Commercial Business Measurement Period Handbook-Medical Cost Target Model For Enhanced Personal Health Care Measurement Period beginning: 01/1/17

Transcription

1 Commercial Business Measurement Period Handbook-Medical Cost Target Model For Enhanced Personal Health Care Measurement Period beginning: 01/1/17 CBMCT Version V3

2 Introduction: Welcome to your Commercial Business Measurement Period Handbook-Medical Cost Target Model. 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 you will see definitions of some of the most important terms used in this handbook and the details of your Incentive Program: Medical Cost Target 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 Target (MCT) report via our secure website. The Medical Cost Target report shows medical costs incurred by your Attributed Patients over the course of the Baseline Period. This information is used as the starting point for the projected medical trends used to establish 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 Risk Corridor), 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 twelve (12) month period during which we measure Medical Cost Performance (MCP) and quality and utilization performance for purposes of calculating shared savings between Anthem Blue Cross and Blue Shield (Anthem) and the Medical Panel. Quality Gate. The minimum clinical quality scores that your provider organization must deliver in order to earn any shared savings under the Incentive Program. Your quality gate will be set at 10 th percentile. Further information about the Quality Gate is reviewed in the shared savings section, on page 10. 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. Minimum Risk Corridor. (MRC) the percentage of MCT that Anthem retains before sharing any savings with the Medical Panel. This percentage is determined by Anthem and is designed to limit savings payouts that are driven by random variation. Upside Cap The maximum Incentive Program shared savings that you can earn through the Incentive Program. As is the case with the Gross Savings, the Upside Cap is adjusted by the Paid/Allowed Ratio as defined in the Program Description. Performance Scorecard Report. In addition to the MCT report, you will also be able to access your provider organization s Performance Scorecard via our secure website ( 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 Medical Cost Target report, your Performance Scorecard and the scoring methodology. After reviewing, if you have any questions, please send an to our dedicated Enhanced Personal Health Care mailbox. 2 CB Version V3

3 Table of Contents Introduction:... 2 Section 1: Medical Cost Target... 4 Where to Find Your MCT Report and Supporting Materials... 4 Section 2: Performance Scorecard & Your Measures... 5 Overview... 5 Scorecard Report Example... 5 Quality Measures for Your Measurement Period... 6 Section 3: Calculating Your Shared Savings Overview Quality Gate Did you pass the Quality Gate? Weighting Composites Calculating Composite Scores Summary of your scoring INDEX Scorecard Measure Specifications CB Version V3

4 Section 1: Medical Cost Target 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. The Medical Cost Target Report shows medical costs incurred by a given Medical Panel s Attributed Members over the course of the Baseline Period. This information is used to establish the Medical Cost Targets (MCTs) for the Incentive Program. The Medical Cost Target Report lists supporting member months, average risk scores and claims expenditures incurred by Attributed Members over the course of the Baseline Period. 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 projected) and if you meet or exceed the Program s quality benchmarks. The better the quality score, the higher the potential shared savings payment. The Medical Cost Target Report is meant to give you a sense of the baseline cost trend from which you are starting. This level-set 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 year. Where to Find Your MCT Report and Supporting Materials Your MCT report will be available within 45 days following the start of your Measurement Period or as soon thereafter as practicable. To view your MCT report or to view a useful Quick Reference Guide for MCT, select the Provider Online Reporting link on 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). 4 CB Version V3

5 Section 2: Performance Scorecard & 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 Scorecard Report Example The Performance Scorecard report includes information for providers on: Earned Contribution: The proportion of the Shared Savings Potential earned for each 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. 5 CB Version V3

