GLOBAL P4P. Pay for Performance (P4P) Program Guide

GLOBAL P4P Pay for Performance (P4P) Program Guide Contact: QualityPrograms@iehp.org Published: March 28, 2018

PROGRAM OVERVIEW This program guide provides an overview of the 2018 Global Quality Pay for Performance (GQ P4P) Program for Primary Care Providers (PCPs). In this third year of the program, IEHP has made enhancements based on feedback from Providers in an effort to continually improve program effectiveness. The IEHP GQ P4P Program for PCPs is designed to reward PCPs for high performance and year-over-year improvement in key quality performance measures. This program overview is designed for Physicians and their staff as an easy guide to help maximize GQ P4P. This year s GQ P4P Program continues to provide financial rewards to PCPs for improving healthcare quality across multiple domains and measures. The 2018 GQ P4P program focuses on performance-based incentives to PCPs for services rendered in 2018. If you would like more information about IEHP s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal at www.iehp.org, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054. What s New? The Program incentive for 2018 PCP performance is now $67 million - This is an increase of $29 million additional incentive dollars to the annual program budget Four measures were retired - Annual Monitoring for Patients on Persistent Medications - Total - Childhood Immunizations - Combo 3 - Comprehensive Diabetes Care - Eye Exam - Member Satisfaction Survey Access to Routine Care Two measures were moved to reporting-only status - Encounter Data PCP PMPY - SPD - Encounter Data PCP PMPY - Non-SPD Three measures were added to the Clinical Quality Domain - Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis - Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents - Concurrent Use of Opioids and Benzodiazepines (monitoring only) New Tier 1 and Tier 2 goal methodology includes a practical significance standard New Quality Per Member Per Month (PMPM) Payments methodology 1

Eligibility and Participation To be eligible for incentive payments in the 2018 GQ P4P Program, PCPs must meet the following criteria: Have at least 200 Medi-Cal Members assigned as of January 2018 Have at least 30 Members in the denominator as of December 2018 for each quality measure to qualify for scoring Have at least 3 quality measures that meet minimum denominator requirements in order for a global quality score to be calculated PCP enrollment into the GQ P4P program is automatic once the above three criteria have been met. Minimum Data Requirements Encounter Data Encounter data is foundational to performance scoring and is essential to success in the GQ P4P Program. Complete, timely and accurate encounter data should be submitted through normal reporting channels for all services rendered to IEHP Members. Please use the codes listed in Appendix 2 to help with proper coding to meet measure requirements. Lab Results Data from lab results data is also foundational to Program performance scoring. Providers should ensure they submit complete lab results data for services rendered to IEHP Members. Work with your IPA to ensure you are using the appropriate lab vendors for IEHP Members, and submitting lab results data to IEHP. Lab results that are performed in the office (e.g., point of care HbA1c testing, urine tests, etc.) should be coded and submitted through your encounter data. 2

Immunizations To maximize performance in immunization-based measures, IEHP strongly encourages all Providers to report all immunizations via the California Immunization Registry (CAIR2). For more information on how to register for CAIR2, please visit http://cairweb.org/. IEHP is working closely with CAIR in establishing a data sharing arrangement to be used in Global Quality P4P reporting. IEHP s Traditional P4P Data provided to IEHP as part of Traditional P4P Programs will be used as a data source to support the performance scoring methodology for measures in the Clinical Quality domain. P4P Program data are not used in scoring methodology for encounter data performance measures. P4P Program data are subject to retrospective data validation and must pass all quality assurance checks prior to inclusion into final Provider performance scores. Financial Overview Providers are eligible to receive financial rewards for performance excellence and for performance improvement. Financial rewards are based on a tiered system, providing increasing financial rewards for reaching higher tiered level performance. The 2018 GQ P4P Program incentive pool is $67 million for the PCP Program. Incentive dollars for the 2018 performance period will be distributed monthly via a new monthly per Member per month (PMPM) Quality Payment beginning in July 2019 and continuing through June 2020. 3

Performance Measures Appendix 1 provides a list of the 22 measures included in the 2018 GQ P4P Program and includes thresholds and benchmarks associated with respective tier goals. These measures have been categorized into four domains: Clinical Quality, Behavioral Health Integration; Patient Experience; Encounter Data. Most measures included in the Clinical Quality Domain primarily use standard Healthcare Effectiveness Data and Information Set (HEDIS ) process and outcomes measures that are based on the specifications published by the National Committee for Quality Assurance (NCQA). Non-HEDIS measures that are included in the Clinical Quality Domain come from the California Department of Health Care Services (DHCS) Medi-Cal Managed Care Quality Program and the Pharmacy Quality Alliance (PQA). Clinical Quality Domain Measures: Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (New) Breast Cancer Childhood Immunizations Combo 10 Comprehensive Diabetes Care HbA1c Control < 8 Concurrent Use of Opioids and Benzodiazepines (New) Immunizations for Adolescents Combo 2 Initial Health Assessment Medication Management for People with Asthma 75% rate Timely Postpartum Care Timely Prenatal Care Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (New) - Counseling for Physical Activity - Counseling for Nutrition - BMI Percentile Well-Child 3-6 Years of Life IEHP s HEDIS 2019 data set (measurement year 2018) will be used to evaluate Providers year-end performance. This measure set undergoes an independent audit review prior to rate finalization. The Initial Health Assessment (IHA) measure follows IEHP s IHA internal compliance monitoring methodology and is not a HEDIS measure. 4

