January 1, 2017
RE:
Community First Health Plans Incentive/Alternative Payment Structure Methodology for Primary
Care Physicians
Community First Health Plans would like to recognize the efforts you are making towards meeting our
combined CHIP and STAR standards for Clinical Quality Measures, increased generic prescriptions, and
reduced ED utilization. We would also like to acknowledge those providers who have been nationally
recognized as a Patient-Centered Medical Home and those who are improving PCP access for CFHP
members. Towards that end, please see below a description of our Incentive/Alternative Payment that
will start January 1, 2017.
Participation Eligibility (evaluated on quarterly basis):
• Primary Care Physicians who have a combined STAR and CHIP panel size of 30 or more
members.
• Member satisfaction with the PCP – this will be measured through the number of times a PCP
switch occurs due to “dissatisfaction with the PCP and/or office staff”. This rate should not
increase over the previous measurement year.
Program Description:
In addition to the above stated “Participation Eligibility”, this program will be based on an accumulation
of points in each of the above-referenced categories. Calculations will be based on a rolling calendar
year. There are seven (7) measures and total possible points equals nine and a half (9 1/2). The
calculated final points equate to a per member per month dollar (pmpm) value that will be awarded to
each eligible physician on a quarterly basis.
Measures:
I.
Clinical Quality Measures –
A. Well-Child Medical Checkups for STAR and CHIP members ages 3,4,5, and 6 - Two (2)
possible points
Receipt and payment of a clean claim for a well-child medical checkup on an annual
basis. In addition, the qualifying NPI and taxonomy of the rendering physician must be
on the claim. Appropriate CPT codes for this service include: 99381-99385, 9939199395, 99461, G0438, and G0439. Acceptable diagnosis codes are: Z00.00, Z00.01,
Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4,
Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, and Z02.9.
HSM ǀ 4.00395 Ver. 5 12/16
Points will be awarded based on following:
•
•
•
attaining the NCQA 75th percentile of the current HEDIS© benchmark will earn
one-half (½) point
attaining the NCQA 90th percentile of the current HEDIS© benchmark will earn
1 point
attaining the NCQA 95th percentile of the current HEDIS© benchmark (goal) will
earn 2 points
B. Adolescent Well-Child Medical Checkups for STAR and CHIP members ages 12-19 (CHIP)
and 12-20 (STAR) - Two (2) possible points
Receipt and payment of a clean claim for a well-child medical checkup on an annual
basis. In addition, the qualifying NPI and taxonomy of the rendering physician must be
on the claim. Appropriate CPT codes for this service include: 99381-99385 and 9939199395. Acceptable diagnosis codes are: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121,
Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79,
Z02.81, Z02.82, Z02.83, Z02.89, and Z02.9.
Points will be awarded based on following:
•
•
•
attaining the NCQA 75th percentile of the current HEDIS© benchmark will earn
one-half (½) point
attaining the NCQA 90th percentile of the current HEDIS© benchmark will earn
1 point
attaining the NCQA 95th percentile of the current HEDIS© benchmark (goal) will
earn 2 points
C. Flu Vaccination Measure (in effect the months of October through December) - Half
(1/2) possible point
Administration of the influenza vaccine (90630, 90658, 90656, 90685, 90686, 90688,
90661, 90662, 90672, 90653, 90674, 90657 or 90673) to members ages 6 months or
older. A 10% increase from your calendar year 2016 baseline will meet eligibility
requirements and will earn ½ point.
II.
Decreased ER Utilization – Two (2) possible points
This quarterly measure is calculated based on the size of your panel as visits/thousand. A 5%
decrease from your calendar year 2016 baseline will meet eligibility requirements for the
following:
•
•
•
III.
a 10% decrease from the calendar year 2016 CFHP rate will earn ½ point
a 15% decrease from the calendar year 2016 CFHP rate will earn 1 point
a 25% decrease from the calendar year 2016 CFHP rate (goal) will earn 2 points
Increased Generic Prescription Utilization - Two (2) possible points
Any improvement from your calendar year 2016 baseline rate will meet eligibility
requirements for the following:
•
•
•
HSM ǀ 4.00395 Ver. 5 12/16
a rate greater than or equal to 75% will earn ½ point
a rate greater than or equal to 80% will earn 1 point
a rate greater than or equal to 85% (goal) will earn 2 points
IV.
Recognition as a Patient Centered Medical Home - Half (1/2) possible point
PCMH designation received from one of the following accreditation bodies will result in the
award of ½ point:
•
•
•
V.
National Committee for Quality Assurance (NCQA);
Joint Commission; or
Utilization Review Accreditation Commission (URAC).
Encouraging PCP Access - Half (1/2) possible point
Provider will be awarded ½ point for an increase in panel size from previous year baseline.
The required increase is as follows:
•
•
•
30-1999 members – 10% increase;
2000-4999 members – 7.5% increase; or
5000+ members – 5% increase.
Points Award - Per Member Per Month Incentive Value:
Total possible points = 9 1/2
1-2 points = $1.00 pmpm (per member per month) incentive
3-4 points = $1.50 pmpm incentive
5-6 points = $2.00 pmpm incentive
7-8 points - $2.50 pmpm incentive
>9points = $3.00 pmpm incentive
All HEDIS®-based metric s will be calculated based on current HEDIS® technical specifications.
If you should have any questions about this incentive, please contact us at (210) 358-6145.
Sincerely,
Priti Mody-Bailey, MD
Chief Medical Officer
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