6 Total Shared Savings-Example The PCMS Scorecard shows the Total Shared Savings Percentage on the Summary tab. The % Shared Savings (in this example, 23.20%) is calculated by multiplying the total earned percentage (in this example, 66.29% as shown on the previous page) to the Upside Shared Savings Potential (in this example, 30%). 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. Acute and Chronic Care Management Measures o Medication Adherence - Proportion of Days Covered (PDC): Oral Diabetes - Proportion of Days Covered (PDC): Hypertension (ACE or ARB) - Proportion of Days Covered (PDC): Cholesterol (Statins) o o o Diabetes Care - Diabetes: Urine Protein Screening - Diabetes: HbA1c Testing - Diabetes: Eye Exam Annual Monitoring for Persistent Medications - Annual Monitoring for Patients on Persistent Medications: Digoxin - Annual Monitoring for Patients on Persistent Medications: ACE/ARB - Annual Monitoring for Patients on Persistent Medications: Diuretics Other Acute and Chronic Care Measurement - Appropriate Testing for Children with Pharyngitis - Appropriate Treatment for Children with Upper Respiratory Infection - Osteoporosis Management in Women Who Had a Fracture - Persistence of Beta-Blocker Treatment After a Heart Attack - Arthritis: Disease Modifying Anti-rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis - Medication Management for People with Asthma 6 CB Version V3

7 Preventive Measures o o - New Episode of Depression: Effective Acute Phase Treatment - New Episode of Depression: Effective Continuation Phase Treatment 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 - Well-Child Visits Ages Years Old Adult Prevention - Breast Cancer Screening - Cervical Cancer Screening Utilization Measures Three different utilization measures are included in the Program scorecard. The measures focus on appropriate emergency room (ER) utilization, management of ambulatory-sensitive care conditions as measured by hospital admissions, and generic dispensing rates for a select set of drug classifications. 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 Sinusitis 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. Adult and Pediatric, Ambulatory Sensitive Care Hospital Admissions 7 CB Version V3

8 The Agency for Healthcare Research and Quality (AHRQ) has developed a Prevention Quality Indicators (PQI) composite measure of 11 potentially avoidable hospitalizations for ambulatory care sensitive conditions that are the basis of this measure. They are: 1. Diabetes short-term complications 2. Diabetes long-term complications 3. Chronic obstructive pulmonary disease or asthma in older adults 4. Hypertension 5. Heart Failure 6. Dehydration 7. Bacterial pneumonia 8. Urinary tract infection 9. Angina without procedure 10. Uncontrolled diabetes 11. Asthma in younger adults Generic Dispensing Rate We assess the generic dispensing rate for five classes of medication: 1. Statins 2. ADHD Medications 3. ARBs and ARB Combinations 4. Beta Blockers and Beta Blocker Combinations 5. Serotonin Agonists and Serotonin Agonist Combinations (Migraine Medications) 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 Adherences: Statins 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. 8 CB Version V3

9 Composite Overview Scorecard points are divided into five 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 calculated at the sub-composite level. The sub-composites are scored as the sum of the numerators for the measures within the sub-composite divided by the sum of the denominators. Scoring of the clinical measure sub-composites occurs at the provider organization level. If all of the clinical sub-composites have a denominator less than 30, or if the Annual Monitoring for Persistent Medications is the only clinical sub-composite with a denominator of at least 30, then scoring will occur at the Medical Panel-level. The Utilization Measures will always be scored at your Medical Panel-level to achieve sufficient denominator sizes for meaningful measurement. The five major composites are: 1. Acute and Chronic Care Management 2. Preventive Care 3. Utilization 4. Clinical Quality Improvement 5. Patient-Centered Medical Home (PCMH) Recognition from the National Committee for Quality Assurance (NCQA) *Is an optional category; full shared savings can be earned without PCMH Recognition. Composite Details 1. The Acute and Chronic Care Management Composite has four sub-composites. Each of the sub-composites has multiple care measures that contribute to the Acute and Chronic Care Management calculation: Medication Adherence Diabetes Care Annual Monitoring for Persistent Medications Other Acute and Chronic Care Management 2. The Preventive Care Composite has two sub-composites, with five individual care measures: Adult Preventive Pediatric Preventive 3. The Utilization Composite is made up of three sub-composites: Potentially avoidable ER visits Admissions for ambulatory sensitive care Generic drug dispensing rate for five classifications 4. The Clinical Quality Improvement Composite has five measures, and was outlined previously. 5. Patient-Centered Medical Home NCQA Recognition In addition to the opportunity to earn shared savings based on quality and cost, provider organizations that have obtained NCQA PCMH Levels 2 and 3 recognition can earn credit for that achievement. Your provider organization will not be penalized if you do not have NCQA PCMH recognition. A score of 75% is awarded if a provider organization receives Levels 2 or 3 recognition for 20% to 50% of provider organization locations. A score of 100% is awarded for Levels 2 or 3 recognition if received for 50% or more of provider organization locations. Groups that have not obtained this recognition are not penalized. The overall Shared Savings Potential percentage remains the same 9 CB Version V3

