Commercial Business Medical Cost Target

Transcription

1 Commercial Business Medical Cost Target Measurement Period Handbook For Enhanced Personal Health Care Measurement Period beginning: January 1, 2019 CBMCT V35%

2 Introduction Welcome to your Commercial Business Medical Cost Target Model Measurement Period Handbook. This handbook applies to those Providers who are contracted for the Enhanced Personal Health Care Medical Cost Target Program. As explained in the Program Description, the Incentive Program gives you the opportunity to share in savings achieved by your Medical Panel during a given Measurement Period. If you meet both quality and cost performance targets, your provider organization could share in the cost savings. To determine whether or how much of a shared savings payment you are eligible for, we measure your performance against quality, utilization and cost targets. In this handbook, you ll have the chance to learn more about those targets and how you can learn more about your performance. Below are definitions of some of the most important terms used in this handbook and the details of your Incentive Program. Additional terms that are used in this handbook are defined in the EPHC Attachment and Program Description. Medical Cost Baseline Report. Prior to the start of your Measurement Period, or as soon thereafter as practicable, you will be able to access your provider organization s Medical Cost Baseline (MCB) report via our secure website. The Medical Cost Baseline report shows medical costs incurred by your Attributed Patients over the course of the Baseline Period. This information is used as a starting point to establish the baseline cost that will be utilized to create the Medical Cost Targets (MCTs) for the Incentive Program. You are eligible to earn shared savings when the Medical Cost Performance (MCP) during the Measurement Period comes in below the MCT (with consideration to the Minimum Risk Corridor (MRC)), and your measured performance on quality metrics and outcomes meets or exceeds the Program s Quality Gate. Measurement Period Start Date. The first day of the 12-month period during which we measure MCP and quality, cost and utilization performance for purposes of calculating shared savings between Anthem Blue Cross and Blue Shield (Anthem) and the Medical Panel. Your Measurement Period will begin on (xx/xx/xxxx) and continue through (xx/xx/xxxx). Quality Gate. The minimum Performance Scorecard percentage that your provider organization must deliver in order to earn any shared savings under the Incentive. Further information about the Quality Gate is reviewed in the shared savings section Upside Shared Savings Potential. The maximum percentage of savings under the Incentive Program that you may be entitled to share, as long as your provider organization meets the Quality Gate and other Non-Cost Program Targets. Your Upside Shared Savings Potential is X%. Minimum Risk Corridor. (MRC) The percentage of MCB that Anthem retains before sharing any savings with the Medical Panel. Like the Gross Paid Upside Cap, the MRC is adjusted by the Paid/Allowed Ratio. This percentage is determined by Anthem and is designed to limit savings payouts that are driven by random variation. Your MRC is X.X%. 2

3 Gross Paid Upside Cap (Upside Cap). The maximum limit on Gross Paid Savings that can be generated through the Incentive Program. The Upside Cap is a percentage that includes the MRC value which is calculated as a percentage of the MCB and is adjusted by the Paid/Allowed Ratio to determine the Upside Cap value expressed as a PMPM. The Upside Cap value expressed as a PMPM is compared to Gross Paid Savings and the lesser of these two values apply to the determination of Net Aggregate Savings. Your Upside Cap is XX%. Performance Scorecard Report. In addition to the MCB report, you will also be able to access your provider organization s Performance Scorecard via our secure provider portal at ( The Performance Scorecard shows your performance on the selected clinical, quality and utilization measures listed in this handbook. The Performance Scorecard is a tool to help you assess your quality and utilization performance on a quarterly basis. The information included in this handbook is designed to help you understand your MCB report, your Performance Scorecard and the scoring methodology. Commented [A1]: NOTE: Standard arrangements that use 1.5% MRC will use a 5.5% Upside Cap. (It is derived by the 4% standard Upside Cap + MRC of 1.5% = 5.5%.) If a provider has a different MRC, determine the Upside Cap percentage by adding 4% to the MRC. For example: Provider with a 2% MRC will have a 6% Upside Cap. Provider with a 1% MRC will have a 5% Upside Cap. * This section assumes 2nd dollar. FPCCs will include this language within the FPCC template/attachment. Downside arrangements and 1st dollar arrangements may be handled differently. Please contact B. Cannon for clarification on these instances. 3

4 Contents Introduction... 2 Section 1: Medical Cost Baseline... 5 Overview... 5 Where to Find Your MCB Report and Supporting Materials... 5 Section 2: Performance Scorecard and Your Measures... 6 Overview... 6 Performance Scorecard Report... 6 Quality Measures for Your Measurement Period... 7 Section 3: Calculating Your Shared Savings Overview Quality Performance Tiers Summary of your scoring Table 8: Example: Performance Scorecard summary INDEX Performance Scorecard Measure Specifications

