interpreting your value based p4p preliminary resource use & … · 2019-12-17 · •ipu,...

August 9, 2016

Interpreting Your Value Based P4P

Preliminary Resource Use & Total Cost

of Care Results

© 2016 Integrated Healthcare Association. All rights reserved. 2

1. About your reports

2. What’s new for MY 2015

3. How ARU and TCC are used in VBP4P

4. Program reminders

5. Questions

• Submit questions during the call via WebEx “chat”

Welcome!


Full timeline available in the MY 2015 VBP4P Manual

Updated MY 2015 Report Release Timeline

Activity Date

Preliminary Quality Reports May 25, 2016

Quality Questions and Appeals Period May 25 - June 15, 2016

Final Quality Reports July 6, 2016

Preliminary ARU & TCC Reports August 4, 2016

ARU & TCC Review Period August 4– August 25, 2016

Final ARU & TCC Reports September 2, 2016

We are here!

August 4 report release includes preliminary results for both commercial

and Medicare Advantage product lines for Measurement Year 2015

http://www.iha.org/sites/default/files/resources/my_2015_value_based_p4p_manual.pdf


Value Based P4P Domains


• Commercial and Medicare

Advantage product lines

• Preliminary results for Total

Cost of Care and Appropriate

Resource Use measures for

MY 2015

• Based on 9 participating health

plans

Included in Preliminary ARU & TCC Reports

• Aetna (PCR only)

• Anthem Blue Cross

• Blue Shield of California

• Cigna Health Care of

California

• Health Net

• Kaiser Permanente

(TCC+PCR only)

• Sharp Health Plan

• UnitedHealthcare

• Western Health

Advantage

Measure PaymentPublic

ReportingAwards

Total Cost of Care X X X

All CauseReadmissions

X X

Inpatient Utilization X

ED Visits X

OutpatientProcedures Utilization - % Done in an Outpatient Facility

X

Generic Prescribing X

Frequency of Selected Procedures


• 2nd year Public Reporting of Total Cost of Care

• 3rd year recognizing Excellence in Healthcare Award winners

• Six selected procedures were added to the Frequency of Selected Procedures measure• Hysterectomy, Tonsillectomy, Cholecystectomy, Prostatectomy,

Mastectomy, & Lumpectomy

• Risk adjustment model updated to use version 4.1.1, which incorporates ICD-10 diagnosis codes

Report Highlights for ARU & TCC


Accessing & Reviewing Your

Results


VBP4P Reporting Portal: https://analytics.iha.org

• Your username is your email address

• Click “Forgot Password” to retrieve lost password

• Click “Email [email protected]” for questions

Technical requirements

We recommend that you use Google Chrome, Mozilla

Firefox, or Internet Explorer versions 9+ to access the

Reporting Portal.

Accessing Your Results

https://analytics.iha.org/

mailto:[email protected]


• Only contacts associated with a physician organization or health plan can view that organization’s VBP4P results on the Reporting Portal. To receive access to your organization’s results:

• Sign up for an account on the Reporting Portal. Make sure you fully complete the registration process.

• Request to be added as a contact by an existing contact. Need to know who is already a contact at your organization? Email [email protected].

• The existing contact then needs to add you as a contact:• Existing Contact logs in to the VBP4P Reporting Portal

• Click "Contacts" on the top navigation bar

• Click the "Add Contacts" button

• Search for New Contact by email and click "Add“

• Note that sometimes the system takes up to a day to sync new contacts - if a new contact doesn't show up immediately when you search for them, check back the next day.

• Reporting Portal contacts are automatically subscribed to the Value Based P4P newsletter, which includes upcoming deadlines, program updates, and other important VBP4P information.

Adding a Contact on the Reporting Portal





Once logged in, click the “Measures” tab in the top navigation to access

your preliminary results.

Select which results to view at the second navigation banner heading:

• Any of the organizations for which you are an added contact

• Current and previous measurement years (MY 2012 – MY 2015)

• Commercial HMO/POS or Medicare Advantage

Use the tabs in the far left navigation bar to access measure specific

information (“Measures”), and your preliminary ARU results as a .csv file

(“Downloads”).

Navigating the site


• 2 tabs for each measure:

• OVERVIEW – detailed measure view showing PO rates

specific to your plan

• VISUALIZATIONS – line graph comparing plan-specific

and aggregated performance distribution and PO results

rank ordered

• Tables are sortable by headers; click the header and the

arrow icon will appear next to category used to sort

Measures Tab


ZIP package containing a bundle of export files (.CSV) for all Appropriate

Resource Use (ARU) measures by year, with each year on a separate row.