10 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 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 MCT by the MRC, 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. We calculate that score for the Measurement Period and compare it to the distribution of performance across the market for the same time period. The market distribution of performance includes provider organizations (including primary care and specialist providers, whether participating in the Program or not) that have at least one of the 6 quality subcomposites with a denominator of 30 or more. Your provider organization s clinical quality score must meet or exceed the market 10th percentile to pass the Quality Gate. For provider organizations with denominators of at least 30 in all 6 clinical sub-composites, the sub-composite rates are proportionally weighted by the assigned Shared Savings Potential to arrive at the overall clinical quality score. When provider organizations have one to five sub-composites with denominators of 30 or more, the weights are redistributed accordingly and then a final overall quality composite score is calculated. If your overall quality composite score is greater than the Quality Gate, you are eligible to earn shared savings. Examples follow in the tables below: 10 CB Version V3

11 Table 1: Clinical Sub-Composites and Weights for Calculating the Overall Quality Composite: In this example the group had sufficient denominators to be scored in all categories. The Quality Gate, using the 10 th percentile, equates to a 22% performance rate across all sub-composites. When the sub-composite scores are aggregated proportional to the we ights, the group has an overall score of 42%. Since the Quality Gate was set at 22%, this group would pass the Quality Gate. Example One Clinical Sub-Composites Performance Rate Weight Medication Adherence % 25.0% 11% Diabetes Care % 12.5% 3% Annual Monitoring for Persist Meds % 5.0% 4% Other Acute and Chronic Care Management % 20.0% 14% Pediatric Preventive % 12.5% 3% Adult Preventive % 25.0% 7% 100% QUALITY GATE 42% Overall Contribution Percentage Table 2: Clinical Sub-Composites and Weights for Calculating the Overall Quality Composite : In this example the group did not have sufficient denominators to be scored in all categories, so the weights were proportionally redistributed accordingly, producing an overall quality composite score of 45%. Since the Quality Gate was set at 22%, this group would pass the Quality Gate. Example Two Clinical Sub-Composites Performance Rate Weight Overall Contribution Percentage Medication Adherence % 28.6% 13% Diabetes Care % 14.3% 4% Annual Monitoring for Persist Meds % 5.7% 5% Other Acute and Chronic Care Management % 22.9% 16% Pediatric Preventive NA NA NA Adult Preventive % 28.6% 8% 100% QUALITY GATE 45% 11 CB Version V3

12 Weighting Composites The composite, sub-composites, and care measures do not contribute equally to the 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 50% or 60% of the scorecard points depending on the presence of NCQA PCMH Recognition. 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 40% of the scorecard points. Table 3: Composite Weights - Example Category Allocation of Shared Savings Potential With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Medication Adherence Diabetes Care 5 6 Annual Monitoring for Persist Meds Other Acute and Chronic Care Management Clinical: Preventive Pediatric 5 6 Adult Clinical: Improvement Utilization NCQA PCMH Recognition 10 N/A TOTAL 100% 100% Table 4: Shared Savings Potential per Composite in Absolute Terms - Example Category Percentage of Shared Savings With NCQA Recognition Without NCQA Recognition Clinical: Acute and Chronic Care Management Medication Adherence 3.00% 3.60% Diabetes Care 1.50% 1.80% Annual Monitoring for Persist Meds 0.60% 0.72% Other Acute and Chronic Care Management 2.40% 2.88% Clinical: Preventive Pediatric 1.50% 1.80% Adult 3.00% 3.60% Clinical: Improvement 3.00% 3.60% Utilization 12.00% 12.00% NCQA PCMH Recognition 3.00% NA TOTAL 30% 30% 12 CB Version V3