5 Section 1: Medical Cost Baseline Overview As part of our Enhanced Personal Health Care Program, we track overall medical costs incurred by our members, and under the incentive portion of the Program, we reward participating providers who are able to provide appropriate care in a cost-effective manner while maintaining or improving performance against nationally recognized quality measures. You are eligible to earn shared savings if your performance during the Measurement Period creates Net Savings (i.e., costs in the Measurement Period come in lower than the target) and if you meet or exceed the Program s quality benchmarks. The better the quality score, the higher the potential shared savings payment The MCB Report shows medical costs incurred by a given Medical Panel s Attributed Patients over the course of the Baseline Period. This information is used to establish the Medical Cost Target (MCTs) for the Incentive Program. The MCB Report lists supporting Member Months, average risk scores and claims expenditures incurred by Attributed Patients over the course of the Baseline Period. The MCB Report is meant to give you a sense of the baseline cost from which you are starting. This levelset helps you hit the ground running at the beginning of the Measurement Period for the Incentive Program. This report is produced at the start of each annual Measurement Period. You will receive periodic reports that show your Medical Cost Performance (MCP) over the course of the Measurement Period. Where to Find Your MCB Report and Supporting Materials Your MCB report will be available prior to the start of your Measurement Period or as soon thereafter as practicable. To view your MCB report or to view a useful Quick Reference Guide for MCB, select the Provider Online Reporting link at Availity.com. If you are unsure where this is located or need further assistance, please send an to our dedicated Enhanced Personal Health Care mailbox (XXXXXXX@XXXXX.com). 5

6 Section 2: Performance Scorecard and Your Measures Overview The Performance Scorecard is comprised of Clinical Quality and Utilization Measures. In addition to serving as a basis for Incentive Program savings calculations, these measures are used to establish a minimum level of performance expected of you under the Program, and to encourage improvement through sharing of information. The Performance Scorecard allows you to monitor your progress in these measures throughout the year. It will identify: Historic measure rate during the Baseline Period Rolling measure rate Rolling measure numerator and denominator Benchmarks for your Measurement Period Performance Scorecard Report The Performance Scorecard, appears in our web-based provider reporting system. The report includes: Earned Percentage Contribution: The proportion of the Shared Savings Potential earned for each Performance Scorecard category and for the overall Program. Maximum Possible Shared Savings: The maximum percentage (out of 100%) of Shared Savings to which the provider is entitled under the Incentive Program. Total Shared Savings The Performance Scorecard shows the Total Shared Savings Percentage. The percent Shared Savings is calculated by multiplying the total earned percentage to the Upside Shared Savings Potential. 6

7 Quality Measures for Your Measurement Period Clinical Quality Measures The clinical quality measures for the Program are grouped into two categories: (1) Acute and Chronic Care Management and (2) Preventive Care. These categories are then further broken out into six subcomposites. These measures cover care for both the adult and pediatric populations. Nationally standardized specifications are used to construct the quality measures in conjunction with Plan data. o Acute and Chronic Care Management Measures o Medication Adherence - Medication Adherence: Cholesterol o o o Diabetes Care - Diabetes: Urine Protein Screening - Diabetes: HbA1c Testing Other Acute/Chronic/Safety - Adult - Appropriate use of Imaging for Lower Back Pain - Asthma Medication Ratio - Appropriate Treatment for Adults with Acute Bronchitis Other Acute/Chronic/Safety - Pediatric - Asthma Medication Ratio - Appropriate Testing for Children with Pharyngitis - Appropriate Treatment for Children with Upper Respiratory Infection o Preventive Measures o Pediatric Prevention - Childhood Immunization Status: MMR - Childhood Immunization Status: VZV - Well-Child Visits Ages 0-15 Months - Well-Child Visits Ages 3-6 Years Old - Chlamydia Screening o Adult Prevention - Breast Cancer Screening - Cervical Cancer Screening - Chlamydia Screening 7

8 Utilization Measures Two different utilization measures are included in the Program Performance Scorecard. The measures focus on appropriate emergency room (ER) utilization and formulary compliance rates. As with the clinical metrics, administrative data are used to construct the utilization measures. Potentially Avoidable ER Visits This measure was developed using research that determines ER visits that were potentially avoidable by identifying visits that could have been treatable in an ambulatory care setting. Visits for treatment of conditions, such as the following, are considered potentially avoidable: Conjunctivitis Otitis media Sinusitis Bronchitis Gastritis Constipation Urinary tract infection Menstrual disorders Cellulitis Dermatitis Sun burn Osteoarthrosis Joint pain Backache Cramps Insomnia Malaise and fatigue Throat pain Cough Nausea or vomiting alone Diarrhea Sprains Abrasions Contusions First degree burns Strep throat Vaccinations Routine child Prenatal Gynecological and adult exams Change of wound dressings Radiology and laboratory exams Health screenings. 8

9 Brand Formulary Compliance Rate The overall percentage of carve-in pharmacy claims for brand name drugs that are on formulary. (Exclusions detailed further below and in the Index) Quality Improvement Measures In addition to assessing performance against thresholds, a subset of the clinical measures (listed below) will be scored for improvement. The selection of these measures is a subset of the current set of performance measures. These improvement measures will be assessed at your provider organization level and will be weighted equally for each measure that has a denominator greater than or equal to 30. If the denominator for each of the improvement measures is less than 30, then we will not use a score for that category. 1. Breast Cancer Screening 2. Medication Adherence: Cholesterol 3. Diabetes: HbA1c Testing 4. Well Child Visits ages 3-6 Years Old 5. Appropriate Testing for Children with Pharyngitis Note: In some instances, pharmacy information may not be available for certain membership. Membership that is lacking pharmacy detail will be excluded from the measures that require pharmacy information. Once pharmacy information becomes available to Anthem, the data will be phased into the measures Composite Overview Scorecard points are divided into categories, or composites. Several of the composites are based upon subcomposites. Then, within some of the sub-composites there are specific care measures. Performance on the clinical measures listed above will be grouped at the sub-composite level, but scored at the individual metric level. Scoring of the individual metrics occurs at the provider organization level. If a metric has a denominator less than 30, scoring will then move to a Medical Panel-level. The metric will be scored in a proportional fashion between the provider organization and the Medical Panel. For instance, if a metric denominator for a provider organization has only twenty (20) members but the panel has more than thirty (30) members, then the scoring would reflect 66.67% based on the provider organization performance (20 members in their denominator/30 members required for metric denominator) and 33.33% based on the Medical Panel performance. If all of the clinical metrics have a denominator less than 30then scoring will occur at the Medical Panel-level. The major composites are: 1. Acute and Chronic Care Management 2. Preventive Care 3. Utilization 4. Clinical Quality Improvement 9

