QI Program

2017 QUALITY PROVIDER INCENTIVE PROGRAM

YEAR 3:  January 1 – December 31, 2017

 

PROGRAM OVERVIEW

We are pleased to announce Year 3 of the Quality Provider Incentive Program.  Providers are rewarded for giving quality care to California Health & Wellness members.  The 2017 program provides significant financial rewards for closing care gaps, demonstrating year-over-year improvement and connecting with your new CHW members by completing an Initial Health Assessment (IHA).

ELIGIBILITY

To be eligible for care gap closure and Initial Health Assessment incentive payments providers must be active and contracted with California Health & Wellness.  Providers with an average member panel size of 1000 or more members during 2017 are also eligible for the year-over-year improvement reward.

PARTICIPATION

  • There is no need to sign up.  All contracted providers are eligible to participate in the program.
  • Reporting and payout is based on Tax Identification Number
  • Providers need to submit timely, complete and accurate claims through their normal submission process for all services rendered to CH&W members.
  • Provider submission of data to the Immunization Registry is essential for success in this reward program.

What’s NEW In Year 3?

  • CHW will no longer accept medical records as proof of care gap closures.   Care gap closures will be based on claims and encounter data.
  • Removed WCC – BMI %
  • Removed Star Ratings Incentive and replaced with Overall Quality Improvement incentive.
  • Removed NOP Bonus
  • Added New Member Initial Health Assessment (IHA) Incentive

PROGRAM DETAILS - 3 INCENTIVE OPPORTUNITIES

INCENTIVE #1: PATIENT LEVEL COMPLIANCE

CH&W will pay for each Care Gap closed, based on claims submissions for the following measures

Measure

Description

Payout Amount

CCS

Cervical Cancer Screening

$100

CDC – HbA1c Testing

Comprehensive Diabetes Care – HbA1c Testing

$75

CDC – Eye Exam

Comprehensive Diabetes Care – Eye Exam

$25

PPC –Prenatal

Prenatal and Postpartum Care – Timeliness of Prenatal Care

$75

PPC – Postpartum

Prenatal and Postpartum Care - Postpartum

$25

CIS- Combo 3

Childhood Immunization Status – Combo 3

$100

IMA – Combo 2

Immunization for Adolescents – Combo 2

$25

WCC – Counselling Nutrition

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents - Nutrition

$15

WCC – Counselling Physical Activity

Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents – Physical Activity

$15

W34

Well-Child Visits in the 3rd, 4th, 5th and 6th years of life

$75


*Performance on the measures highlighted in bold are weighted heavier and have a greater role in determining performance scores and rankings and incentive payments.  Please pay extra attention to these measures to maximize performance and incentive rewards.

INCENTIVE #2:  OVERALL QUALITY PERFORMANCE IMPROVEMENT

Eligibility for this reward is based on 2 steps:

Step 1:  Providers must have an average member panel size of 1000+ CHW members throughout 2017 and

Step 2:  Provider must show year-over-year improvement in their overall rating.  Providers will be notified of their final 2016 overall rating, which will be their baseline for the 2017 program.  If at the end of the 2017 program their overall rating is greater than their baseline rating they will be eligible for this reward.

Payout Determination:

At the end of the year, the provider’s final rate for each measure will determine their Level of Performance.  The final rates will be benchmarked against the Medicaid National Percentile rankings which correlate to one of four levels. Each level is assigned a monetary value.  Payout is determined by multiplying the Level of Performance per measure by the average number of assigned members during 2017 (must be 1000+).

Levels of Performance

Assigned Value

Level 1 = Medicaid 25th National Percentile (Minimum Performance Level)

$0.64 PMPM

Level 2 = Medicaid 50th National Percentile

$0.71 PMPM

Level 3 = Medicaid 75th National Percentile

$0.79 PMPM

Level 4 = Medicaid 90th National Percentile

$0.86 PMPM

PMPM = Per Member Per measure

The following measures are used for calculating the Overall Quality Performance Improvement incentive:

  • CCS – Cervical Cancer Screening
  • CDC – HbA1c Testing
  • CDC – Eye Exam
  • PPC – Timeliness of Prenatal Care
  • PPC – Postpartum Care
  • CIS – Childhood Immunization Status – Combo 3
  • IMA – Immunization for Adolescents – Combo 2
  • WCC – Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents – Nutrition
  • WCC – Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents – Physical Activity
  • W34 – Well-Child Visits in the 3rd, 4th, 5th and 6th years of life
  • AAB – Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
  • LBP – Use of Imaging Studies for Low Back Pain
  • AMR – Asthma Medication Ratio

INCENTIVE #3:  INITIAL HEALTH ASSESSMENT (IHA)

California Health & Wellness believes that members who establish a patient – physician relationship are more likely to receive important preventive screenings, have fewer emergency department visits and experience improved satisfaction with their primary care provider. 

To encourage the establishment of the members newly assigned to the provider panel we will pay $30.00 for each Initial Health Assessment (IHA) completed within 120 days of assignment to your practice.  There are 2 components to an IHA and both must be completed for the incentive credit:

  • Completion of New Patient Office Visit (use CPT codes 99201 – 99205 for incentive credit)
  • Completion of an Individual Health Education Behavioral Assessment (IHEBA).  The Staying Healthy Assessment is an acceptable IHEBA.   (a review of medical records for the completed IHEBA associated with the New Patient Office Visit will be conducted to ensure eligibility for this incentive)

To help identify which members are new to the provider’s panel a “New Member List” will be sent monthly to the provider which includes the member’s names and contact information. 

SCORING & PAYMENT FOR EACH INCENTEIVE

Patient Level Compliance Incentive

Scoring:  Determined by the number of care gaps closed via claims, encounter, immunization registry data and/or lab data.

Payout: 

  • 1st payout – 4th Quarter 2017
  • 2nd / Final Payout – 2nd Quarter 2018 (this allows for claims processing of services received thru 12/31/2017)

Overall Quality Performance Improvement

Scoring:  Providers who have an average member panel size of 1000+ members during 2017 and have shown improvement in their overall Quality Performance rating are eligible for the payout.

Payout: 2nd Quarter 2018

Initial Health Assessment (IHA)

Scoring:  Determined by the total number of completed Initial Health Assessments (New Patient Office Visit) and Individual Health Education Behavioral Assessment (e.g. Staying Health Assessment) within 120 days of assignment to the provider panel.

Payout: 2nd Quarter 2018

GETTING HELP

Email us for:

  • Questions and/or comments about CHW’s program
  • To request remote or on-site 1:1 consultation with one of our Practice Coaches who can assist you with implementation of this program.

Program Terms and Conditions:

  • Participants in the CHW 2017 Quality Provider Incentive Program, as well as acceptance of incentive payments, does not in any way modify or supersede any terms or conditions of any agreement between CHW and providers/provider groups, 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 CHW provider/provider group incentive program.  The CHW 2017 Quality Provider Incentive Program and/or its terms and conditions may be modified or terminated at any time, with or without notice, at CHW’s sole discretion.
  • Criteria for calculating incentive payments are subject to change at any time, with or without notice, at CHW’s sole discretion.
  • The determination of CHW performance scoring and payments of the 2017 Quality Provider Incentive Program is final.
  • As a condition of receiving payment under the CHW 2017 Quality Provider Incentive Program, provider/provider groups must be active and contracted with CHW and have active assigned members, at the time of payment.