13 Adult Preventive Sub-composite Eligible Population Compliant with Measure Rate Level 1-20th percentile Earned Shared Savings = 30% Level 2-40th Percentile Earned Shared Savings 50% Level 3-60th Percentile Earned Shared Savings 70% Level 4-80th Percentile Earned Shared Savings 100% Measurement Level Earned Contribution Upside Shared Savings Potential Shared Savings Percentage Calculating Composite Scores As mentioned above, there are five composites that are calculated for the scorecard. Each area is explained in detail below. Composites 1 & 2: Acute and Chronic Care Management and Preventive Care Measures We use four steps to determine the proportion of shared savings earned for the acute and chronic care management and preventive care. The table below is a visual representation of the process. Table 5: The Four Steps That Are Used to Calculate for Preventive Care Measures - Example Organizations Current Performance Market Thresholds Shared Savings % 52% 60% 65% 72% Group 50% 4.20% 2.1% Step 1 Step 2 Step 3 Step 4 Step 1. Calculate sub-composite rate Sub-composite rates are calculated by summing- the numerators (the number compliant with measure) across each of the measures within the sub-composite, and then dividing by the sum of the denominators (eligible population). Step 2. Compare performance to market thresholds Market thresholds are established for each of the sub-composites at the <20th, 20th, 40th, 60th and 80th 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. Provider organizations with a sub-composite denominator less than 30 are excluded from the calculation of the relevant sub-composite thresholds. 13 CB Version V3

14 Step 3. Assign percentage of the category earned The four levels of market thresholds are used to categorize four (4) tiers of performance. After passing the lowest market threshold, each performance tier is associated with a greater proportion of earned shared savings: (0 - < 20th percentile) = 0% of shared savings earned Level 1 (20th-<40th percentile) = 30% of shared savings earned Level 2 (40th-<60th percentile) = 50% of shared savings earned Level 3 (60th-<80th percentile) = 70% of shared savings earned Level 4 (80th -<100th percentile) = 100% of shared savings earned Step 4. 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 for the Sub-composite. This yields the earned shared savings for the subcomposite. 14 CB Version V3

15 Level 4 Level 3 Level 2 Level 1 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 That Are Used to Calculate Utilization Measures - Example Measures Member Months Current Performance Market Benchmark Shared Savings Visits Risk Adj. Factor Risk Adj. Rate Upside Shared Savings Potential Earned Contribution Shared Savings % Commercial Adult 98, % 30.00% 0.89% Commercial < 18 18, % 00.00% 0.00% Weighted Subcomposite Total: 3.50% 25.33% 0.89% 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. Ambulatory Sensitive Admits and Potentially Avoidable ER measures: o 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 o The numerator is the count of qualifying events during the Measurement Period. o The denominator is the sum of Member Months for members attributed to the Medical Panel during the Measurement Period. o The unadjusted rate is computed as (numerator/denominator)*12,000. o This rate is risk-adjusted by dividing the actual raw rate for the provider panel by the relative risk score. o The Medical Panel risk score is calculated as the sum of weighted retrospective diagnostic cost grouping risk scores for members attributed to the Medical Panel, divided by number of Attributed Members with a risk score. That rate is then divided by the average Risk Score of all members within the line of business/age group (excluding BlueCard). Generic Dispensing Rates o 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 Generic Dispensing Rate is calculated separately for each of the five therapeutic classes. = count of all prescriptions for the Medical Panel s attributed patient population within each of the five generic classes. 15 CB Version V3

