Patient-Centered Medical Home

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1 2017 Primary Care Commercial and QUEST Integration January 2017 HMSA Patient-Centered Medical Home Getting Started and Ongoing Management P R O G R A M G U I D E An Independent Licensee of the Blue Cross and Blue Shield Association

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3 Table of Contents Introduction... 2 Program Rules and Expectations for Providers... 4 Program Requirements Appendix A: PCMH Framework PCMH Program Guide 1

4 Introduction HMSA s Patient-Centered Medical Home (PCMH) programs have helped advance provider practices on the journey toward HMSA s vision of creating a sustainable health care system for Hawaii. The PCMH programs are built on the foundation of the Institute for Healthcare Improvement s (IHI) Triple Aim: Improving the experience of care; Improving the health of populations; and Reducing per capita health care costs. Summary of 2017 PCMH Program Changes New 2017 PCMH Requirements We re introducing new requirements that will help PCPs and POs focus on engagement and practice transformation behaviors that are a core part of our new primary care payment transformation program. Refer to the PCMH Program Requirements section for details. The development of PCMH practice infrastructures enabled providers participation in HMSA s value-based programs such as the pay-for-quality programs that focus on improving care management and quality outcomes. Although the principles of the PCMH framework are fundamental to continual practice transformation, there s clearly a need for stronger alignment of practice design, incentives, and care outcomes. To meet this need, HMSA s new primary care payment model and incentive structure integrates greater flexibility in care delivery and addresses nonmedical social determinants of health and well-being. To that end, HMSA s PCMH programs are evolving to help primary care providers (PCPs) and physician organizations (POs) meet transformation goals, objectives, and expectations for more-robust population health management while delivering true patient-centered, high-value care to the people of Hawaii. REQUIREMENT Access to and Use of Cozeva Panel Management Engagement with Ecosystem EPSDT Completion Rate Sharecare Engagement HIGH-LEVEL DESCRIPTION PCPs and/or their office staff or delegate will use Cozeva at least once a month. Cozeva lets providers manage their member panel and monitor care gaps. PCPs will check on the well-being of attributed members in their panel at least once per year. This requirement will be measured using an annual member survey administered to a sample of each PCP s attributed members at the end of the year. PCPs will refer patients to programs in the ecosystem such as HMSA health education workshops and Dr. Ornish s Program for Reversing Heart Disease. PCPs with participating provider agreements for QUEST Integration will submit EPSDT (Early and Periodic, Screening, Diagnostic, and Treatment) exam forms DHS 8015 or DHS 8016 for attributed QUEST Integration members under age 21 who had an EPSDT visit due during the year. The number of members who are expected to have a visit will be based on the EPSDT periodicity schedule and the number of members attributed to the provider at the end of year. PCPs will sign up for and create a profile on the Sharecare application. In 2017, this measure only applies to providers in internal medicine, general practice, family medicine, and pediatrics. These new requirements are not applicable to PCPs who are affiliated with federally qualified health centers (FQHCs). For information on program rules and requirements for FQHCs, please see the 2017 PCMH Program Guide for FQHCs online at hmsa.com/providers/pcmh. Cozeva is a registered trademark of Applied Research Works, Inc. Applied Research Works is an independent company that provides COZEVA, an online tool for HMSA providers to engage members on behalf of HMSA. Dr. Ornish s Program for Reversing Heart Disease. All rights reserved. Sharecare, Inc., is an independent company that provides well-being programs to engage members on behalf of HMSA. 2 PCMH Program Guide

5 PCMH Level Advancement As we transition to the new primary care payment transformation program, there are some elements of PCMH that will stop. Beginning January 1, 2017, we ll no longer accept and process requests to advance PCMH levels. A PCP s PCMH Level in the 2017 program will be their PCMH Level as of December 1, PCPs will continue to receive population health management (PHM) fees based on that level. See the Program Rules and Expectations section for details on PHM fees. Expectations for PCPs and POs The basic expectations for PCPs and POs will align with the new primary care payment transformation program. PCPs are expected to fulfill these expectations and the new PCMH requirements while participating in the 2017 PCMH program and receiving PHM fees. Refer to the 2017 HMSA Payment Transformation Program Guide for details. PCMH Program Guide 3

6 Program Rules and Expectations for Providers In 2017, the PCMH program rules and expectations for PCPs will align with the new primary care payment transformation program. Refer to the following sections in the 2017 HMSA Payment Transformation Program Guide for details: - PCP Program Eligibility - PCP Membership in a PO Rules of Engagement - Member Attribution to PCPs The 2017 budget per member per month (PMPM) is outlined below. Commercial PCMH program: Level 1 = $0.00 Level 2 = $2.50 Level 3 = $3.00 QUEST Integration PCMH program: Level 1 = $0.00 Level 2 = $1.00 Level 3 = $ PCMH Program Guide

