Paid through United Concordia Dental (UCD) 2

Details Qualifying practices = individual practices/groups with > 50 members per product as of 12/31/2017 Each practice will be eligible for quarterly widget payments Additional incentive dollars can

3 Details Qualifying practices = individual practices/groups with > 50 members per product as of 12/31/2017 Each practice will be eligible for quarterly widget payments Additional incentive dollars can be earned by increasing membership throughout year End of year payments are based on membership as of 12/31/2017 with minimum 10 members per scored measure End of year payments align with national benchmarks (NCQA Quality Compass) PCMH promotes access, availability and quality but is not required to participate in the GPE program 3

4 2018 GPE Program Components MEDICAID HEDIS GAP CLOSURE Well Child Visits 1 $10 6 visits by 15 months $ years old annual $ years old annual Reducing ER Utilization $10 Tele postdischarge nurse 1 $15 Tele postdischarge prov 1 $25 Visit post discharge 1 $15-$25 after hours visit Reducing Readmissions $40 E&M visit within 7 days or $20 E&M visit within 14 days PCMH Certification Payments (PMPM) by Level: MA $3.00 II, $4.00 III MC $4.00 II, $8.00 III 1 One incentive payment per member per year 4

5 2018 GPE Program Components MEDICAID HEDIS GAP CLOSURE Asthma 4 Medication Management Controlling High BP 2,3 $10 BP <140/90 Diabetes 2,3 $10 HbA1c < 9 PCMH Certification Payments (PMPM) by Level: MA $3.00 II, $4.00 III MC $4.00 II, $8.00 III 2 One incentive payment per member per quarter 3 Additional $5 for electronic submission 4 Quarter 5 payment only 5

6 2018 GPE Program Components MEDICAID HEDIS GAP CLOSURE Maternity Care $200 Tri 1 visit + ONAF $100 > 81% of expected prenatal visits $75 postpartum visit Dental Visits 5 $30 6 months- 5 years old new patient $ years old new patient $ years old returning patient $ years old returning patient PCMH Certification Payments (PMPM) by Level: MA $3.00 II, $4.00 III MC $4.00 II, $8.00 III 5 Returning Patient: Patient has had any previous prophylactic dental claims with the dental provider in the past (2017) calendar year or current (2018 calendar year. Age for payout level is not rounded. Example: 5.9 years old on 9/30/18 is 5 years old. Payments will be made for year old members who received the oral exam and teeth cleaning but no fluoride treatment. 6

7 Annual Well Child Visits Age 0 through 15 months of life - $10 Perform 6 comprehensive Well Child visits Submit claims for payment Bonus paid to PCP attributed to member at age 15 months Ages 3-6 years of age - $10 Perform at least 1 comprehensive Well Child visit Submit a claim for payment Bonus paid to PCP attributed to member at end of quarter for which gap was closed Ages years of age - $10 Perform at least 1 comprehensive Well Child visit Submit a claim for payment Bonus paid to PCP attributed to member at end of quarter for which gap was closed or the Obstetrician or Gynecologist who closed the gap Bonus paid for closing ONE open care gap, however Gateway Health strongly encourages practitioners to align checkups with the periodicity schedule. Modifier 25 may be used when an unrelated and significant separately identifiable evaluation and management (E/M) is furnished on the same day as a preventive service. 7

8 Emergency Room Utilization Two options for payment Any member who has an ER visit during 2018 is included. Payments are rewarded if a telephone E/M service or face-to-face visit occurs within 7 calendar days of an ER visit. (One payment per member per year; Visit must occur with attributed PCP) Option #1: Telephone Assessment & Evaluation Option #2: After-Hours Service Codes Code Description Bonus Rate Code Description Incentive Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service of procedure within the next 24 hours or soonest appointment. Telephone evaluation and management services provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment. $10 $ Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (holidays, Saturday or Sunday) Services provided in the office during regularly scheduled evening, weekend, or holiday office hours. (These are hours that are posted as regular hours but fall outside of standard business hours) $25 $15 Any face-to-face provider encounter with a physician, nurse practitioner or physician assistant within 7 calendar days of ER visit $25 8

Reducing Preventable Readmissions: Following In-Patient Stay Members who have had an acute non-behavioral health inpatient stay $40 payout will be made for any face-to-face visit with the

9 Reducing Preventable Readmissions: Following In-Patient Stay Members who have had an acute non-behavioral health inpatient stay $40 payout will be made for any face-to-face visit with the provider within 7 days of discharge * $20 payout will be made for any face-to-face visit with the provider within 14 days of discharge * * Providers can only earn one per inpatient stay. 9

Controlling High Blood Pressure Members 18-85 years of age with a diagnosis of hypertension and whose BP was < 140/90 mm Hg The $10 incentive bonus is paid for ONE new date of service in each quarter

10 Controlling High Blood Pressure Members years of age with a diagnosis of hypertension and whose BP was < 140/90 mm Hg The $10 incentive bonus is paid for ONE new date of service in each quarter of 2018 via submission of CPT II codes on the encounter claim. The maximum payout is four times per program year per member for: Systolic Values 3074F: <130 mmhg 3075F: mmhg Diastolic Values 3078F: < 80 mmhg 3079F: mmhg An additional $5 is paid if submitted electronically One incentive payment per member per quarter Q5 Bonus An additional payment of $100 will be rewarded during Q5 if at least two blood pressure readings are submitted in The last must be controlled to earn the bonus. 10

Diabetes Care: HbA1c Members 18-75 years of age who have been diagnosed with Diabetes The $10 payout to PCPs is for each controlled member in each quarter.