16 o = count of generic prescriptions during Measurement Period within each of the five generic classes. o The rate is computed as (numerator/denominator) percentage for each line of business/age group within each of the five generic classes separately. Step 2 Compare performance to market thresholds. o Market Thresholds are established for each of the utilization measures for three distinct line of business/age groups (commercial adult, commercial <18). o Four levels of thresholds are calculated based on the overall market: <20th, 20th, 40th, 60th and 80th percentiles for the year prior to the Program Measurement Period. o We will provide performance thresholds soon after the start of the Measurement Period. Note: Market thresholds exclude BlueCard. Step 3 Determine Shared Savings Potential for each line of business/age group. o Upside shared savings -Potential for the utilization measures: o Potentially avoidable emergency room visits = 3.5% o Generic dispensing rate (GDR) = 7% o Ambulatory sensitive care admissions = 3.5% o Since these measures are assessed by line of business/age groups, the shared savings opportunity for each of these groups must be determined. o Upside shared savings opportunity for each GDR drug class is determined by distributing the overall Upside Shared Savings Potential for GDR (7%) based on the proportion of prescriptions within that drug class compared to the overall (total) GDR prescription count. o Within each drug class, the shared savings opportunity is determined for each line of business age/group based on the proportion of prescriptions within that line of business/age group. Step 4 Assign the earned contribution percentage. The four levels of market thresholds are used to categorize four tiers of performance. After passing the lowest market threshold, each performance tier is associated with a greater proportion of earned shared savings: o (0 - < 20th percentile) = 0% of shared savings earned o Level 1 (20th-<40th percentile) = 30% of shared savings earned o Level 2 (40th-<60th percentile) = 50% of shared savings earned o Level 3 (60th-<80th percentile) = 70% of shared savings earned o Level 4 (80th -<100th percentile) = 100% of shared savings earned 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. 16 CB Version V3

17 Overall Scoring Summary for Utilization Components The chart below 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: Overall scoring for Utilization Measures - Example Step 4 Step 3 Step 5 17 CB Version V3

18 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 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 both 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. o The Baseline Period used for the improvement measures is 12 months preceding a Measurement Period with 3 months claims run-out and approximately a 1 month period to perform calculations. 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%. If your denominator 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 3 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 1 month while the quality metrics take 3 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. 18 CB Version V3

19 Composite 5: NCQA PCMH Level 2 and 3 Recognition Component Groups that have obtained NCQA PCMH Levels 2 and 3 recognition can receive credit for that achievement. Groups that do not have recognition ARE NOT penalized. The section bellow explains how PCMH recognition is calculated into the scorecard. Provider organizations with 20% or more of their locations having achieved NCQA PCMH Level 2 or 3 Recognition during the Measurement Period will receive up to 10% of the upside shared savings payout automatically as part of this scorecard component. 10% of the upside shared savings payout will be awarded to provider organizations that have Level 2 or Level 3 recognition for 50% or more of their locations. In absolute terms 10% x 30% maximum payout equals a guaranteed 3.0% payout. 7.5% of the upside shared savings payout will be awarded to provider organizations that have Levels 2 or Level 3 recognition for between 20% and 50% of its provider organization locations. In absolute terms 7.5% x 30% maximum payout equals a guaranteed 2.25% payout of shared savings. The remaining 2.5% of the possible payout for NCQA PCMH Recognition shall not be reallocated to the other clinical quality and improvement components. Instead, provider organizations receiving partial credit for the NCQA PCMH recognition shall have their clinical quality and improvement components measured using both the with and without NCQA PCMH weights and shall be awarded the result with the greatest payout amount. The maximum payout level (3.5% of the total 30% maximum shared savings payout assigned to this component) is subtracted from the total possible payout levels available in the clinical quality and improvement components. For example, a provider organization with no NCQA PCMH recognition has a maximum payout opportunity from clinical quality and improvement components of 21%, whereas this provider organization with all of its locations having achieved NCQA PCMH level 3 recognition would be guaranteed a 3.5% payout from NCQA PCMH recognition and an opportunity to earn up to 17.5% (21% - 3.5%) from performance in the clinical quality and improvement measures. Provider Organizations that have not obtained this recognition are not penalized. The overall shared savings percentage remains the same and can be earned entirely from the utilization, clinical quality and improvement components. Information about your NCQA PCMH status by location must be communicated to Anthem no later than 30 days after the close of any Measurement Period for which recognition was in effect by completing the electronic attestation form. 19 CB Version V3

