Medicare Advantage Freestanding Patient Centered Care (FPCC) Program

Transcription

1 2015 Anthem Blue Cross and Blue Shield Provider Expo Medicare Advantage Freestanding Patient Centered Care (FPCC) Program Kathy Morris, Provider Network Manager II Anthem Medicare Advantage This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

2 Payment redesign Physicians will be incentivized to provide quality and cost effective care through aligned reimbursement. Per Member Per Month (PMPM) Clinical Coordination Payments*: Targeted PMPM payments pay practices fixed fees for important clinical interventions that occur outside of a patient visit. These payments provide physicians with a predictable cash flow that lets them invest to improve their practice. Shared Savings: The Freestanding Patient Centered Care Program introduces a shared savings incentive program that allows you to earn a portion of the savings that accrue when you provide patient centered care as long as you meet the programs quality measures. The shared savings payments reward providers for improving the health of your patients and provide compensation for non-visit based clinical interventions, such as care planning, completing the Health Risk Assessments annually, and closing gaps on members diagnosis, that have a positive impact on patient outcomes and cost. * Some exceptions apply Payment redesign 2 2

3 Payment redesign Physicians will be incentivized to provide quality and cost effective care through aligned reimbursement. Important building blocks of the incentive program are: Attribution Medical Panels Quality Metrics Performance Payment redesign 3 3

4 Attribution What is it and how does it work? Attribution is the foundation for many aspects of the program. It is the method for identifying your patient population. Two processes are used for attribution depending on the product type Open Access Products (PPO) Attribution is based on historical claims data incurred in a 24-month period Products requiring PCP selection Attribution is based on covered individuals selection during a 12-month period 4 4

5 General parameters for Medical Panels FPCC and Physician groups with >1,500 attributed members on its own Standard Program - Market Medical Panel formed with 1,500 patients Quality, Member Premiums, and Measurement Period Medical Loss Ratio (MPMLR) are all calculated at the Provider Groups level Quality Performance and Member Premium will be evaluated at the physician group level* MPMLR will be calculated at the Medical Panel level to determine the sharedsavings percentage *If the denominator for any sub-composite does not meet the minimum number of 20, that subcomposite will be measured at the panel level. Otherwise, quality will be measured at the practice level. 5 5

6 Quality Measures for Performance assessments Stars measures are used for the quality portion of the scorecard. The measures are categorized as two different types: Standard Measures are measures that use data that is readily available, widely used by all Providers, and provide a conclusive answer. These measures results are derived solely on an evaluation of claims. Enhanced Measures are measures that require documentation submitted on the claim in addition to standard CPT codes, and documented in the medical record. The additional information used to evaluate the measure, can be attained by submitting CPTII or V codes on the members claim that correspond with the members medical record. The enhanced measures serve as a bonus opportunity to increase your overall shared savings potential, and will not reduce your shared savings potential if not achieved. The use of CPT II codes are further explained in the Measurement Period Handbook. 6 6

7 Linking Performance on Quality Metrics to Shared-Savings The Quality Measures serve two functions: Quality gate Standard Program - Providers must meet a minimum performance threshold on clinical quality measures of a weighted average 4 star rating before they are eligible to earn shared savings. FPCC Provider must meet the minimum performance threshold on clinical quality measures of 4 stars on each individual measure to qualify for shared savings percentages for that measure. Overall determinant of proportion of shared savings earned by the physician After the quality gate is satisfied, the proportion of shared savings the physician receives depends their overall percentage they earn on the scorecard. 7 7

8 Incentive Program The Incentive Program offers financial rewards for Providers who have successfully increased their accountability for the cost, quality and efficiency of the care they provide to their defined patient population. The Incentive Program is based on a Percent of Premium. The Percent of the Premium is based on two pieces: Target Medical Loss Ratio (MLR) Measurement Period MLR 8 8

9 Incentive Program The practice will qualify for the incentive program The amount that can be earned is determined by: When performance on quality measures meets or exceeds standards The level of quality of care achieved When savings are achieved for the medical costs for the defined member population The total amount of savings calculated during the measurement period 9 9

10 Exchange of information We will provide actionable analytic reports on Provider Care Management Solutions (PCMS) such as: Avoidable ER use Gaps in care Attributed high-risk/high-cost members Specialty referral management We provide interpretive guidance Provides you with the data to improve the health status of their patients and reduce costs associated with avoidable ER, readmissions, etc. Exchange of meaningful use of information 10 10

11 Program Summary Medicare Advantage FPCC and Standard The Provider will receive a PMPM (optional) as a clinical coordination fee for each Medicare Advantage member. It is based on a flat rate multiplied by the Hierarchical Condition Category (HCC) score. The percentage of shared savings that a provider can participate in is determined by how well they perform in quality which is based on Stars Measures. They must meet the quality gate of an overall weighted four star rating for the Standard Measures in the FPCC/Standard Program. For the FPCC the Quality Gate is at each measure and is set at 4 Stars. The Program scorecard is comprised of clinical quality measures as identified by the Centers for Medicare and Medicaid Services ( CMS ) that align with the Medicare Stars Program

12 Program Summary Medicare Advantage FPCC and Standard continued MMeeeeeeeeeeee LLLLLLLL RRRRRRRRRR TTTTTTTTTTTT (MMMMMMMM) = TTTTTTTTTT MMMMMMMMMMMMMM EEEEEEEEEEEEEE PPPPPPPPPPPPPP The Provider can impact the Shared Savings by: o Increasing Revenue via HCC Scores via closing gaps and identifying new diagnoses which will raise the premium received for the Medicare Advantage membership o Decrease the Total Medical Expenses for the Medicare Advantage membership by transforming their practice into a patient-centered care model, leading to better management of the members conditions and lowering costs as a result 12 12

13 Medicare Advantage Freestanding Patient Centered Care (FPCC) Program Questions? Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association