Amerigroup Louisiana, Inc. 1
Agenda • Introduction • Behavioral Health • Member-PCP Alignment • Clinic Days • Provider Quality Incentive Program • Potential Missed Care Opportunities 2
Behavioral health • Effective December 1, 2015, all Behavioral Health will be carved in to Bayou Health Plans • Providers will be responsible for completing the credentialing and contracting process directly with the Health Plans • Please send us your updated rosters with behavioral health providers highlighted, as well your credentialing information: – Email your scanned PDFs to lainterpr@amerigroup.com – Fax to 1-888-375-5063: Attention: Network development – Louisiana – Mail through FedEx, UPS or U.S. Postal Service to: Amerigroup Network Development – Louisiana 5353 Essen Lane, Suite 300 Baton Rouge, LA 70809 3
Member-PCP alignment • We know it is essential to connect and build the relationships between our members and our PCPs • Your relationships with our members help them make good decisions about their care and produce better health outcomes • Effective [June 1, 2015], PCPs will only be reimbursed for providing services to members who are on their assigned member listing or the listing of another participating PCP in their group • Please provide your covering provider information immediately as claim payments may be affected 4
Covering Provider Information 5
Clinic Day Program Guide Overview Objective: Conduct a series of Clinic Day events at high-volume provider offices with a minimum of 10 member per Clinic Day 6
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Provider Quality Incentive Program (PQIP) A shared savings program that rewards our providers for improving quality and medical cost management 8
PQIP Objectives • Improve clinical quality results – Empower providers to reach all assigned members for preventive services and chronic condition management • Improve medical cost management – Provide incentives and tools so providers reduce unnecessary utilization and costs • Enhance provider service – Increase contact with individually assigned Amerigroup Louisiana, Inc. provider representative on provider-specific initiatives • Promote quality, safe and effective patient care across the health care delivery system 9
Program Components Eligibility requirements • Minimum of 1,000 members per PCP or PCP group in total • Participating during entire measurement year prior to the program year • Open panel status (group level) • Signed Letter of Agreement Note: PCP is defined as either a solo PCP, a PCP group or an independent practice PQIP model components association, whichever is the highest level of • Quality Scorecard contractual relationship with Amerigroup Louisiana. • Shared Savings • Provider reporting 10
Quality Scorecard Component • Uses administrative-only measures attributable to PCPs • Measurement will be at the highest contracted level • A set of 13 HEDIS-like indicators will be measured • The top four indicators, in terms of measured members, are used for scoring; at least 30 measured members are required for each of the top four measures • Points assigned for absolute score versus peers and for levels of improvement • The weighted average peer comparison percentile for the top four measures must exceed the 40th percentile to meet the Quality Threshold Level and participate in the Shared Savings component 11
HEDIS-like Quality Measures 1. Well-child visits – during the first 15 months of life 2. Well-child visits – (ages 3-6) 3. Adolescent well-care visits (ages 12-21) 4. Adult access to preventive/ambulatory health services 5. Diabetic HbA1c testing 6. Diabetic eye screening 7. Diabetic nephropathy screening 8. Breast cancer screening 9. Cervical cancer screening 10. Appropriate treatment for children with upper respiratory infection 11. Appropriate testing for children with pharyngitis 12. Appropriate management of children and adults with asthma 13. Appropriate follow-up/management of children with newly prescribed medication for attention deficit hyperactivity disorder 12