20 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 scorecard component. Your shared savings for each scorecard component is calculated by multiplying the Upside Shared Savings Potential (shown above in table 4) 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 Tables 8 and 9 below. The tables below, which you will receive with your 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. Table 8: In this example, the provider organization does not have NCQA PCMH recognition and would earn % of a Shared Savings Pool. Summary one - Without NCQA PCMH Recognition - Example Category Passed Quality Gate (10th percentile) > Savings Potential (1) Clinical: Acute and Chronic Care Mgmt. 7.50% Category % Earned Savings Earned Medication Adherence 3.60% 85% 3.06% Diabetes Care 1.80% 50%.9% Annual Monitoring for Persistent Medications 0.72% 0% 0.00% Other Acute and Chronic Care 2.88% 100% 2.88% (2) Clinical: Preventive 4.50% Pediatric Preventive 1.80% 15% 0.27% Adult Preventive 3.60% 85% 3.06% (3) Clinical: Improvement 3.60% 75% 2.70% (4) Utilization 12.00% 50% 6.00% OVERALL SAVINGS POTENTIAL 30% EARNED SHARED SAVINGS 18.87% YES 20 CB Version V3

21 Table 9: In this example, the provider organization does have NCQA PCMH recognition and would earn 18.98% of a Shared Savings Pool. Summary two - With NCQA PCMH Recognition Category Savings Potential Category % Earned Savings Earned Passed Quality Gate (10th percentile) > (1) Clinical: Acute and Chronic Care Mgmt. Medication Adherence 3.00% 85% 2.55% Diabetes Care 1.50% 50% 0.75% Annual Monitoring for Persistent Medications 0.60% 0% 0.00% Other Acute and Chronic Care 2.40% 100% 2.40% (2) Clinical: Preventive Pediatric Preventive 1.50% 15% 0.23% Adult Preventive 3.00% 85% 2.55% (3) Clinical: Improvement 3.00% 75% 2.25% (4) Utilization 12.00% 50% 6.00% (5) NCQA PCMH Recognition 3.00% 75% 2.25% OVERALL SAVINGS POTENTIAL 30% EARNED SHARED SAVINGS 18.98% YES 21 CB Version V3

22 INDEX 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 Proportion of Days Covered (PDC): Oral Diabetes This measure identifies patients with at least two prescriptions for diabetic oral agents in the measurement year who have at least 80% days covered (PDC) since the first prescription of an oral diabetic agent during the year. Patients in the denominator with at least 80% days covered for an oral diabetic Rx since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for an oral diabetic drug during the last 365 days. >=80% days covered (PDC) for Diabetic Oral Agents (removing overlapping days for Rx) from index event to end of measurement year. >=2 Rx claims for diabetic oral agents from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year using HEDIS gap method, <=1 gap <=45 days max; >=18yo No Rx claims for 'Insulin' from index event to end of measurement year. CMS Part D Specifications 2014 Proportion of Days Covered (PDC): Hypertension (ACE or ARB) This measure identifies patients with at least two prescriptions for an ACE/ARB in the measurement year who have at least 80% days covered (PDC) since the first prescription of an ACE/ARB during the year. Patients in the denominator with at least 80% days covered for an ACE/ARB since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for an ACE/ARB during the last 365 days. >=80 days covered (PDC) for ACE/ ARB (removing overlapping days) from index event to end of measurement year. >=2 Rx claims for ACE/ ARB from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year, using HEDIS gap method, <=1 gap <=45 days max; >=18yo. CMS Part D Specifications 2014 Proportion of Days Covered (PDC): Cholesterol (Statins) This measure identifies patients with at least two prescriptions for a Statin in the measurement year who have at least 80% days covered (PDC) since the first prescription of a Statin during the year. Patients in the denominator with at least 80% days covered for a Statin since the first prescription for the drug during the last 365 days. Patients who have at least two prescriptions for a Statin during the last 365 days. >=80% days covered (PDC) for Statins (removing overlapping days) from index event to end of measurement year. >=2 Rx claims for Statins from end of measurement year-365 to end of measurement year, saving earliest instance as index event (IE); Rx eligibility from index event to end of measurement year using HEDIS gap method, <=1 gap <=45 days max; >=18yo. CMS Part D Specifications CB Version V3

23 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 between 18 and 75 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 2016 specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. 23 CB Version V3

24 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. 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 2016 specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 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. 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. 24 CB Version V3