This files include the results for all Physician Organizations (POs) contracted

with your health plan during the measurement year. The files contains (1)

results based on your health plan's own experience, and (2) results that have

been aggregated across participating health plans.

A ZIP package containing a bundle of export files (.CSV) for Appropriate

Resource Use (ARU) measures recommended for payment, by year, with two

years side-by-side on the same row. Fields relevant to year-over-year units of

improvement are displayed in the side-by-side comparison for the purposes of

IHA's recommended Value Based P4P incentive methodology.

Summary statistics and percentiles for physician organizations across

California, by measure and product line. These numbers are based on results

that have been aggregated across health plans for a Physician Organization.

Summary statistics and percentiles for physician organizations across

California, by measure and product line. These numbers are based on results

that have been aggregated across health plans for a Physician Organization.

Downloads


• OUTLIER (OL)

• IPU, IPBD, EDV all have established outlier criteria for plan-specific results

• Rates are not calculated and displayed, but…

• “All Results” file includes the underlying numerator and denominator if you

want to calculate

• “Small PO Pooled Rates” are calculated if PO has less than 1,500 member

years

• PLAN REPORTING THRESHOLD (PRT)

• Suppresses aggregated results if based on disproportionate share from

health plans

• Results must be based on data from at least 3 plans and calculated p-

percent must be at least 20% to meet the threshold

Results Not Displayed


New in MY 2015


• Existing metrics: Angioplasty, Back Surgery, Bariatric Weight Loss Surgery, Cardiac

Catheterization, Carotid Endarterectomy, CABG, Total Hip Replacement, Total Knee Replacement

• New in MY 2015: Cholecystectomy (CCY), Hysterectomy (HYST), Tonsillectomy (TONS),

Prostatectomy (PROST), Mastectomy (MAST), & Lumpectomy (LX)

New Frequency of Selected Procedures Metrics


• To account for the illness burden of population, risk adjustment in P4P relies on combination of age, gender, and diagnosis information

• For comparable measurement we accept and use up to:

• 7 dx codes from professional claims/encounters

• 13 dx codes from facility claims/encounters

• Supporting informational metrics are provided in ARU section:

• Relative Risk Score: summary output from DCG Model 18, Version 4.1.1

• Median age

• Percent female

• Diagnosis coding frequency

Risk Adjustment in VBP4P – Why & How

P4P Measure Method

Total Cost of Care (TCC) DCG

All-Cause Readmissions (PCR) HCC

Inpatient Bed Days (IPBD) DCG

Inpatient Discharges (IPU) DCG

ED Visits (EDV) DCG

Frequency of Selected Procedures (FSP)

Age &gender

Average Length of Stay (ALOS) CMS DRG


• Measures with risk adjustment include both an observed rate (measure

abbr_OBS) and a risk adjusted rate (measure abbr_RISK_ADJ)

• Observed rate: each contracted PO’s observed utilization without adjustment for the

measure

• Expected rate: based on risk of your members and observed P4P utilization, what

is expected utilization for contracted PO

• O/E ratio: Observed rate divided by expected rate; summarizes performance given

population risk

• 1.0 means utilization as expected given members’ risk

• 1.1 means utilization 10% higher than expected given members’ risk

• 0.9 means utilization 10% lower than expected given members’ risk

• Risk-Adjusted Rate: Translate O/E ratio back to a utilization rate that can be used

to compare (i.e., multiples O/E ratio by P4P population observed rate)

Risk Adjustment – How to Interpret


Reminder: The version of the risk adjustment model for MY

2015 was updated to use 4.1.1, which incorporates ICD-10

diagnosis codes.

Please use caution when comparing risk-adjusted rates between years.

New Risk Adjustment Version


Use of ARU/TCC Results for

VBP4P


• PAYMENT • Value Based P4P incentive payments

• Uses both Appropriate Resource Use and Total Cost of Care results

• AWARDS• Excellence in Healthcare Award and Bangasser Memorial Award for

Quality Improvement

• Uses Total Cost of Care results

• PUBLIC REPORTING • Office of the Patient Advocate’s 2016-2017 Report Card

• Uses Total Cost of Care results and All-Cause Readmissions

Use of VBP4P Results


VBP4P Incentive Design

Performance Gates

• Quality

• TCC Trend

ARU Improvements

• Shared savings on ARU measures

Quality Adjustment

Net Adjusted Shared Savings

Combined Shared

Savings &Attainment

IncentivePerformance

Gates

• Quality

• TCC Amount

ARU Attainment

• Assess ARU against benchmark

Adjusted Attainment

Incentive



Performance Gates

• Quality

• TCC Trend

ARU Improvements


Quality Adjustment


Combined Shared

Savings &Attainment


Gates

• Quality

• TCC Amount

ARU Attainment


Adjusted Attainment

Incentive

To be eligible for an incentive, a PO’s Total Cost of Care Trend must not exceed the TCC Trend Gate, which is set at CPI+3% (=4.1% for MY 2015)



Performance Gates

• Quality

• TCC Trend

ARU Improvements


Quality Adjustment


Combined Shared

Savings &Attainment


Gates

• Quality

• TCC Amount

ARU Attainment


Adjusted Attainment

Incentive

Improvements on ARU measures generate shared savings, which become the basis for incentive payments


ARU & TCC Results for VBP4P

Key “Downloads” File VBP4P Purpose Fields to Note

Year-Over-Year Improvement• IPBD_OBS• PCR18OV_IHS_RISK_ADJ• EDV_OBS• OSU• GRX

• ARU shared savings • Units of Improvement

Year-Over Year Improvement• TCC_OBS• TCC_RISK_ADJ

• TCC Trend Gate • Lower Limit of 85% Confidence Interval Around Risk-Adjusted TCC Trend

All Results• TCC_GEO_RISK_ADJ-all-fields

• Identifying high cost POs• TCC Amount Gate

• Is High-Cost PO?• High-Cost Percentile Range

Plan Aggregated Thresholds • ARU attainment thresholds

• 75th and 90th percentiles


The following methodologies related to measuring ARU improvement are applied in your reports for payment purposes:

Generic Prescribing Targets• The 25th percentile of improvement across all POs within a plan is used to calculate

the target rate

• This approach is employed to account for changes in generic prescribing rates that may be part due to market trends (e.g., patent expirations, new brand drugs)

• For MY 2015 targets were adjusted for two categories:• Cardiovascular

• Diabetes

Small PO Pooling• Additional metric provided for payment purposes only

• Included for POs with less than 1,500 member years per plan

• Weighted average of PO’s own result and the result for all small POs for the plan

• As membership increases more weight placed on PO’s own result

Notes About ARU Improvement


EXCELLENCE IN HEALTHCARE

Recognizes exceptional

physician organizations who

demonstrate value – winners

must have performance in the

top 50% of clinical quality

AND patient experience AND

cost domains.

Excellence in Healthcare Award


• IHA shares results with

the Office of the Patient

Advocate (OPA) for

public reporting

• Along with Quality &

Patient Experience the

release of the 2016-

2017 Edition of the

Report Card will

include:

• Total Cost of Care

• All-Cause Readmissions

Public Reporting


• ARU & TCC reports are open for review and questions

until August 25, 2016

• Please direct questions to [email protected]

• If your plan is interested in scheduling a review with IHA

and Truven staff, please email [email protected]

Resource Use Review and Questions Period




• Are the results complete?• All contracted POs

• All fields needed for payment

• Does observed performance make sense?• Top and worst performers

• Change in performance between years

• Check out organization’s with unique populations

• Do you see any issues with PO data quality?• Non-primary diagnosis codes are consistently populated

• Reasonable relationship between relative risk score and median age

Tips for Health Plan Review


Available Now

• MY 2015 P4P Manual

(measure specifications)

• MY 2015 Preliminary

ARU/TCC Thresholds

• Aggregated (across all plans)

• Thresholds specific to your plan

Available with Final ARU/TCC

Results in September

• VBP4P plug-and-play

• Health plan “skinny” files

• PO member-level detail files

(from HP skinny files)

• Final MY 2015 Thresholds

Additional Deliverables


Program Reminders


Registration is now open!

September 23rd, 2016 | Hilton LAX Hotel – Los Angeles, CAhttps://www.regonline.com/IHAStakeholdersMeeting2016

Physician Organizations participating in Value Based P4P receive two complimentary

registrations. To redeem your complimentary registration, enter your 7-digit DMHC ID at

registration. Need your DMHC ID? Email [email protected].

This year’s agenda includes:

• Important updates on Value Based P4P

• Excellence in Healthcare and Bangasser Most Improved Awards Ceremony

• Six breakout sessions on a variety of topics, including reducing overuse, encounter

data, performance improvement, patient experience, Medi-Cal, and more

15th Annual IHA Stakeholders Meeting

https://www.regonline.com/IHAStakeholdersMeeting2016



VBP4P public comment period marks the release of several important

program documents for stakeholder review and comment, including:

• General program policy updates

• MY 2016 Testing Measures

• MY 2017 Proposed Measure Set

• MY 2016 Draft Program Manual

VBP4P staff review every comment and take this feedback to the VBP4P

Committees governing the program.

Public Comment Period: September 1 - 30, 2016

interpreting your value based p4p preliminary resource use & … · 2019-12-17 · •ipu,...

Documents