2015 PQIP Quality Scorecard Peer Comparison Component Example for ABC PCPs Current quality scorecard measurement period (MP) Current MP Peer Peer peer comparison Peer comparison Eligible Compliant with Current comparison score (from Measure comparison earned population measure MP rate percentile table below) weighting weighting contribution Measure number 1 Highest # of measured members 830 508 61% 70th 70% x 25% x 80% = 14% 2 Second highest 357 261 73% 55th 70% x 25% x 80% = 14% 3 Third highest 144 109 76% 94th 120% x 25% x 80% = 24% 4 Fourth highest 92 79 86% 36th 25% x 25% x 80% = 5% Weighted Average 64th Peer Comparison Percentile Total Peer Comparison Earned Contribution 57% Quality Threshold Level met (i.e., > 40th) Determination of Peer Comparison Score: 0 to 24.9th percentile = 0% 25th to 49.9th percentile = 25% 50th to 74.9th percentile = 70% 75th to 89.9th percentile = 85% 90th to 100th percentile = 120% Peer Comparison Component is weighted at 80 percent and Quality Improvement Component is weighted at 20 percent. 13
2015 PQIP Quality Scorecard Quality Improvement Compone nt nt Example for ABC PCPs Current quality scorecard measurement period Quality Quality Quality Improvement Quality Quality improvement Eligible Compliant with Current Prior MP improvement improvement target improvement Measure improvement earned population measure MP rate rate baseline rate target rate achieved? score weighting weighting contribution Measure Highest # of Measured Members 830 508 61% 55% 65% 57% Y 100% x 25% x 20% = 5% Second highest 357 261 73% 72% 82% 74% N 0% x 25% x 20% = 0% Third highest 144 109 76% 71% 65% 65% Y 100% x 25% x 20% = 5% Fourth highest 92 79 86% 77% 75% 75% Y 100% x 25% x 20% = 5% Total Quality Improvement Earned Contribution 15% Quality Improvement Baseline Rate = HEDIS Quality Compass 50th Percentile rate for that measure Quality Improvement Target Rate = the rate needed to close 20 percent of the gap between the prior-year rate and the Quality Improvement Baseline Rate Quality Improvement Score = 100 percent if the Quality Target Rate is achieved or if the current-year rate is greater than the Quality Improvement Baseline Rate Peer Comparison Component is weighted at 80 percent and Quality Improvement Component is weighted at 20 percent. 14
2015 PQIP Quality Scorecard Total Earned Contribution Example for ABC PCPs Total Peer Comparison Earned Contribution 57% Total Quality Improvement Earned Contribution 15% Total Earned Contribution 72% Peer Comparison Earned Contribution is added to the Quality Improvement Earned Contribution to arrive at the Total Earned Contribution. The Total Earned Contribution drives the amount of Shared Savings that are earned. 15
Enhanced Pay Component • Must meet Quality Threshold Level to participate • Enhanced Pay is a shared savings structure based on adjusted medical loss ratio (MLR) • The target MLR and shared savings rates are structured in corridors based on the prior-year MLR Corridor Prior-year MLR Target MLR Shared savings rate • 1 0%-80% 80% If calendar year MLR is reduced 50% • If calendar year MLR is increased 30% 2 80%-85% Prior Year – 2% 50% 3 > 85% Prior Year – 2% 20% • Maximum shared savings are capped at 25 percent of a PCP’s underlying reimbursement 16
PQIP Earned Shared Savings Example Example for ABC PCPs Assumptions: Calculations: Prior Year MLR 85% Unadjusted Shared Savings: Thus, MLR Target = 83% Difference in Target MLR and Program Year MLR: 5% Thus, Shared Savings Potential = 50% x Program Year Total Premium $ 2,000,000 Equals Unadjusted Shared Savings $ 100,000 Current Year MLR 78% Earned Shared Savings: Program Year Total Premium $ 2,000,000 Unadjusted Shared Savings $ 100,000 x Shared Savings Potential 50% Total Earned Contribution 72% x Total Earned Contribution 72% Equals Earned Shared Savings $ 36,000 17
Total Medical Costs Definition: The costs incurred by Amerigroup Louisiana for payment of all covered services (including hospital, medical, pharmacy and nonhospital services) provided to each member by all providers (participating or nonparticipating, including the provider and PCPs) furnishing such services to members, adjusted for the PQIP Stop-loss Premiums and Recoveries and Value-added Benefits The calculation of Total Medical Expenses will be as follows: • Claims and capitation paid through the defined claims run-out period • Plus a reasonable amount for incurred but not reported costs • Plus the PQIP Stop-loss Premium • Minus the PQIP Stop-loss Recoveries 18
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