The Concurrent Use of Opioids and Benzodiazepines measure specification is developed and maintained by the PQA. This measure will not be used for incentive calculations but will be collected to establish a baseline rate for 2018. See Appendix 2 for measure details. Behavioral Health Integration Domain Measures: The Behavioral Health Integration Domain includes two measures derived from the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) measure set.1 for Clinical Positive Depression with Follow-Up Plan Patient Experience Domain Measures: Patient Experience Domain measures include Member Satisfaction Survey questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey that is published by the Agency for Healthcare Research and Quality (AHRQ). IEHP conducts a Member Satisfaction Survey that is a modified CAHPS survey and is the sole data source supporting the performance scoring methodology for this measure domain. The IEHP Member Satisfaction Survey is conducted between June and December of each year. Surveys received from the 2018 Member Satisfaction Survey will be used to calculate the Patient Experience Domain measures. A copy of the current Member Satisfaction Survey is included in Appendix 4. Access to Care Needed Right Away Coordination of Care Rating of Personal Doctor Encounter Data Domain Measures: The fourth measure domain is Encounter Data. The measures in this domain will not be used for incentive calculations but will be produced for monitoring purposes only. Since encounter data is critical to capturing the services provided in primary care settings, encounter data monitoring is essential in performance measurement improvement efforts. PCPs are encouraged to work with their IPA throughout the year to monitor encounter data completeness and reporting to IEHP. 1 For information on the PQRS measure set: https://www.cms.gov/medicare/ Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html 5

Scoring Methodology Payment will be awarded to PCPs based on individual performance in reaching established Quality Goals (e.g., Tier Goals for each measure). In the Clinical Quality Domain, HEDIS measure results are based on each measure s total eligible population assigned to the PCP. The eligible population is defined as the set of Members who meet the denominator criteria specified in the current year s HEDIS Technical Specifications (Volume 2) published by NCQA. Members in the eligible population are attributed to the assigned PCP on each measure s anchor date, as defined within the HEDIS measure. Members contribute to a PCP s HEDIS measure denominator if continuous enrollment criteria are met at the health plan level. For each measure, the HEDIS score reflects the proportion of the eligible population that is in compliance with the numerator criteria as defined in the current HEDIS technical specifications (Volume 2). In the Clinical Quality Domain, Non-HEDIS measure (i.e., Initial Health Assessment) results are based on new health plan Members who are assigned to the PCP during the measurement year and who remain enrolled with IEHP and the PCP through the 120 day post-enrollment period. See Appendix 2 for measure details. In the Patient Experience Domain, monthly Member Satisfaction Survey measures are based on Members who meet eligibility criteria to receive a mailed survey between June and December of the measurement year. Members eligible to receive a Member Satisfaction Survey must have been continuously enrolled with IEHP for at least six months in the measurement year (2018) and must have had an office visit in the prior six months based on encounter data submitted to IEHP. Members who meet the survey eligibility criteria are randomly sampled to receive a survey. Survey measure results are attributed to the Member s assigned PCP based on the most recent encounter that qualified the Member to be eligible for the survey. A Member is eligible to receive only one survey per calendar year. For PCPs, the Encounter Data Domain measures assess the volume of PCP encounters received for all assigned PCP Members. The denominator is all assigned Medi-Cal Members each month of the measurement year (2018). All monthly assigned Members are summed to create the denominator (i.e., Member months). The numerator is the sum of all unique encounters (e.g., unique Member, Provider, date of service) in the measurement year for all assigned Members in the denominator. A Per Member Per Year (PMPY) rate is calculated following this formula: (Total Unique Encounters / Total Member Months) x 12 = PMPY 6

Payment Methodology PCP performance for each quality measure will be given a point value (i.e., a Quality Score). Points are assigned based on the Tier Goal achieved (i.e. Tier 1 = one point, Tier 2 = two points, Tier 3 = three points) for each measure. Providers who have at least three quality measures that meet the minimum denominator size (n = 30) will be considered for payment calculations. An average of all eligible Quality Scores will determine the overall GQ Performance Score. GQ P4P Program payments will be awarded according to the following formula: [Global Quality Performance Score] x [# Medi-Cal Average Member Months] = Member Points [Member Points] x [Payment Amount per Member Point] = Incentive Payout Total The payment amount per Member point is dependent on the total incentive money available for PCPs. PCP PMPM Quality Payment Methodology From July 2019 June 2020, PCPs will receive a monthly PMPM (per Member per month) quality payment based on 2018 GQ P4P performance using the following formula: 2018 Global Quality P4P Payments Total Medi-Cal Member Months Quality PMPM Payment Amount PCP payment example: PCP with monthly average of 2,500 Members (30,000 Member Months) and 2.0 GQ Quality Score (A) Global P4P Payments: $247,200 Total Member Months: 30,000 Quality PMPM Payment Amount: $8.24 ~ $20,600 monthly payment * ~$247,200 annual payment * *Assuming stable membership volume 7