25 Measure Description / Technical Specifications Measure Citation Diabetes: Eye Exam This measure identifies patients between 18 and 75 years old who have diabetes and who had a retinal eye exam from an eye care professional in the last 2 years. Patients in the denominator who had a retinal eye exam from an eye care professional in the last 2 years. Patients between the ages of 18 and 75 who have diabetes. 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 2016 specs: Added requirement to look for at least 2 diabetes diagnoses from an inpatient setting. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, 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. At least 1 claim for an eye exam as specified by HEDIS in the last 730 days Exe exams are defined either as o non-specific office visits with an ophthalmologist or optometrist. o specific eye care code sets for a diabetic retinal screening OR At least 1 claim for an eye exam as specified by HEDIS in the last 365 days. Note that HEDIS specifications only count retinal eye exams from the previous year if the results were negative, but due to data limitations this measure was loosened to accept all eye exams from the previous year regardless of result. 25 CB Version V3

26 Sub-composite: Annual Monitoring for Persistent Medications Measure Description / Technical Specifications Measure Citation Annual Monitoring for Patients on Persistent Medications: Digoxin The percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for digoxin during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Patients in the denominator who had at least one serum potassium test and one serum creatinine test and one serum digoxin test during the measurement year. Patients who had at least 180 ambulatory treatment days for digoxin during the measurement year. At least 1 claim for a lab panel test AND 1 claims for a serum digoxin test during the measurement year OR at least 1 claim for a serum potassium test AND 1 claims for serum creatinine test AND at least 1 claim for a serum digoxin test during the measurement year Age >18 years on analysis date Has member and prescription eligibility during the measurement year, no more than 1 gap of no more than 45 days Has member and prescription eligibility with no gaps on analysis date Has at least a 180-day supply for digoxin during the measurement year, translating claims forward, including prescription filled prior to the beginning of the measurement year the days supply overlaps with the measurement year Has no claims from acute inpatient place of service during the measurement year OR has no claims from non-acute inpatient place of service during the measurement year National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, Annual Monitoring for Patients on Persistent Medications: ACE/ARB The percentage of patients 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for an ACE inhibitor or ARB during the measurement year and at least one serum potassium and one serum creatinine test during the measurement year. Patients in the denominator who had at least one serum potassium test and one serum creatinine test during the measurement year. Patients who had at least 180 ambulatory treatment days for ACE inhibitors or ARBs during the measurement year. At least 1 claim for a lab panel during the measurement year OR at least 1 claim for serum potassium and serum creatinine tests during the measurement year. Age >18 years on analysis date Has member and prescription eligibility during the measurement year, no more than 1 gap of no more than 45 days Has member and prescription eligibility with no gaps on analysis date Has 180-day supply of ACE inhibitors or ARBs during the measurement year, translating claims forward, including prescription filled prior to the measurement year if the days supply overlaps with the measurement year Has no claims from acute inpatient place of service during the measurement year OR has no claims from Non-Acute Inpatient place of service during the measurement year Latest Date of Service: Preserve the latest day of service for the lab tests for all patients in denominator. National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, CB Version V3

27 Measure Description / Technical Specifications Measure Citation Annual Monitoring for Patients on Persistent Medications: Diuretics This measure identifies patients age 18 or older who had at 180 ambulatory treatment days for diuretics during the measurement year who had at least 1 serum potassium and 1 serum creatinine therapeutic monitoring test during the measurement year. Patients in the denominator who had at least one serum potassium test and one serum creatinine therapeutic monitoring test during the measurement year. Patients who had at least 180 ambulatory treatment days for diuretics during the measurement year. At least 1 claim for a lab panel during the measurement year OR at least 1 claim for serum potassium and serum creatinine tests during the measurement year. Age >18 years on analysis date Has member and prescription during the measurement year, no more than 1 gap of no more than 45 days Has member and prescription eligibility with no gaps on analysis date Has 180-day supply of diuretics during the measurement year, translating claims forward, including prescription filled prior to the measuremet year if the days supply overlaps with the measurement year Has no claims from acute inpatient place of service during the measurement year OR has no claims from non-acute inpatient place of service during the measurement year National Committee for Quality Assurance. HEDIS Washington, DC: National Committee for Quality Assurance. Technical Specifications Vol 2, Latest Date of Service: Preserve the latest day of service for the lab tests for all patients in denominator. 27 CB Version V3