7 Program Requirements Access to and Use of Cozeva Description PCPs and/or their office staff or Cozeva delegate will use Cozeva at least once a month. Cozeva enables providers to manage their member panel, monitor care gaps, and displays the PCPs performance and payment potential on performance measures. Requirements for Compliance PCP or office staff or Cozeva delegate must have logged on to the PCP s Cozeva profile at least once a month for all 12 months during the measurement year. This requirement will be tracked via the Cozeva login history. Panel Management Description PCPs will check on the well-being of all individual members in their panel at least once a measurement year. This requirement will be measured using an annual member survey administered to a sample of each provider s attributed members at the end of the measurement year. In the last 12 months, did this provider or someone else from their office contact you about your health and well-being? (Check all that apply.) Numerator Had an in-person visit. (1) Called me. (2) ed me. (3) Provider interacted with me via HMSA s Online Care. (4) Texted me. (5) Sent me a letter, postcard, or brochure/pamphlet. (6) No contact. (7) Members without any visit-based claims in the measurement year who responded to the survey with 2, 3, 4, 5 or 6, and members who had at least one visit with the provider (claim filed) during the measurement year. Members will be counted only once in the numerator. Denominator Members without any visit-based claims in the measurement year who responded to the survey and members who had a claim filed by their attributed PCP. Members will be counted only once in the denominator. Exclusions None. Requirements for Compliance To meet the requirement for this measure, the performance rate must be greater than or equal to 75 percent. Engagement with Ecosystem Description PCPs will refer patients to programs in the ecosystem (including programs such as HMSA Care Model, HMSA health education workshops, Dr. Ornish s Program for Reversing Heart Disease TM, etc.). Requirements for Compliance Confirmation and description of referrals to programs in the ecosystem submitted via an attestation form in Cozeva by the end of the measurement year including: Identifying and describing which programs the patients were referred to. Approximate number of members that was referred to programs. Sharecare Engagement Description PCPs will sign up for and create a profile on the Sharecare application, including the submission of a photo and biographical information, within 90 days of their contract date for PT or within 90 days of the beginning of the measurement period (for PCPs whose contract date was prior to January 1, 2017). PAYMENT TRANSFORMATION EFFECTIVE DATE January 1, 2017 or prior March 31, 2017 April 1, 2017 June 30, 2017 DUE DATE FOR SHARECARE ENGAGEMENT MEASURE July 1, 2017 September 30, 2017 Other Requirements for Compliance 90 days from effective date Additional information about how to meet the requirements for this measure will be provided at least 30 days prior to the due date. EPSDT Completion Rate (Applicable to QUEST Integration PCPs only.) Description PCPs with participating provider agreements for QUEST Integration will submit EPSDT exam forms (DHS 8015 or DHS 8016) for attributed QUEST Integration members under the age of 21 who had an EPSDT visit due during the measurement year. The number of members expected to have a visit will be calculated based on the EPSDT periodicity schedule and the number of patients attributed to the provider. Denominator The number of members age 4 months to 21 years of age on the last day of the measurement period. PCMH Program Guide 5

8 Numerator The number of members that completed all EPSDT screenings that are due during the current measurement year and within the eligible screening period. The eligible screening period start date and due date are relative to each member s birth date. See table below. EPSDT SCREENING VISIT ELIGIBLE SCREENING PERIOD START ELIGIBLE SCREENING PERIOD END (DUE DATE) 4 months 4 months 6 months less 1 day 6 months 6 months 9 months less 1 day 9 months 9 months 12 months less 1 day 12 months 12 months 15 months less 1 day 15 months 15 months 18 months less 1 day 18 months 18 months 2 years less 1 day 2 years 2 years 3 years less 1 day 3 years 3 years 4 years less 1 day 4 years 4 years 5 years less 1 day 5 years 5 years 6 years less 1 day 6 years 6 years 8 years less 1 day 8 years 8 years 10 years less 1 day 10 years 10 years 12 years less 1 day 12 years 12 years 14 years less 1 day 14 years 14 years 16 years less 1 day 16 years 16 years 18 years less 1 day 18 years 18 years 20 years less 1 day 20 years 20 years 21 years less 1 day Click the icon below for allowable numerator codes. Requirements for compliance To meet the requirement for this measure, the performance rate must be greater than or equal to 70 percent. In 2017, performance on this measure will not be scored for payment purposes (i.e., will not impact the base PMPM payment in 2018). Cozeva will implement this measure as a display only measure in PCMH Program Guide

9 Appendix A: PCMH Framework PCMH: A Path to Quality, Affordable Health Care PCMH is a health care model that facilitates partnerships between individual patients and their personal providers as well as the patient s family, when appropriate. This model puts the patient at the center of care and surrounds the patient with a care coordination team led by a PCP. It s a way to give the patient better, more personal care. HMSA s PCMH program adopts the Joint Principles of the Patient-Centered Medical Home as developed by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. 1 The Joint Principles of the Patient-Centered Medical Home Personal Provider Payment Structure Enhanced Access to Care Provider & Patient Care Team Provider- Directed Medical Practice Whole-Person Orientation Quality and Safety Coordinated Care Across Health Care System 1 PCMH definition and Joint Principles of PCMH are available at pcpcc.net. PCMH Program Guide 7

10 Building a Sustainable Health Care System for Hawaii HMSA s mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state. The PCMH model of care promotes meaningful collaboration with patients, health care providers, and employers. PCMH fosters engaging relationships between HMSA members and their PCPs so that together they can achieve greater health. Additionally, PCMH lays the foundation of an integrated system of health care that reliably delivers high quality and the best value. PCMH lays the foundation for a redesigned health care system that provides better value for Hawaii. To that end, we embrace the vision embodied in the IHI s Triple Aim: Improving the experience of care. Improving the health of populations. Reducing per capita health care costs. 2 By enhancing the experience of care, including quality, access, and consistency, a transformed health care system will better succeed in the Institute of Medicine s (IOM s) six aims for improvement. 3 The synergy between these concepts leads to the transformation of health care in Hawaii as depicted in the diagram below. Improvement Aims for a Sustainable Health Care System Ultimate Goal: Access to affordable, quality care at the right time in the right place Sustainability Optimize performance in three dimensions of care to improve the health care system IHI s Triple Aim Population Health Patient Experience Per Capita Cost Adoption of core beliefs for delivering quality health care IOM s Six Aims for Improvement Safe Effective Patient- Centered Timely Efficient Equitable 2 IHI Triple Aim: 3 Institute of Medicine (IOM), Crossing the Quality Chasm : Quality%20Chasm%202001%20%20report%20brief.pdf 8 PCMH Program Guide

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