Provider Update: 2019 CCO Metrics Payment Methodology
Date: 03/15/19
*This update applies to Trillium Oregon Health Plan (OHP) providers.
The Oregon Health Authority (OHA) Coordinated Care Organization (CCO) Incentive Metrics Program uses quality health metrics to demonstrate how well CCOs are improving the health of the communities they serve. Incentive metrics are integral to the success of the CCO model, encouraging health plans and their provider partners to develop innovative approaches to serve Oregon Health Plan members. These metrics measure quality of care, access to care, and health outcomes for individuals enrolled in CCOs. OHA develops the measures and awards funds from the quality pool to CCOs based on their annual performance on the measures. Each CCO establishes the methodology for distributing the incentive funds to participating providers. The Trillium 2019 CCO Incentive Metrics Funding Methodology was determined by the Trillium Compensation Metrics Subcommittee with approval from the Compensation Committee and the Board of Directors. This methodology is effective for calendar year 2019.
Distribution of funds will be determined through a two stage process. In round one, providers receive funds for measures where Trillium met the improvement target. Remaining funds are distributed in round two, for measures where the PCPCH, behavioral health clinic, or specialist clinic met the measure, regardless of whether Trillium met the measure improvement target.
Please note, calendar year 2018 improvement targets are included when available for reference only; OHA will produce final targets on or before June 30, 2019, and non-OHA behavioral health final targets will become available September 2019. Trillium will send out updated versions of this document each time final targets are received.
PRIMARY CARE PROVIDER (PCP) INCENTIVE METRIC FUNDING METHODOLOGY
- Limited to participating providers
- A minimum of 50 members assigned to the contracted provider organization
- No incentive payments will be issued if less than $50 earned by the contracted provider organization
- Clinics not participating in PCPCH or below tier 3 status as of Dec. 31, 2019 will not be eligible for the 2019 CCO Incentive Metric Funding Program
- Clinic Primary Care Patient Centered Home (PCPCH) tier status as of Dec. 31, 2019 will be used to determine the incentive metrics payment, by clinic site, as follows:
- PCPCH Tier 5 will receive 110% of their earned incentive Page 1 of 5
- PCPCH Tier 4 will receive 105% of their earned incentive
- PCPCH Tier 3 will receive 90% of their earned incentive
- All measures will be triple-weighted except as follows:
- Ambulatory care: ED Utilization will be double-weighted to ensure the majority of quality funds don’t go to this measure only;
- Depression Screening and Follow Up Plan and Screening, Brief Intervention, and Referral to Treatment (SBIRT) will be funded in individual pools (see EHR Measures for more details)
EHR MEASURES
- Quarterly submission of EHR data is mandatory for clinics currently submitting data on a yearly basis through Trillium to the state, and for clinics planning to submit data for 2019. Clinics who don’t submit quarterly EHR data will not be eligible to earn incentives for the EHR measures.
- Template for EHR data submission will be emailed to participating clinics, with a 1 month submission period per quarter. Q1 2019 data will be due May 1, 2019.
- Depression Screening: OHA states that there will not be a target performance benchmark for this measure in 2019. Clinics must report on a minimum population threshold (not yet determined by OHA) to meet this measure. 1/18th of earned funds will be distributed proportional to total membership to clinics who meet this threshold.
- SBIRT: OHA has decided that 2019 data will be used to establish a target performance benchmark for this measure. Clinics must submit data report on a minimum population threshold of 20% to meet this measure. 1/18th of earned funds will be distributed proportional to total membership to clinics who meet this threshold.
COLORECTAL CANCER SCREENING
Use of CPT II code 3017F for tracking compliant colorectal cancer screenings is required to qualify for the incentive. 3017F, colorectal cancer screening results documented and reviewed, may be used by PCP to note current and historical (compliant for 2019, e.g., colonoscopy between 2010–2018) screenings. CCO metric performance for OHA is based on chart review of 411 members, but clinic performance and incentive metric funding will be based on the use of claims data including all screenings which count toward the measure (i.e. FITs, FOBTs, colonoscopies, etc.), and supplemental data.
ADOLESCENT WELL CHILD VISIT
Trillium will pay for one visit per year. For incentive payments, if two clinics perform this visit, both will be eligible to receive an incentive payment for submitted claims. Additionally, the PCP where the member is assigned will continue to receive credit for the member if they received an AWC, even if they did not perform that service. Similar to previous methodology, incentive payments are weighted based on percentage of time a member is assigned to a PCP in the measurement year.
EFFECTIVE CONTRACEPTIVE USE
When both an OB/GYN and a PCP see a member and submit claims for ECU, both will be eligible to receive an incentive payment for submitted claims. Additionally, the PCP where the member is assigned will continue to receive credit for ECU, even if they did not perform that service. Similar to previous methodology, incentive payments are weighted based on percentage of time a member is assigned to a PCP in the measurement year.
| Measure | 2018 Improvement Target |
|---|---|
Adolescent well-care visits | 49.4% of members age 12-21 |
Ambulatory Care: Emergency Department utilization | 48.7 per 1000 member months |
Childhood immunization status | 75.3% of members turning 2 |
Cigarette smoking prevalence* | 36.9% of members age 13 and older with a visit |
Colorectal cancer screening | 51.9% of members age 51-75 |
Controlling high blood pressure* | 70.6% of members age 18-85 with a diagnosis of essential hypertension |
Depression screening and follow up plan*ˆ | TBD minimum population threshold of members 12 and older |
Developmental screening in the first 36 months of life | 74.0% of children turning 1,2,3 |
Diabetes: HbA1c Poor Control* | 22.6% of members age 18-75 with diabetes |
Effective contraceptive use among women at risk of unintended pregnancy | 50.0% of members age 15-50 |
Emergency department utilization among members with mental illness | 103.9 per 1000 member months |
Weight assessment and counseling in children and adolescents* | 30.4% of members age 3-17 with a visit |
Screening, Brief Intervention, and Referral to Treatment (SBIRT)* | 20% minimum population threshold of members 12 and older |
*EHR measures
ˆDue to a change in SNOMEDCT codes, the PHQ9 as a follow-up to a positive PHQ2 no longer counts as additional evaluation and cannot be counted for numerator compliance.
Behavioral Health Payment Methodology
- Limited to participating providers
- A minimum of 50 members seen by the contracted provider organization
- No incentive payments will be issued if less than $50 earned by the contracted provider organization
- All measures will be triple-weighted
- Payments are made at the clinic level. A member is counted without regard to which provider(s) they see
Behavioral Health Member Assignment
Members are considered assigned when either (A) two or more Substance Use Disorder (SUD) encounters or (B) three or more Mental Health encounters occur within the measurement year. Once a member meets A or B, they are considered to be assigned to that clinic. A member can be assigned to multiple clinics if they meet the assignment criteria listed above at more than one clinic. Visits are defined using appropriate behavioral health or chemical dependency taxonomies and diagnosis codes.
- Behavioral health member assignment is applied to the following measures:
- Emergency department utilization among members with mental illness
- Follow-up care after behavioral health hospitalization within seven days
- Foster children with behavioral health assessment within 60 days of DHS custody
- “Members with both BH and a PCP preventive visit” applies to any assigned BH member that has a PCP preventive visit
| Measure | 2018 Improvement Target |
|---|---|
Emergency department utilization among members with mental illness (CCO Metric) | 103.9 per 1000 member months |
Follow-up care after behavioral health hospitalization within seven days* | TBD % of members age 6 years and older |
Foster children with behavioral health assessment within 60 days of DHS custody (CCO Metric) | 90% of members age 4-17 |
Continuity of care – Follow-up within 14 days of initial assessment* | TBD % of all BH members age XX-XX |
Members with both BH and a PCP preventive visit* | TBD % of all BH members age XX-XX |
*2019 Target will be based on plan calendar years 2017-18 plan average, TBD Sept 2019.
Specialists’ payment Methodology
- Limited to participating providers
- A minimum of 20 members seen by the contracted provider organization
- No incentive payments will be issued if less than $50 earned by the contracted provider organization
- Measures will be tabulated using claims data and supplemental data (Colorectal Cancer Screening and Timeliness of Postpartum Care). Charts for measures allowing supplemental data may be submitted through the Novillus Care Gap Management Application at https://trillium.novillus.com beginning May 2019
- Payments are made at the clinic level. A member is counted without regard to which provider(s) they see
- Specialists eligible include OB/GYN, Gastroenterology, and entities like Planned Parenthood who perform similar services
- All measures will be triple-weighted
| Measure | 2018 Improvement Target | Applicable Taxonomies |
|---|---|---|
Adolescent well-care visits | 49.4% of members age 12-21 | OB/GYN, NP, PA |
Colorectal cancer screening | 51.9% of members age 51-75. | GI, OB/GYN |
Effective contraceptive use among women at risk of unintended pregnancy | 50.0% members age 15-50 | OB/GYN, Midwife, Planned Parenthood & similar entities |
Timeliness of Postpartum care | TBD % of members with a live birth from Nov.17, 2018 -Nov. 18 2019 | OB/GYN |