Quality Incentive Payout Timeline: Provider Communication Timeline Interim 2017 GQ P4P payment (PCP & IPA) Final 2017 GQ P4P payment (PCP & IPA) Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 End of Traditional PCP P4P Program Monthly Quality PMPM payments based on 2017 GQ P4P Performance year results (PCP only) Monthly Quality PMPM payments based on 2017 GQ P4P Performance year results (PCP only) Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Getting Help Monthly Quality PMPM payments based on 2018 GQ P4P Performance year results (PCP & IPA) Please direct questions and/or comments related to this program to IEHP s Provider Call Center at 909-890-2054 or to IEHP s Quality Department at QualityPrograms@iehp.org. Program Terms and Conditions Participation in IEHP s GQ P4P Program, as well as acceptance of incentive payments, does not in any way modify or supersede any terms or conditions of any agreement between IEHP and Providers or IPAs, whether that agreement is entered into, prior to or subsequent to, the date of this communication. There is no guarantee of future funding for, or payment under, any IEHP Provider incentive program. The IEHP GQ P4P Program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at IEHP s sole discretion. Criteria for calculating incentive payments are subject to change at any time, with or without notice, at IEHP s sole discretion. In consideration of IEHP s offering of the IEHP GQ P4P Program, participants agree to fully and forever release and discharge IEHP from any and all claims, demands, causes of action, and suits, of any nature, pertaining to or arising from the offering by IEHP of the IEHP GQ P4P Program. The determination of IEHP regarding performance scoring and payments under the IEHP GQ P4P Program is final. As a condition of receiving payment under the IEHP GQ P4P Program, Providers and IPAs must be active and contracted with IEHP and have active assigned Members at the time of payment. 8

APPENDIX 1: 2018 PCP Global Quality P4P Program Measures 2018 GQ P4P PROGRAM MEASURE LIST Domain Measure Name Population Tier 1 Tier 2 Tier 32 Clinical Quality Clinical Quality Clinical Quality Behavioral Health Integration Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 1 Comprehensive Diabetes Care - HbA1c Control <8 Medication Management for People with Asthma - 75% for Clinical Depression in Primary Care Adult Adult Adult Improvement demonstrated by meeting the following 2 conditions: Improvement demonstrated by meeting the following 2 conditions: 39.0% 58.0% 48.0% 10% 20% Adult and reduction reduction Adolescent in noncompliance in noncompliance 50.0% Behavioral Health Positive Depression Adult and Integration with Follow-Up Plan Adolescent 90.0% AND AND Clinical Quality Breast Cancer Women 71.0% Improvement Improvement Clinical Quality Women of at least 2.0 of at least 3.0 70.0% Clinical Quality Timeliness of Prenatal Care Women percentage percentage 91.0% points points Clinical Quality Postpartum Care Women 74.0% Childhood Immunizations - Combo 10 Clinical Quality Child 46.0% Clinical Quality Improvement Improvement Immunizations for Adolescents - demonstrated demonstrated Combo 2 Child by meeting by meeting 32.3% Clinical Quality Well-Child Visits 3-6 Years of Life Child the following the following 83.0% Weight Assessment and Counseling 2 conditions: 2 conditions: Clinical Quality for Nutrition and Physical Activity for Children and Adolescents 1 - Counseling for Physical Activity Clinical Quality Clinical Quality Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 1 -Counseling for Nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 1 - BMI Percentile Child 10% reduction in noncompliance 20% reduction in noncompliance 72.0% Child 80.0% AND AND Improvement Improvement Child of at least 2.0 percentage of at least 3.0 percentage 86.0% points points Clinical Quality Initial Health Assessment All 50.0% Clinical Quality Patient Experience Patient Experience Patient Experience Encounter Data Encounter Data Concurrent Use of Opioids and Benzodiazepines 1 ** Member Satisfaction Survey - Access to Care Needed Right Away Member Satisfaction Survey - Coordination of Care Member Satisfaction Survey - Rating of Personal Doctor Encounter Data for PCPs PMPY SPD** Encounter Data for PCPs PMPY - Non-SPD** All Baseline Reporting Year All 84% 86% 88% All 82% 85% 86% All 81% 83% 85% All 2 2.5 3 All 1.5 2 2.5 1 New Measure for 2018. 2Tier 3 goals set at the 90th percentile as published in the NCQA 2017 Mid-year Benchmarks and Thresholds and 2016 HEDIS and Exclusion Audit Means, Percentiles source files. ** Reporting Only Measure. Not eligible for incentive dollars. 9