HbA1c levels 9% via evidence of submission of CPT II codes on the encounter claim must be received.

11 Diabetes Care: HbA1c Members years of age who have been diagnosed with Diabetes The $10 payout to PCPs is for each controlled member in each quarter. The incentive bonus is paid for ONE new date of service per quarter. HbA1c levels 9% via evidence of submission of CPT II codes on the encounter claim must be received. The maximum payout is four times per program year per member: CPT II Code HbA1c Level 3044F Value < F Value 7-9 An additional $5 is paid if submitted electronically. Q5 Bonus An additional payment of $100 will be rewarded during Q5 if at least two HbA1c s are submitted in The last must be controlled to earn the bonus. 11

12 Maternity OBSTETRICAL PROGRAM HAS THREE BONUS POSSIBILITIES First Trimester Prenatal Care Bonus = $200 (first trimester paid via claims) ONAF submission within 5 days of intake E & M code for first trimester prenatal visit (with U9 modifier & pregnancy dx codes) CPT Codes T1001-U9, HD * FQHCs must bill T1015 and the E & M code Total Prenatal Visits = $100 (paid through GPE program) >81% of expected prenatal visits during pregnancy Post Partum Visit (between days after delivery) = $75 (paid through GPE program) Bonus payments are in addition to normal contracted payment for services. Members must be seen by a provider to bill for first trimester incentive. Primary care physicians who perform OB services are eligible for bonus. 12

13 Dental Visits Dentists will receive incentives if the following episodes of care occur and claims are submitted as outlined below. Oral Care Service Codes Oral Examination Codes Dental Prophylaxis Topical Application of Fluoride (with or without varnish) D0120, D0145, and D0150 D1110 or D1120 D1206 (with varnish) D1208 (without varnish) 13

Asthma Management Members 5-64 years of age during the measurement year who were identified as having persistent asthma and dispensed appropriate medications according to the

14 Asthma Management Members 5-64 years of age during the measurement year who were identified as having persistent asthma and dispensed appropriate medications according to the HEDIS 2017 specifications at any point during 2017 and Q5 Bonus Measure A $100 payout will be awarded for >75% asthma medication adherence, as defined by HEDIS specifications. 14

PCMH PRIMARY CARE PRACTICES Must be FFS Must have 50+ members (MA + MC combined) PMPM payment based on PCMH Certification from accrediting body Level II = $3.00 (Medicaid) and $4.

15 PCMH PRIMARY CARE PRACTICES Must be FFS Must have 50+ members (MA + MC combined) PMPM payment based on PCMH Certification from accrediting body Level II = $3.00 (Medicaid) and $4.00 (Medicare) Level III = $4.00 (Medicaid) and $8.00 (Medicare) Status changes due 45 days prior to effective months No retro PMPM payments to this program 2011 and 2014 NCQA eligibility amendments are accepted Accrediting Bodies: NCQA URAC TJC AAAHC PCMH certification in itself does not provide GPE eligibility 15

16 End of Year Payment Calculations End of year payments will be determined based on residual GPE funds. This is in addition to quarterly GPE payments and practices must be at the 50 th, 75 th, and 90 th percentiles NCQA Quality Compass National Benchmarks. Only those measures from the 2018 GPE program with 10 or more qualified members will be considered for End of year payment. 16

17 Medicaid End of Year Payment Structure Overall End of Year Performance NCQA Quality Compass Percentile Base Bonus Modifier Final Bonus <50% 0 N/A 50% to <74% 0.5*$X* # Compliant Members in Measure TBD* 75% to <89% 1.75*$X* # Compliant Member is Measure TBD* 90% 2.25*$X* # Compliant Member is Measure TBD* *End of year payout is made on a per measure level in 2018 and based on residual DHS GPE funds. Providers must reach or exceed the 50th percentile as determined by the NCQA Quality Compass National Benchmark to be eligible for final bonus. Qualifying Measures: Well Child Visits (15 months, Years 3 6, and Adolescent) Providers must have 10 qualifying members in a measure to participate in the year end bonus. 17

18 Payment Schedule The following payment schedule applies to Medicaid: QUARTERLY PAYMENTS 2 nd Quarter rd Quarter th Quarter th Quarter 2018 End-of- Year Bonus for dates of service 1/1 3/31* paid through 3/31 for dates of service 1/1 6/30* paid through 6/30 for dates of service 1/1 12/31* paid through 9/30 for dates of service 1/1 12/31* paid through 12/31 Payments to go out no later than June 30, 2019 * Claims previously paid from the prior quarter will be excluded. 18

19 Practice Resources Reporting New PCP Dashboards Includes open and closed gaps Quarterly Practice Scorecards Monitor progress toward year end overall practice performance NaviNet Secure Messaging & Document Exchange Practice Reference Guide HEDIS measures and details CPT II reference guide & BMI Diagnosis Codes Provider Engagement Team Clinical Transformation Consultants Gateway P4P Ready Reference Guide (ONAF, ACT) 19

2018 Quality Rewards Program

2018 Quality Rewards Program UnitedHealthcare Community Plan of Pennsylvania Quality Rewards Program Overview We created the UnitedHealthcare Community Plan of Pennsylvania Quality Rewards Program to: