Download Patient Centered Primary Care

2015 Anthem Blue Cross and Blue Shield
Provider Expo
Medicare Advantage
Freestanding Patient
Centered Care (FPCC)
Program
Kathy Morris, Provider Network Manager II
Anthem Medicare Advantage
This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.
Payment redesign
Physicians will be incentivized to provide quality and cost
effective care through aligned reimbursement.
Per Member Per Month (PMPM) Clinical Coordination
Payments*:
• Targeted PMPM payments pay practices fixed fees for important clinical
interventions that occur outside of a patient visit. These payments
provide physicians with a predictable cash flow that lets them invest to
improve their practice.
Shared Savings:
• The Freestanding Patient Centered Care Program introduces a shared
savings incentive program that allows you to earn a portion of the
savings that accrue when you provide patient centered care as long as
you meet the programs’ quality measures.
• The shared savings payments reward providers for improving the health
of your patients and provide compensation for non-visit based clinical
interventions, such as care planning, completing the Health Risk
Assessments annually , and closing gaps on members diagnosis, that
have a positive impact on patient outcomes and cost.
* Some exceptions apply
Payment
redesign
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Payment redesign
Physicians will be incentivized to provide quality
and cost effective care through aligned
reimbursement.
 Important building blocks of the incentive
program are:
• Attribution
• Medical Panels
• Quality Metrics Performance
Payment
redesign
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Attribution
What is it and how does it work?
Attribution is the foundation for many aspects of
the program. It is the method for identifying your
patient population.
Two processes are used for attribution
depending on the product type
Open Access
Products (PPO)
Products requiring
PCP selection
Attribution is
based on historical
claims data
incurred in a
24-month period
Attribution is
based on covered
individuals
selection during
a 12-month
period
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General parameters for Medical Panels
FPCC and Physician
groups with >1,500
attributed
members
on its own
Quality, Member
Premiums, and
Measurement Period
Medical Loss Ratio
(MPMLR) are all
calculated at the
Provider Groups level
Standard Program Market Medical
Panel formed
with 1,500
patients
Quality Performance
and Member Premium
will be evaluated at the
physician group level*
MPMLR
will be calculated at the
Medical Panel level to
determine the sharedsavings percentage
*If the denominator for any sub-composite does not meet the minimum number of 20, that subcomposite will be measured at the panel level. Otherwise, quality will be measured at the
practice level.
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Quality Measures for Performance assessments
Stars measures are used for the quality portion of the
scorecard. The measures are categorized as two different
types:
 Standard Measures are measures that use data that is readily
available, widely used by all Providers, and provide a conclusive
answer. These measures results’ are derived solely on an evaluation of
claims.
 Enhanced Measures are measures that require documentation
submitted on the claim in addition to standard CPT codes, and
documented in the medical record. The additional information used to
evaluate the measure, can be attained by submitting CPTII or V codes
on the members claim that correspond with the members medical
record.
The enhanced measures serve as a bonus opportunity to increase your
overall shared savings potential, and will not reduce your shared
savings potential if not achieved. The use of CPT II codes are further
explained in the Measurement Period Handbook.
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Linking Performance on
Quality Metrics to Shared-Savings
The Quality Measures serve two functions:
 Quality gate –
• Standard Program - Providers must meet a minimum
performance threshold on clinical quality measures of a
weighted average 4 star rating before they are eligible to earn
shared savings.
• FPCC – Provider must meet the minimum performance
threshold on clinical quality measures of 4 stars on each
individual measure to qualify for shared savings percentages
for that measure.
 Overall determinant of proportion of
shared savings earned by the physician – After the
quality gate is satisfied, the proportion of shared savings the
physician receives depends their overall percentage they earn
on the scorecard.
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Incentive Program
The Incentive Program offers financial rewards for
Providers who have successfully increased their
accountability for the cost, quality and efficiency of the
care they provide to their defined patient population.
The Incentive Program is based on a Percent of Premium.
The Percent of the Premium is based on two pieces:
 Target Medical Loss Ratio (MLR)
 Measurement Period MLR
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Incentive Program
The practice will qualify
for the incentive program
The amount that can be
earned is determined by:
When performance
on quality
measures meets or
exceeds standards
The level of quality
of care achieved
When savings are
achieved for the
medical costs for
the defined
member population
The total amount of
savings calculated
during the
measurement period
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Exchange of information
We will provide actionable analytic reports on
Provider Care Management Solutions (PCMS)
such as:




Avoidable ER use
Gaps in care
Attributed high-risk/high-cost members
Specialty referral management
We provide interpretive guidance
 Provides you with the data to improve the health status of
their patients and reduce costs associated with avoidable
ER, readmissions, etc.
Exchange of
meaningful use
of information
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Program Summary Medicare Advantage
FPCC and Standard
The Provider will receive a PMPM (optional) as a clinical
coordination fee for each Medicare Advantage member. It is based
on a flat rate multiplied by the Hierarchical Condition Category
(HCC) score.
The percentage of shared savings that a provider can participate in
is determined by how well they perform in quality which is based
on Stars Measures. They must meet the quality gate of an overall
weighted four star rating for the Standard Measures in the
FPCC/Standard Program. For the FPCC the Quality Gate is at
each measure and is set at 4 Stars.
The Program scorecard is comprised of clinical quality measures as
identified by the Centers for Medicare and Medicaid Services
(“CMS”) that align with the Medicare Stars Program.
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Program Summary Medicare Advantage
FPCC and Standard continued
∑ 𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻 𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴 𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬𝑬
𝑴𝑴𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆𝒆 𝑳𝑳𝑳𝑳𝑳𝑳𝑳𝑳 𝑹𝑹𝑹𝑹𝑹𝑹𝑹𝑹𝑹𝑹 𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻𝑻 (𝑴𝑴𝑴𝑴𝑴𝑴𝑴𝑴) =
∑ 𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷𝑷
The Provider can impact the Shared Savings by:
o Increasing Revenue via HCC Scores via closing gaps and
identifying new diagnoses which will raise the premium received
for the Medicare Advantage membership
o Decrease the Total Medical Expenses for the Medicare
Advantage membership by transforming their practice into a
patient-centered care model, leading to better management of
the members conditions and lowering costs as a result
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Medicare Advantage Freestanding Patient
Centered Care (FPCC) Program
Questions?
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Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS
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