APPENDIX 2: Measures Overview Population: Adult Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) Methodology: HEDIS Measure Description: The percentage of adults 18-64 years of age (with a diagnosis of acute bronchitis) who were not dispensed an antibiotic prescription on or three days after the Index Episode Start Date (IESD). Episode Date is the date of service for any outpatient or emergency department (ED) visit during the Intake Period (January 1, 2018-December 24, 2018) with a diagnosis of acute bronchitis IESD: the earliest Episode Date during the Intake Period with a diagnosis of acute bronchitis that meets all of the following criteria: 1. Episode Date is the date of service for any outpatient or ED visit during the Intake Period with a diagnosis of acute bronchitis. 2. A 30-day Negative Medication History prior to the Episode Date. 3. A 12-month Negative Comorbid Condition History prior to and including the Episode Date. 4. A Negative Competing Diagnosis during the 38-day period from 30 days prior to the Episode Date through seven days after the Episode Date. 5. The member was continuously enrolled one year prior to the Episode Date through seven days after the Episode Date. The measure is reported as an inverted rate [1 (numerator/eligible population)]. A higher rate indicates appropriate treatment of adults with acute bronchitis (i.e., the proportion for whom antibiotics were not prescribed). Members in hospice are excluded from the eligible population. Exclude denied claims when assessing numerator criteria. Do not include ED visits or observation visits that result in an inpatient stay. When an ED or observation visit and an inpatient stay are billed on separate claims, the visit results in an inpatient stay when the admission date for the inpatient stay occurs on the ED/ observation date of service or one calendar day after. An ED or observation visit billed on the same claim as an inpatient stay is considered a visit that resulted in an inpatient stay. 10

Denominator: Members 18-64 years of age, who had an outpatient visit, an observation visit or an ED visit between January 1 December 24 of the measurement year (2018) with a diagnosis of acute bronchitis. Numerator: Dispensed prescription for an antibiotic medication on or three days after IESD for the Members in denominator. Description AAB ANTIBIOTIC MEDICATIONS Prescription Aminoglycosides Amikacin Tobramycin Gentamicin Streptomycin Aminopenicillins Amoxicillin Ampicillin Beta-lactamase inhibitors Amoxicillin-clavulanate Piperacillin-tazobactam Ticarcillin-clavulanate Ampicillin-sulbactam First-generation Cefadroxil Cefazolin Cephalexin cephalosporins Fourth-generation cephalosporins Cefepime Ketolides Telithromycin Lincomycin derivatives Clindamycin Lincomycin Azithromycin Erythromycin Erythromycin Macrolides Clarithromycin Erythromycin lactobionate ethylsuccinate Erythromycin stearate Aztreonam Daptomycin Metronidazole Miscellaneous antibiotics Chloramphenicol Erythromycin- Vancomycin Dalfopristin-quinupristin sulfisoxazole Linezolid Penicillin G benzathine- Penicillin G procaine Penicillin V potassium Natural penicillins procaine Penicillin G sodium Penicillin G Penicillin G potassium benzathine Penicillinase resistant Dicloxacillin Nafcillin Oxacillin penicillins Quinolones Ciprofloxacin Levofloxacin Norfloxacin Gemifloxacin Moxifloxacin Ofloxacin Rifamycin derivatives Rifampin Second-generation cephalosporin Cefaclor Cefoxitin Cefuroxime Cefotetan Cefprozil Sulfonamides Sulfadiazine Sulfamethoxazole-trimethoprim Tetracyclines Doxycycline Minocycline Tetracycline Cefdinir Cefotaxime Ceftibuten Third-generation Cefditoren Cefpodoxime Ceftriaxone cephalosporins Cefixime Ceftazidime Fosfomycin Nitrofurantoin macrocrystals-monohydrate Urinary anti-infectives Nitrofurantoin Nitrofurantoin macrocrystals Trimethoprim 11

Comprehensive Diabetes Care (CDC) HbA1c Control (<8.0) Methodology: HEDIS Measure Description: The percentage of Members 18-75 years of age with diabetes (type 1 and type 2) who had the following: HbA1c Control (<8.0%) This includes diabetics whose most recent HbA1c test during the measurement year (2018) has a value <8.0%. - The Member is not numerator compliant if the result for the most recent HbA1c test is 8.0% or is missing a result, or if an HbA1c test was not done during the measurement year (2018). The eligible population in this measure meets all of the following criteria: 1. Members who are 18-75 years old as of December 31 of the measurement year (2018). 2. Continuous enrollment in the measurement year (2018) with no more than one gap of up to 45 days during the measurement year. 3. Members who meet any of the following criteria during the measurement year (2018) or the year prior to the measurement year (2017). Count services that occur over both years: At least two outpatient visits, observation visits, ED visits or nonacute inpatient encounters on different dates of service, with a diagnosis of diabetes. Visit type need not be the same for the two visits. At least one acute inpatient encounter with a diagnosis of diabetes. Members who were dispensed insulin or hypoglycemics/ antihyperglycemics on an ambulatory basis during the measurement year (2018) or the year prior to the measurement year (2017). CODES TO IDENTIFY HbA1c TESTS Service Code Type Code Code Description HbA1c Test (<7.0%) CPT-CAT-II 3044F Hg A1c Level Lt 7.0% HbA1c Test CPT 83036 Hemoglobin Glycated HbA1c Test CPT 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use HbA1c Test CPT-CAT-II 3044F Most recent hemoglobin A1c (HbA1c) level < 7.0% HbA1c Test CPT-CAT-II 3045F Most recent hemoglobin A1c (HbA1c) level 7.0-9.0% HbA1c Test CPT-CAT-II 3046F Most recent hemoglobin A1c (HbA1c) level > 9.0% HbA1c Test LOINC 17856-6 Hemoglobin A1c/hemoglobin.total In Blood By Hplc HbA1c Test LOINC 4548-4 Hemoglobin A1c/hemoglobin.total In Blood HbA1c Test LOINC 4549-2 Hemoglobin A1c/hemoglobin.total In Blood By Electrophoresis 12

Members who met any of the following criteria are excluded: 1. Members in hospice are excluded. 2. Members who did not have a diagnosis of diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017) and who had a diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year (2018) or the year prior to the measurement year (2017). Denominator: Members 18-75 years of age who meet all the criteria for eligible population. Numerator: Members in the denominator who had the most recent HbA1c level <8 during the measurement year (2018). Medication Management for People with Asthma 75% rate (MMA) Methodology: HEDIS Measure Description: The percentage of Members 5 64 years of age during the measurement year (2018) who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75 percent of their treatment period. (Treatment Period: The period of time beginning on the Index Prescription Start Date through December 31,2018.) The eligible population in this measure meets all of the following criteria: 1. Age 5-64 as of December 31 of the measurement year (2018). 2. Continuous enrollment during the measurement year (2018) and the year prior to the measurement year (2017) with no more than one gap in enrollment of up to 45 days during each year of continuous enrollment. 3. Members had: a) At least one ED visit with a principal diagnosis of asthma, OR b) At least one acute inpatient encounter with a principal diagnosis of asthma, OR c) At least four outpatient visits or observation visits on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events for any controller medication or reliever medication. Visit type need not be the same for the four visits, OR d) At least four asthma medication dispensing events for any controller medication or reliever medication. 13

Description ASTHMA CONTROLLER MEDICATIONS: Prescription Antiasthmatic Dyphylline-guaifenesin Guaifenesin-theophylline combinations Antibody inhibitors Omalizumab Anti-interleukin-5 Mepolizumab Reslizumab Inhaled steroid Budesonide-formoterol Fluticasone-vilanterol combinations Fluticasone-salmeterol Mometasone-formoterol Beclomethasone Flunisolide Inhaled corticosteroids Budesonide Fluticasone CFC free Ciclesonide Mometasone Leukotriene modifiers Montelukast Zafirlukast Zileuton Mast cell stabilizers Cromolyn Methylxanthines Dyphylline Theophylline ASTHMA RELIEVER MEDICATIONS Description Prescriptions Short-acting, inhaled beta-2 agonists Albuterol Levalbuterol Pirbuterol Members who meet any of the following criteria are excluded: 1. Members who had no asthma controller medications dispensed during the measurement year (2018). 2. Members in hospice are excluded. 3. Members with the following diagnosis any time during the Member s history through December 31 of the measurement year (2018) are excluded: COPD, Acute Respiratory Failure, Cystic Fibrosis, Chronic respiratory conditions and Emphysema. Denominator: Members 5 64 years of age during the measurement year (2018) who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Numerator: Members in denominator who remained on an asthma controller medication for at least 75% of their treatment period. 14

Population: Adult and Adolescent for Clinical Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool during the measurement year (2018). Denominator: All Members aged 12 years and older with a PCP visit in the measurement year (2018). Member counted only once in the denominator. Service for Clinical for Clinical for Clinical for Clinical PRIMARY CARE PROVIDER VISIT CODES: Code Code Code Description Type CPT 99201 CPT 99202 CPT 99203 CPT 99204 Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Typically, 20 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Typically, 30 minutes are spent face-to- face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 15

Service for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical PRIMARY CARE PROVIDER VISIT CODES: Code Type Code CPT 99205 CPT 99212 CPT 99213 CPT 99214 CPT 99215 G0101 G0402 G0438 G0439 Code Description Office or other outpatient visit for the evaluation and management of a new patient which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Typically, 25 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient which requires at least two of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Initial preventive physical examination face-to-face visits services limited to new beneficiary during the first 12 months. Annual wellness visit includes a personalized prevention plan of service (pps) initial visit. Annual wellness visit includes a personalized prevention plan of service (pps) subsequent visit. 16

Service for Clinical for Clinical PRIMARY CARE PROVIDER VISIT CODES: Code Type Code Code Description G0444 Annual depression screening 15 minutes. CPT 97003 Occupational therapy evaluation Numerator: Members screened for clinical depression on the date of the encounter using an age appropriate standardized tool during the measurement year (2018). CODES TO IDENTIFY SCREENING FOR CLINICAL DEPRESSION: Service Code Type Code Code Description for Clinical CPT 1220F Patient screened for depression (sud) for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical for Clinical CPT CPT CPT CPT 3351F 3352F 3353F 3354F Negative screen for depressive symptoms as categorized by using a standardized depression screening/ assessment tool (mdd) No significant depressive symptoms as categorized by using a stan dardized depression assessment tool (mdd) Mild to moderate depressive symptoms as categorized by using a standardized depression screening/ assessment tool (mdd) Clinically significant depressive symptoms as categorized by usin g a standardized depression screening/assessment tool (mdd) CPT 3725F for depression performed (dem) G0444 Annual depression screening 15 minutes G8431 G8433 G8510 G8511 G8940 Positive screen for clinical depression using a standardized tool and a follow-up plan documented for clinical depression using a standardized tool not documented patient not eligible/appropriate Negative screen for clinical depression using a standardized tool patient not eligible/appropriate for follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified for clinical depression documented follow-up plan not documented patient not eligible/ appropriate 17

Definitions: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Tool A normalized and validated depression screening tool developed for the Member population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to: Adolescent Tools (12-17 years): Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), and PRIME MD-PHQ2 Adult Tools (18 years and older): Patient Health Questionnaire (PHQ-9 or PHQ-2), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale, and PRIME MD-PHQ2 18

Positive Depression with Follow Up Plan Methodology: IEHP-defined Quality Metric Modified from PQRS measure (NQF 0418) Measure Description: The percentage of Members aged 12 years and older who screened positive for clinical depression using an age appropriate standardized depression screening tool who also have a follow-up plan documented during the measurement year (2018). Denominator: All Members aged 12 years and older with a PCP visit with a positive depression screening in the measurement year (2018). Member counted only once in the denominator. CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING DURING A PRIMARY CARE PROVIDER VISIT: Service Code Type Code Code Description Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan Positive Depression with Follow Up Plan CPT CPT 3353F 3354F G8431 G8511 G8940 Mild to moderate depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment tool (mdd) Positive screen for clinical depression using a standardized tool and a follow-up plan documented Screen for clinical depression using a standardize tool documented follow up plan not documented reason not specified for clinical depression documented follow-up plan not documented patient not eligible/ appropriate Numerator: Members screened positive for clinical depression with a follow-up plan documented during the measurement year (2018). 19

CODES TO IDENTIFY POSITIVE DEPRESSION SCREENING WITH FOLLOW-UP PLAN: Service Code Type Code Code Description Positive Depression Plan for follow-up care for major depressive disorder CPT 0545F with Follow Up Plan documented (mdd adol) Positive Depression Positive screen for clinical depression using a G8431 with Follow Up Plan standardized tool and a follow-up plan documented Positive Depression with Follow Up Plan G8940 for clinical depression documented follow-up plan not documented patient not eligible/ appropriate Definitions: Follow-Up Plan Documented follow-up for a positive depression screening must include one or more of the following: Additional evaluation for depression Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression 20

Population: Women Breast Cancer (BCS) Methodology: HEDIS Measure Description: The percentage of women 50 74 years of age who had a mammogram to screen for breast cancer any time on or between October 1 two years prior to the measurement year (2016) and December 31 of the measurement year (2018). The eligible population in the measure meets all of the following criteria: 1. Women 52-74 years as of December 31 of the measurement year (2018). 2. Continuous enrollment from October 1 two years prior to the measurement year (2016) through December 31 of the measurement year (2018) with no more than one gap in enrollment of up to 45 days for each calendar year of continuous enrollment. No gaps in enrollment are allowed from October 1 two years prior to the measurement year (2016) through December 31 two years prior to the measurement year (2016). CODES USED TO IDENTIFY MAMMOGRAPHY Service Code Type Code Code Description Breast Cancer CPT 77055 Mammography Unilateral Breast Cancer CPT 77056 Mammography Bilateral Breast Cancer CPT 77057 Mammography Bilateral (2-view Film Study Of Each Breast) Breast Cancer CPT 77061 Digital Breast Tomosynthesis Unilateral Breast Cancer CPT 77062 Digital Breast Tomosynthesis Bilateral Breast Cancer CPT 77063 Digital Breast Tomosynthesis Bilateral (list Separately In Addition To Code For Primary Procedure) Breast Cancer CPT 77065 Diagnostic Mammography W/computer-aided Detection; Unilateral Breast Cancer CPT 77066 Diagnostic Mammography W/computer-aided Detection; Bilateral Breast Cancer CPT 77067 Mammography Bilateral (2-view Film Study Of Each Breast Including Computer-aided Detection (cad) Breast Cancer G0202 Mammography, Bilateral (2-view Study Of Each Breast), Including Computer-aided Detection (cad) When Performed (g0202) Breast Cancer G0204 Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Bilateral (g0204) Breast Cancer G0206 Diagnostic Mammography, Including Computer-aided Detection (cad) When Performed; Unilateral (g0206) 21

Members who meet any of the following criteria are excluded: 1. Members who have had a bilateral mastectomy any time during their history through December 31, 2018 may be excluded. To exclude Members who meet the exclusion criteria, please complete Member Historical Data Form and fax to IEHP s Quality Informatics Team at 909-477-8568. A copy of the Historical Data Form is available in Appendix 3. 2. Members in hospice are excluded. Denominator: Women 52-74 years of age who met the criteria for eligible population. Numerator: Members in denominator who had one or more mammograms any time on or between October 1 two years prior to the measurement year (2016) and December 31 of the measurement year (2018). (CCS) Methodology: HEDIS Measure Description: The percentage of Women 21 64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21 64 who had cervical cytology performed every 3 years. Women age 30 64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. The eligible population in the measure meets all of the following criteria: 1. Women 24-64 years as of December 31 of the measurement year (2018). 2. Continuous enrollment during the measurement year (2018) with no more than one gap in enrollment of up to 45 days. CODES TO IDENTIFY CERVICAL CYTOLOGY Service Code Type Code Code Description CPT 88141 CPT 88142 Cytopathology Cervical Or Vaginal (any Reporting System) Requiring Interpretation By Physician (List separately In addition to code for technical service.) Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Manual screening under Physician supervision 22

CODES TO IDENTIFY CERVICAL CYTOLOGY Service Code Type Code Code Description CPT 88143 CPT 88147 CPT 88148 CPT 88150 CPT 88152 CPT 88153 CPT 88154 CPT 88164 CPT 88165 CPT 88166 CPT 88167 CPT 88174 CPT 88175 G0123 G0124 Cytopathology Cervical Or Vaginal (any Reporting System) Collec Ted In Preservative Fluid Automated Thin Layer Preparation; manual screening Under Physician Supervision: With manual screening and rescreening Under Physician Supervision Cytopathology Smears Cervical Or Vaginal By Automated System Under Physician Supervision Cytopathology Smears Cervical Or Vaginal By Automated System With Manual Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal Manual Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Computer-assisted Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal With Manual And Computer-assisted Rescreening Using Cell Selection And Review Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) Manual Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Computer-assisted Rescreening Under Physician Supervision Cytopathology Slides Cervical Or Vaginal (the Bethesda System) With Manual And Computer-assisted Rescreening Using cell selection and review Under Physician Supervision Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated Thin Layer Preparation Cytopathology Cervical Or Vaginal (any Reporting System) Collected In Preservative Fluid Automated By System Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, By Cytotechnologist Under Physician Supervision (g0123) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, Requiring Interpretation By Physician (g0124) 23

CODES TO IDENTIFY CERVICAL CYTOLOGY Service Code Type Code Code Description LOINC LOINC LOINC LOINC LOINC LOINC LOINC G0141 G0143 G0144 G0145 G0147 G0148 P3000 P3001 Q0091 Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System, With Manual Rescreening, Requiring Interpretation By Physician (g0141) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With Manual And Rescreening By Cytotechnologist Under Physician Supervision (g0143) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With By Automated System, Under Physician Supervision (g0144) Cytopathology, Cervical Or Vaginal (any Reporting System), Collected In Preservative Fluid, Automated Thin Layer Preparation, With By Automated System And Manual Rescreening Under Physician Supervision (g0145) Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System Under Physician Supervision (g0147) Cytopathology Smears, Cervical Or Vaginal, Performed By Automated System With Manual Rescreening (g0148) Papanicolaou Smear, Cervical Or Vaginal, Up To Three Smears, By Technician Under Physician Supervision (p3000) Papanicolaou Smear, Cervical Or Vaginal, Up To Three Smears, Requiring Interpretation By Physician (p3001) Papanicolaou Smear; Obtaining, Preparing And Conveyance Of Cervical Or Vaginal Smear To Laboratory (q0091) 10524-7 Microscopic Observation [identifier] In Cervix By Cyto Stain Microscopic Observation [identifier] In Cervix By Cyto Stain 18500-9 Thinprep General Categories [interpretation] Of Cervical Or Vaginal 19762-4 Smear Or Scraping By Cyto Stain Statement Of Adequacy [interpretation] Of Cervical Or Vaginal 19764-0 Smear Or Scraping By Cyto Stain Microscopic Observation [identifier] In Cervical Or Vaginal 19765-7 Smear Or Scraping By Cyto Stain Microscopic Observation [identifier] In Cervical Or Vaginal 19766-5 Smear Or Scraping By Cyto Stain Narrative Cytology Study Comment Cervical Or Vaginal Smear Or 19774-9 Scraping Cyto Stain 24

CODES TO IDENTIFY CERVICAL CYTOLOGY Service Code Type Code Code Description LOINC 33717-0 Cytology Cervical Or Vaginal Smear Or Scraping Study Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto LOINC 47527-7 Stain.thin Prep Cytology Report Of Cervical Or Vaginal Smear Or Scraping Cyto LOINC 47528-5 Stain CODES TO IDENTIFY HPV TESTS Service Code Type Code Code Description Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT 87620 Papillom Avirus Human Direct Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT 87621 Papillom Avirus Human Amplified Probe Technique Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT 87622 Papillom Avirus Human Quantification Infectious Agent Detection By Nucleic Acid (dna Or Rna) CPT 87624 Human Pap Illomavirus (hpv) High-risk Types (eg 16 18 31 33 35 39 45 51 52 56 58 59 68) CPT 87625 LOINC G0476 21440-3 LOINC 30167-1 LOINC 38372-9 LOINC LOINC 59263-4 59264-2 LOINC 59420-0 LOINC 69002-4 Infectious Agent Detection By Nucleic Acid (dna Or Rna) Human Pap Illomavirus (hpv) Types 16 And 18 Only Includes Type 45, If Performed Infectious Agent Detection By Nucleic Acid (dna Or Rna); Human Papillomavirus (hpv), High-risk Types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) For, Must Be Performed In Addition To Pap Test (g0476) Human Papilloma Virus 16+18+31+33+35+45+51+52+56 Dna [presence] In Cervix By Dna Probe Human Papilloma Virus 16+18+31+33+35+39+45+51+52+5 6+58+59+68 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 6+11+16+18+31+33+35+39+42+43+4 4+45+51+52+56+58+59+68 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus 16+18+31+33+35+39+45+51+52+56 +58+59+66+68 Dna [presence] In Cervix By Probe And Signal Amplification Method Human Papilloma Virus E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method 25

CODES TO IDENTIFY HPV TESTS Service Code Type Code Code Description LOINC 71431-1 LOINC 75694-0 LOINC 77379-6 LOINC LOINC LOINC LOINC 77399-4 77400-0 82354-2 82456-5 LOINC 82675-0 Human Papilloma Virus 31+33+35+39+45+51+52+56+58 +59+66+68 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 18+45 E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papiloma Virus 16 And 18 And 31+33+35+39+45+51+5 2+56+58+59+66+68 Dna [interpretation] In Cervix Human Papilloma Virus 16 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 18 Dna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 And 18+45 E6+e7 Mrna [identifier] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16 E6+e7 Mrna [presence] In Cervix By Probe And Target Amplification Method Human Papilloma Virus 16+18+31+33+35+39+45+51+52+56 +58+59+66+68 Dna [presence] In Cervix By Probe And Target Amplification Method Members who meet any of the following criteria are excluded: 1. Members who have had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during their history through December 31, 2018 may be excluded. To exclude Members who meet the exclusion criteria, please complete Member Historical Data Form and fax to IEHP s Quality Informatics Team at: 909-477-8568. A copy of the Historical Data Form is available in Appendix 3. 2. Members in hospice are excluded. Denominator: Women 24-64 years of age who met the criteria for eligible population. Numerator: Women in the denominator who received a timely screen for cervical cancer. 26

Timeliness of Prenatal Care (PPC) Methodology: HEDIS Measure Description: The percentage of deliveries of live births on or between November 6, 2017 and November 5, 2018 that received a prenatal care visit as a Member of the organization in the first trimester on the enrollment start date or within 42 days of enrollment in the organization. The eligible population in this measure meets all of the following criteria: 1. Continuous enrollment 43 days prior to delivery through 56 days after delivery with no allowable gap. 2. Member who delivered a live birth on or between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018). Include women who delivered in any setting. Multiple births - Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year (2017) and November 5 of the measurement year (2018) count twice. Women who had multiple live births during one pregnancy count once. CODES TO IDENTIFY STAND ALONE PRENATAL VISITS Service Code Type Code Code Description Prenatal Visit CPT 0500F Initial Prenatal Care Visit Prenatal Visit CPT 0501F Prenatal Flow Sheet Prenatal Visit CPT 0502F Subsequent Prenatal Care Visit Prenatal Visit CPT 99500 Home Visit Prenatal Prenatal Visit H1000 Prenatal Care, At-risk Assessment Prenatal Visit H1001 Prenatal Care, At-risk Enhanced Service; Antepartum Management Prenatal Visit H1002 Prenatal Care, At Risk Enhanced Service; Care Coordination Prenatal Visit H1003 Prenatal Care, At-risk Enhanced Service; Education Prenatal Visit H1004 Prenatal Care, At-risk Enhanced Service; Follow-up Home Visit Prenatal Visit Z1032 Initial Antepartum Office Visit Prenatal Visit Z1034 Antepartum Follow-Up Visit Prenatal care visit to an OB/GYN or other prenatal care practitioner or PCP. For visits to a PCP, a diagnosis of pregnancy must be present. Documentation in the medical record must include a note indicating the date when the prenatal care visit occurred, and evidence of one of the following. A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used). 27