10 Composite Details The Acute and Chronic Care Management Composite sub-composites. Each of the sub-composites includes care measures: 1) Medication Adherence 2) Diabetes Care 3) Other Acute/Chronic/Safety Adult 4) Other Acute/Chronic/Safety - Pediatric The Preventive Care Composite sub-composites: 1) Adult Preventive 2) Pediatric Preventive The Utilization Composite sub-composites: 1) Potentially avoidable ER visits 2) Brand Formulary Compliance Rate The Clinical Quality Improvement Composite measures was outlined previously. 10

11 Section 3: Calculating Your Shared Savings Overview The opportunity to share in savings that are realized for your Attributed Members is a key characteristic of the Program. After savings are determined, the proportion of shared savings that you can earn depends on your organization s performance on a scorecard. Your Performance Scorecard serves two functions: (1) it will let you know if you met the Quality Gate, and (2) it will show you the overall percentage of the shared savings you earn. Below, we review the four major steps to determine your shared savings: 1. Savings Pool Funded 2. Quality Gate Passed 3. Earned Contribution Calculated for each Composite 4. Overall Shared Savings Potential Calculated Savings Pool Funded Was the savings pool funded? In order to participate in shared savings, the Savings Pool must be funded. For that to happen, your Medical Panel s Attributed Member population must demonstrate savings over the course of your Measurement Period. As described more fully in the Program Description, Anthem will calculate the Savings Pool by comparing the Medical Cost Performance (MCP) for your Attributed Member population for a specified 12-month Measurement Period to the established Medical Cost Target (MCT). In the event that the MCP is less than the MCT, the Savings Pool is funded. After the pool is funded, the Minimum Risk Corridor (MRC) is calculated by multiplying the MCB by the relevant MRC percentage, and then multiplying the result with the Paid/Allowed Ratio (as outlined further in the Program Description). Ultimately, the Savings Pool is multiplied by your Shared Savings Percentage earned to calculate your shared savings payout. Quality Gate Did you pass the Quality Gate? Your provider organization must meet a minimum threshold of performance on clinical quality measures in order for you to share a portion of the savings pool. That threshold, referred to as the Quality Gate, is based on an overall clinical quality score, which is computed by aggregating your scores across the scorecard s clinical sub-composites. The Quality Gate is set at 40 points out of a total 100 possible points, so Providers with a score under forty (40) points will have no Upside Shared Savings Potential. The final, overall score is compared to the Shared Savings Potential to determine the earned Shared Savings Percentage. Earned Contribution Calculated For Each Composite Weighting Composites The composite, sub-composites, and care measures do not contribute equally to the Performance Scorecard s results they are weighted more heavily toward Clinical Measures: The clinical composites (Acute and Chronic Care Management, Preventive Care and Improvement) are weighted to account for 72% of the Performance Scorecard. The weighting for recognition is explained further in a separate section below. The Acute and Chronic Care composite is weighted more heavily than preventive care. Utilization measures account for 28% of the Performance Scorecard points. The mix of adult and pediatric members in the group will vary the weight of the sub-composite categories as described below. 11

12 Determination of measure weights Measure weights are determined on a provider group specific basis to account for different age mix of Attributed Members between provider groups. To determine metric weights in the Performance Scorecard the provider group s ratio of adult to pediatric membership is calculated from the member month information supplied as part of the potentially avoidable emergency visits metric. If the ratio is greater than 70% for either the pediatric or adult membership, then the fixed subcomposite weightings are adjusted to proportionally weight the metrics specific to the membership with the most significant ratio. Examples are below. 12

13 Table 1: Composite Weights Fixed Weight Example Category Allocation of Shared Savings Potential Clinical: Acute and Chronic Care Management Acute and Chronic Care Management Composite 39.86% Medication Adherence 5.13% Diabetes Care 9.14% Other Acute and Chronic Care and Patient Safety Management - Adult 13.14% Other Acute and Chronic Care and Patient Safety Management Pediatric 12.45% Clinical: Preventive Preventive Composite 20.14% Pediatric 6.64% Adult 13.50% Clinical: Improvement 12.0% Utilization 28.0% TOTAL 100% 13

14 Table 2: Shared Savings Potential per Composite in Absolute Terms with 100%/0% adult/pediatric member mix Category Percentage of Shared Savings Clinical: Acute and Chronic Care Management Medication Adherence 2.61% Diabetes Care 4.65% Other Acute/Chronic/Safety Adult 6.69% Other Acute/Chronic/Safety Pediatric 0.00% Clinical: Preventive Pediatric 0.00% Adult 7.05% Clinical: Improvement 4.20% Utilization 9.80% TOTAL 35% 14

15 Table 3: Shared Savings Potential per Composite in Absolute Terms with 0%/100% adult/pediatric member mix Category Percentage of Shared Savings Clinical: Acute and Chronic Care Management Medication Adherence 0.00% Diabetes Care 0.00% Other Acute/Chronic/Safety Adult 0.00% Other Acute/Chronic/Safety Pediatric 13.95% Clinical: Preventive Pediatric 7.05% Adult 0.00% Clinical: Improvement 4.20% Utilization 9.80% Total 35% 15

16 Table 4: Shared Savings Potential per Composite in Absolute Terms: Fixed for groups with between 70/30 and 30/70 mix Category Percentage of Shared Savings Clinical: Acute and Chronic Care Management Medication Adherence 1.80% Diabetes Care 3.20% Other Acute/Chronic/Safety Adult 4.58% Other Acute/Chronic/Safety Pediatric 4.37% Clinical: Preventive Pediatric 2.33% Adult 4.72% Clinical: Improvement 4.20% Utilization 9.80% TOTAL 35% 16

17 Quality Performance Tiers Providers achieve a given quality score based on how they score on a range of quality measures included in their quality Performance Scorecard. The quality Performance Scorecard is based on quality measures covering areas such as preventive care and coordination of care. Compliance rates for the Provider s Member Population are displayed, along with targets and associated points. The relationship between the Provider s earned points relative to total possible points will determine the percentage of incentive earned. This value, expressed as a percent, is known as the quality score. The Performance Scorecard is comprised of the composites below: Acute and Chronic Care Preventive Care Improvement Utilization The total points earned is based on a maximum of 100 points (not 100%). Points are calculated for each individual measure. Each provider group s compliance rate is calculated for the measure and compared to the benchmarks to determine the percentage of the maximum points for the measure. Acute and Chronic Care The Acute and Chronic Care Management Composite has four Sub-composites: Medication Adherence Other Acute/Chronic/Safety Adult Other Acute/Chronic/Safety - Pediatric Diabetes Care The Acute and Chronic Care Management sub-composites each have related Performance Measures. Performance Measures can vary by Measurement Period. Rates are calculated for each of the Acute and Chronic Care Management Measures where the denominator size is 30 or more for both the Measurement Period and the Baseline Period. Weights for measures with a denominator less than 30 are reallocated to the remaining Acute and Chronic Care Management Measures. 17

18 Preventive Care The Preventive Care Composite has two sub-composites: Adult Preventive Pediatric Preventive These sub-composites each have related Performance Measures. Performance Measures can vary by Measurement Period. Rates are calculated for each of the Preventive Measures where the denominator size is 30 or more for both the Measurement Period and the Baseline Period. Weights for measures with a denominator less than 30 are reallocated to the remaining Preventive Measures. Compare performance to market thresholds Market thresholds are established for each of the measures at the minimum (20 th ) and maximum (80 th ) percentiles for the year prior to the Program Measurement Period. Performance thresholds will be provided soon after the start of the Measurement Period The thresholds are set jointly for all lines of business included in the Program using performance of all providers within the market. Note: Any measure with group performance greater than 95% will receive full credit. Assign percentage of the category earned The levels of market thresholds are used to categorize performance. After passing the minimum market threshold (performance at the 20th percentile guarantees 30% of maximum points for that metric), the higher the performance the greater proportion of earned shared savings. The calculation begins by taking the group rate minus the minimum market threshold and then dividing that by the range of the maximum market threshold minus the minimum market threshold. For example: Step 1. Determines where the Group s performance falls within the range. Maximum points for the metric=12% Group rate = 62% Minimum market threshold = 52% Maximum market threshold = 72% (Group rate-minimum market threshold)/ (Maximum market threshold Minimum market threshold) or (62-52)/ (72-52) = 50% Step 2. Determines the amount of additional earned contribution the group achieves over and above the earned contribution from the minimum market threshold. (Step 1 result) X (70% X maximum points for the metric) (50%) X (70% X 12.0%) = 4.2% Step 3. Adds the earned contribution from the minimum market threshold to the additional earned contribution calculated in Step 2. The result is the total earned contribution achieved. (30% X maximum points for the metric) is added to Step 2. (30% X 12.0%) % = 7.8% 18

19 Calculate shared savings earned After the percentage of the category earned is determined, that value is multiplied by the group s Upside Shared Savings Potential. This yields the earned shared savings. Table 5: How the Benchmark Relates to Earning Potential Relation to Benchmark Earning Potential Below Minimum 0% Between Minimum and Maximum Greater of actual score achieved or 30% At or Above Maximum 100% 19

20 Composite 3: Utilization Measures Calculated We use five steps to determine the proportion of shared savings earned for each utilization sub-composite. Table 6 uses sample data to show hypothetical calculations. Table 6: The Five Steps Used to Score Potentially Avoidable Emergency Room Visits Step 1 Step 2 Step 3 Step 4 Step 5 Step 1. Calculate utilization rates for the Medical Panel for distinct line of business and age categories. Potentially Avoidable ER measure: - To control for variation in patient mix and associated variable utilization between Medical Panels, utilization rates are calculated separately for: Commercial members at least 18 years of age Commercial members less than 18 years of age - The numerator is the count of qualifying events during the Measurement Period. - The denominator is the sum of Member Months for members attributed to the Medical Panel during the Measurement Period. - The actual raw rate is computed as (numerator/denominator)*12,000. Brand Formulary Compliance Rate - To control for variation in patient mix and associated variable utilization between Medical Panels, utilization rates are calculated separately for: Commercial members at least 18 years of age Commercial members less than 18 years of age - The denominator = a count of all brand prescriptions for the Medical Panel s Attributed Patients population. - The numerator = count of formulary brand prescriptions during Measurement Period. - The rate is computed as (numerator/denominator) percentage for each line of business/age group. The metric measures the Brand Formulary Compliance Rate exclusion criteria noted in the Index. 20

21 Note: The list of excluded drugs is available upon request and will be updated quarterly to incorporate new products that meet exclusion criteria. Step 2. Compare performance to market thresholds. Market thresholds are established for each of the utilization measures for three distinct line of business/age groups (commercial adult, commercial <18). The levels of market thresholds are used to categorize performance. After passing the minimum market threshold, the higher the performance the greater proportion of earned shared savings. For Brand Formulary Compliance Rate Only: Informational only baseline benchmarks will be provided at the beginning of the Measurement Period. Throughout the Measurement Period, your performance will be compared to the claims experience of the market, which represents the actual claims for all Providers within your defined market. At the close of your Measurement Period, we will compare your compliance rate during your Measurement Period to the defined market compliance rate which will be used to compute the earned percentage of shared savings. The compliance rates calculated at the end of the Measurement Period will be inclusive of pertinent formulary changes that may have occurred during the period. Step 3 Determine Shared Savings Potential for each line of business/age group. Shared Savings Potential for the utilization measures: - Potentially avoidable emergency room visits = 5.6% - Brand Formulary Compliance Rate = 4.2% Since these measures are assessed by line of business/age groups, the Shared Savings Potential opportunity for each of these groups must be determined. Step 4. Assign the earned contribution percentage The levels of market thresholds are used to categorize performance. After passing the minimum market threshold (performance at the 20th percentile guarantees 30% of maximum points for that metric), the higher the performance the greater proportion of earned shared savings. The calculation begins by taking the group rate minus the minimum market threshold and then dividing that by the range of the maximum market threshold minus the minimum market threshold. For example: Step A. Determines where the Group s performance falls within the range. Maximum points for the metric=12% Group rate = 62% Minimum market threshold = 52% Maximum market threshold = 72% (Group rate-minimum market threshold)/ (Maximum market threshold Minimum market threshold) or (62-52)/ (72-52) = 50% Step B. Determines the amount of additional earned contribution the group achieves over and above the earned contribution from the minimum market threshold. 21

22 (Step 1 result) X (70% X maximum points for the metric) (50%) X (70% X 12.0%) = 4.2% Step C. Adds the earned contribution from the minimum market threshold to the additional earned contribution calculated in Step B. The result is the total earned contribution achieved. (30% X maximum points for the metric) is added to Step 2. (30% X 12.0%) % = 7.8% Step 5. Calculate earned shared savings for each utilization measure and the overall category. The earned shared savings for each measure/group combination is calculated by multiplying the percentage of the category earned for each line of business/age group for each of the utilization measures by the Medical Panel s Maximum Upside Shared Savings Potential. These scores are summed to determine the overall percentage of shared savings for each of the Utilization Metrics, and then summed for an overall utilization shared savings earned. 22

23 Overall Scoring Summary for Utilization Components Table 7 demonstrates how Steps 3, 4 and 5, described above, are used to calculate the overall score for the utilization subcomponents. 3. Determine Upside Shared Savings Potential for each line of business/age group. 4. Assign the earned contribution percentage. 5. Calculate earned shared savings for each utilization measure and the overall category. Table 7: As seen below. Shared Savings Sub composites Measurement Level Earned Contribution Upside Shared Savings Potential Shared Savings % Potentially Avoidable ER Visits Panel 26.86% 5.60% 1.50% Brand Formulary Compliance Rate Panel 44.49% 4.20% 1.87% Utilization Composite Totals 9.80% 3.37% Composite 4: Clinical Quality Improvement Components Calculated There are five clinical improvement measures selected from the clinical quality measures as follows: 1. Breast cancer screening 2. Medication adherence: statins 3. Diabetes: HbA1c Testing 4. Well child visits for ages 3-6 Years old 5. Appropriate testing for children with pharyngitis Scoring of this Performance Scorecard component is performed only at the individual provider organization level. Performance is measured as follows: Rates are calculated for each of the five clinical improvement measures where the denominator size is 30 or more for the Baseline Period and Measurement Periods Weights for measures with a denominator less than 30 are reallocated to the remaining improvement measures. A target rate is set for each of the improvement measures. This target represents an improvement of 20% in closing the quality gap. (1-Group Baseline Rate)*.20)+group baseline rate If the target is achieved, you will receive full credit for that measure. Additionally, if the current rate is 90% or higher, full credit is received. Scoring for improvement measures will always take place at the group level. Each of the five improvement measures will be weighted equally at 20%. 23

24 If the denominator is less than 30 for any measure, that measure will not be scored but the weighting will be redistributed to the remaining measures with sufficient denominator size. If none of the five measures have a denominator of 30 or more, no points will be awarded or reallocated for the improvement component. Note: The Baseline Period for determining both the improvement and quality metrics benchmarks is the 12-month period of incurred service dates which precedes both a three-month paid claims run out period and a period of time needed to calculate and report benchmarks. The period needed for calculation and reporting of the benchmarks for improvement metrics is approximately one month while the quality metrics take three months. As a result, the improvement metrics are based on data which is two months more current than the data used to set the quality metrics benchmarks. Overall Shared Savings Potential Calculated Summary of your scoring The tables below pull together all of the scoring that is described in this Measurement Period Handbook. The performance of your Medical Panel is used to calculate a score (0-100%) for each Performance Scorecard component. Your shared savings for each Performance Scorecard component is calculated by multiplying the Upside Shared Savings Potential by the category score. The sum of your earned shared savings for each scoring components yields your overall earned shared savings examples of this calculation are shown in Table 8 below. The tables below, which you will receive with your Performance Scorecard posted to Availity, will show whether you passed the Quality Gate and the overall percentage of shared savings that you have earned for the Measurement Period. 24

25 Table 8: Example: Performance Scorecard summary Assume 50%/50% adult/pediatric mix, 35% shared savings target. In the example below the provider organization would earn 24.92% of a Shared Savings Pool. Category Savings Potential Measure % Earned Savings Earned Passed Quality Gate > YES (1) Clinical: Acute and Chronic Care Mgmt % 0.00% 0.00% Medication Adherence 1.80% 0.00% 0.00% Cholesterol 1.80% 78% 1.40% Diabetes Care 3.20% 0.00% 0.00% A1C 1.60% 100% 1.60% Proteinuria 1.60% 80% 1.28% Other Acute and Chronic Care and Patient Safety Management Adult 4.60% 0.00% 0.00% Use of AB in Adult Bronchitis 1.53% 25% 0.38% Imaging for Low Back Pain 1.53% 60% 0.92% Asthma Medication Ratio(adult) 1.53% 75% 1.15% Other Acute and Chronic Care and Patient Safety Management - Pediatric 4.37% 0.00% 0.00% Appropriate Treatment for Children with URI 1.46% 80% 1.17% Asthma Medication Ratio (Pediatric) 1.46% 65% 0.95% Appropriate Testing for Children with Pharyngitis 1.46% 80% 1.17% (2) Clinical: Preventive 7.05% 0.00% 0.00% Pediatric Preventive 2.34% 0.00% 0.00% Well Child Visits Age % 65% 0.31% MMR 0.47% 100% 0.47% VZV 0.47% 100% 0.47% Well Child Visits Ages 0-15 months 0.47% 80% 0.38% Chlamydia Screening (Pediatric) 0.47% 50% 0.24% Adult Preventive 4.71% 0.00% 0.00% Breast Cancer Screening 1.57% 74% 1.16% Cervical Cancer Screening 1.57% 77% 1.21% Chlamydia Screening (Adult) 1.57% 55% 0.86% (3) Clinical: Improvement 4.20% 75% 3.15% 25

26 (4) Utilization 9.80% 0.00% 0.00% Potentially Avoidable ER Visits Subcomposite 5.60% 61% 3.42% Brand Formulary Compliance Subcomposite 4.20% 77% 3.23% OVERALL SAVINGS POTENTIAL 35% EARNED SHARED SAVINGS 24.92% 26

27 INDEX Performance Scorecard Measure Specifications *Note: The term patient(s), as used throughout the Index, shall mean and refer only to Attributed Member(s). Acute and Chronic Care Management Measures Sub-composite: Medication Adherence Measure Description / Technical Specifications Measure Citation Medication Adherence: Cholesterol This rule identifies patients 19 years and older as of the end of the measurement year who met the Proportion of Days Covered (PDC) threshold of 80 percent for statins during the measurement year. Patients in the denominator with at least 80% days covered for a statin since the first prescription of the statin in the measurement year. Patients age 19 or older at the end of the measurement year who have at least 2 prescriptions for a statin during the measurement year. Medication possession ratio of at least 80% for the statin from the first fill to the end of the measurement year. At least 19 years old at the end of the measurement year AND at least 2 prescription claims for statins dispensed in the 365 days before the end of the measurement year AND the first fill days before the end of the measurement year AND member eligibility from the first fill to the end of the measurement year, with no more than 1 gap of no more than 30 days Proxy for Rx elig for 3rd party member Current member eligibility Pharmacy Quality Alliance, 27

28 Sub-composite: Diabetes Care Measure Description / Technical Specifications Measure Citation Diabetes: Urine Protein Screening This measure identifies diabetic patients with a nephropathy screening test or evidence of nephropathy during the measurement year. Patients in the denominator with claims for urine protein tests, nephropathy treatment, ESRD, stage 4 CKD, kidney transplant, ACE inhibitors, ARBs, or an outpatient visit with a nephrologist. Patients between the ages of 18 and 75 years old who have diabetes. Any one of the following during the measurement year: At least 1 procedure in any position for urine protein tests OR at least 1 lab LOINC claim for urine protein tests OR at least 1 procedure or diagnosis in any position for treatment for nephropathy OR at least 1 procedure or diagnosis in any position for ESRD OR at least 1 diagnosis in any position for CKD stage 4 OR at least 1 procedure or diagnosis in any position for kidney transplant OR at least 1 prescription claim for ACE inhibitors or ARBs OR at least 1 outpatient visit defined by outpatient with a nephrologist specialist National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, Age years old AND service eligibility during the measurement year with no more than 1 gap of no more than 45 days AND member eligibility with no gaps on analysis date AND identified by the following criteria: o Any one of the following At least 2 claims at least one day apart with a diagnosis of diabetes in any position from an outpatient, observation, acute inpatient ED, or nonacute inpatient setting in the 2 years before the analysis date At least 1 prescription claim for insulin or oral hypoglycemic medication dispensed in the 2 years before the analysis date o Exclude patients with claims for diabetes exclusions Deviation from HEDIS specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. 28

29 Measures Description / Technical Specifications Measure Citation Diabetes: HbA1c Testing This measure identifies patients with diabetes who have had a HbA1c test over the past year. Patients in the denominator who had an HbA1c test during the measurement year. Patients between the ages of 18 and 75 who have diabetes. Either one of the following: At least 1 procedure claim for an HbA1c test during the measurement year OR at least 1 lab result for a HbA1c test during the measurement year. Age between 18 and 75 years as of analysis date Patients identified by the following criteria: o Any one of the following - At least 2 claims at least one day apart with a diagnosis of diabetes in any position from an outpatient, observation, acute inpatient ED, or nonacute inpatient setting in the 2 years before the analysis date - At least 1 prescription claim for insulin or oral hypoglycemic medication dispensed in the 2 years before the analysis date o Exclude patients with claims for diabetes exclusions. o Deviation from HEDIS specifications: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. Continuous member eligibility during the measurement year with maximum 1 gap of no more than 45 days. Member eligibility with no gaps on analysis date. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

30 Sub-composite: Other Acute/Chronic/Safety (Adult and Pediatric) Measure Description / Technical Specifications Measure Citation Appropriate Testing for Children with Pharyngitis This measure identifies children 3 18 years of age who were diagnosed with pharyngitis prior to or during the measurement year, dispensed an antibiotic, and had a test for group A streptococcus for the episode. A higher rate represents better performance (i.e., appropriate testing). Patients in the denominator who had a test for group A streptococcus (strep) for the episode of pharyngitis. Children age 3 to 18 who were diagnosed with pharyngitis and dispensed an antibiotic within 6 months prior to the measurement year or during the first 6 months of the measurement year. At least 1 claim for a group A strep test within 3 days before or after the pharyngitis onset date Age between 3 years and 18 years during the intake period AND at least 1 claim continuing only diagnosis for pharyngitis in any position between 184 and 548 days before the end on the Measurement Year o Exclude ED visit and Observation encounters followed within 2 days by an inpatient visit (to exclude ER visits that may have resulted in an inpatient admission). AND have active prescription for an antibiotic from 0 to 3 days after pharyngitis onset date AND no prescription for antibiotic medications dispensed from in the 30 days before the pharyngitis onset date No prescription claims for antibiotic medications occurring 30 days before the onset date that were active on the onset date AND medicaleligibility in the month before and 3 days after pharyngitis onset date, with no gaps Note: This rule uses medical eligibility as a proxy for prescription eligibility. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

31 Measures Description / Technical Specifications Measure Citation Appropriate Treatment for Children with Upper Respiratory Infection This measure identifies children age 3 months to 18 years who were diagnosed with an upper respiratory infection (URI) who did not receive an antibiotic prescription within 3 days after diagnosis. Patients in the denominator who did not receive an antibiotic prescription within 3 days after the diagnosis. Children age 3 months old as of 18 months prior to the end of the measurement year to 18 years old 6 months prior to the end of the measurement year who were diagnosed with URI between 545 and 180 days prior to the end of the measurement year. No prescription claims for antibiotic medications in the 3 days after the URI diagnosis. Age between 1 year 9 months and 18 years 6 months At least1 claim for upper respiratory infection, solitary diagnosis, 184 and548 days before the analysis date from an outpatient, observation, or ED setting o Exclude claims that are followed by an acute inpatient stay within 2 days to exclude ER admissions or observation that resulted in an inpatient admission No prescription claims for antibiotic medications dispensed in the 30 days after the URI diagnosis No prescription claims for antibiotic medications with an active days supply on the date of URI diagnosis (done by checking for medication possession ratio of at least 80% on diagnosis date) No claim for pharyngitis or competing diagnosis in the 3 days after the URI diagnosis Member eligibility in the 30 days before and 3 days after URI diagnosis, with no gaps Prescription eligibility in the 30 days before and 3 days after URI diagnosis, with no gaps National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

32 Measure Description / Technical Specification Measure Citation Asthma Medication Ratio The measure identifies patients 5 64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year. Patients in the denominator with a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement period. Patients age 5-64 who were identified as having persistent asthma and who have claims for asthma medications. Ratio of controller medications (oral, injectible, or inhaled) to total asthma medications of 0.50 or greater during the measurement year. Age 5-64 years as of the end of the measurement year AND meet the following criteria: o Meets the following criteria Claims for a diagnosis of asthma during the measurement year from an inpatient setting or from an ED setting OR at least 4 claims for a diagnosis of asthma during the measurement year from an Outpatient setting or Observation AND at least 2 prescription claims for leukotrine antagonists, asthma inhalers, or oral or injectable asthma meds OR at least 4 four claims for any combination of leukotrine antagonists, asthma inhalers, or oral or injectable asthma meds during the measurement year AND, if all 4 claims were for leukotriene antagonists or injectable asthma meds, a claim for an asthma diagnosis o AND meets the following criteria: Claims for a diagnosis of asthma in the year before the measurement year from an inpatient setting or from an ED setting OR at least 4 claims for a diagnosis of asthma in the year before the measurement year from an Outpatient setting or Observation AND at least 2 prescription claims for leukotrine antagonists, asthma inhalers, or oral or injectable asthma meds OR at least 4 four claims for any combination of leukotrine antagonists, asthma inhalers, or oral or injectable asthma meds in the year before the measurement year AND, if all 4 claims were for leukotriene antagonists or injectable asthma meds, a claim for an asthma diagnosis AND medical eligibility in the measurement year and the year before the measurement year, with no more than 1 gap of no more than 45 days during each year of the 2-year year AND pharmcy eligibility in the measurement year with no more than 1 gap of no more than 45 days AND medical and pharmacy eligibilty with no gaps on the last day of the measurement year Exclude members with emphysema, COPD, chronic respiratory conditions due to fumes/vapors, acute respirtatory failure, cystic fibrosis, or obstructive chronic bronchitis. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

33 Exclude members with no claims for asthma medications during the measurement year 33

34 Measure Description / Technical Specification Measure Citation Use of Imaging for Lower Back Pain This measure identifies patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, or CT scan) within 28 days of the diagnosis. Patients in the denominator who have no claims for imaging studies within 28 days of the low back pain diagnosis. Patients age with a claim for low back pain, excluding those with malignant neoplasm, drug abuse, neurologic impairment, or trauma. No claims having a procedure from imaging studies with a diagnosis for low back pain within 28 days of diagnosis. Age years AND medical eligibility in the 6 months before the diagnosis of low back pain, with no gaps. AND at least 1 claim for low back pain in the first position during the measurement year in an ED, outpatient, observation, physical therapy, telehealth, online assessment, or osteopathic manipulative treatment setting. Save date as LBP D. Exclude ED visits that result in an inpatient or acute inpatient admission. AND no claims for Low Back Pain in the 6 months before LBP D AND no claims for malignant neoplasms or other neoplasms or history of malignant neoplasm at any time in the past AND no claims for IV drug abuse or neurologic impairment or trauma from in the year before LBP D. AND no 90 consecutive day supply for corticosteroids on LBP D or in the 365 days before LBP D National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

35 Measure Description / Technical Specifications Measure Citation Appropriate Treatment for Adult Bronchitis The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Patients in the denominator who were not dispensed an antibiotic prescription in the 3 days after diagnosis. Patients age of as of the analysis date with 1 claim of acute bronchitis No prescription claim for antibiotic medications in the 3 days after the bronchitis diagnosis. Age as of the analysis date years At least 1 claim with a diagnosis of acute bronchitis with concurrent outpatient or observation during the measurement year OR at least 1 claim with a diagnosis of acute bronchitis with concurrent ED during the measurement year Exclude ED and observation visit type encounters followed within 2 days by a claim for acute inpatient admission (to exclude ER visits that may have resulted in an inpatient admission) AND have member and prescription eligibility from 365 days before through 7 days after diagnosis, with no more than 1 gap of no more than 45 days AND have member and prescription eligibility on date of diagnosis. Exclusions at Episode Level Prescription claims for antibiotic medications in the month before diagnosis OR claims with a diagnosis for HIV, malignant neoplasms, emphysema, COPD, cystic fibrosis, HIV- type 2, disorders of the immune system or comorbid conditions in any position in the year before diagnosis OR claims with a diagnosis for competing diagnosis or pharyngitis from 30 days before to 7 days after diagnosis National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,

36 Preventive Measures Sub-composite: Pediatric Prevention Measure Description / Technical Specifications Measure Citation Childhood Immunization Status: MMR (Continued next page) The percentage of children 2 years of age during the measurement year who had one measles, mumps and rubella (MMR) by their second birthday. Patients in the denominator who have had at least one MMR vaccination on or before the child s second birthday. Enrolled children who turn 2 years of age during the measurement year, excluding children with history of anaphylactic reaction to immunizations, malignant neoplasm of lymphatic tissue, HIV or other disorders of the immune system. One of the following within 730 days of birth: At least 1 claim for measles, mumps, or rubella OR at least 1 claim for MMR vaccine administered in any procedure position OR at least 1 claim for each of o Measles vaccine administered in any position OR a measles diagnosis o Mumps vaccine administered in any position OR a mumps diagnosis o Rubella vaccine administered in any position OR a rubella diagnosis OR at least 1 claim for each of o Measles/rubella vaccine administered in any procedure position o AND mumps vaccine administered in any procedure position OR a mumps diagnosis Turned 2 years old during the measurement year AND have medical eligibility between the ages of 1 and 2 (i.e., days after birth), with no more than 1 gap of no more than 45 days AND have medical eligibility with no gaps on (730 days after birth) National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2,