Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.16-006 - Episodes of Care 1-15 and Section 1 3-15

Current through Register Vol. 49, No. 6, June, 2024
Section
			 I
142.900
Principal
			 Accountable Providers (PAPs)
An Arkansas Medicaid enrolled and qualified provider who is
				licensed to diagnose and treat a beneficiary may be designated as a Principal
				Accountable Provider (PAP) within the Episodes of Care payment improvement
				initiative. Individual providers may be designated as a PAP only by a
				promulgated episode.
181.000
Incentives to Improve Care
			 Quality, Efficiency and Economy
A.
			 Definitions
1. An "episode" refers to a
			 defined bundle of related Medicaid-covered health care services provided to a
			 specific Medicaid beneficiary.
2.
			 An "episode type" is defined by a diagnosis, health care intervention or
			 condition during a specific timeframe (or performance period).
3. "Thresholds" are the upper and lower
			 reimbursement benchmarks for an episode of care.
4. A "valid episode" is defined as any
			 episode that meets criteria for inclusion in a calculation of cost and quality
			 measures for which a PAP is accountable during a performance period.
5. An "invalid (excluded) episode" refers to
			 an episode in which the services or the patient do not meet standard criteria
			 for inclusion set by the definition of each episode type. (Refer to the
			 Episodes of Care Medicaid Manual for episode-specific criteria.)
6. An "incentive" can either be positive
			 (gain-share) or negative (risk-share).
B. Medicaid has established a payment
			 improvement initiative ("payment improvement program") to incentivize improved
			 care quality, efficiency and economy. The program uses Medicaid paid claims
			 data to evaluate the quality, efficiency and economy of care delivered in the
			 course of the episode and to apply payment incentives.
Please refer to
			 the Episodes of Care Medicaid Manual for information about specific Episodes of
			 Care.
C. The payment
			 improvement program is separate from, and does not alter, current methods for
			 reimbursement.
D. The payment
			 improvement program promotes efficiency, economy and quality of care by
			 rewarding high-quality care and outcomes, encouraging clinical effectiveness,
			 promoting early intervention and coordination to reduce complications and
			 associated costs, and when provider referrals are necessary, encouraging
			 referrals to efficient and economic providers who furnish high-quality
			 care.
E. All medical assistance
			 provided in the delivery of care for an episode may be included in the
			 determination of an incentive under the payment improvement program.
F. Incentives may be positive (gain share) or
			 negative (risk share). Incentives are calculated and made retrospectively,
			 after care has been completed and reimbursed in accordance with the published
			 reimbursement methodology. Incentives are based on the aggregate of valid, paid
			 claims across a provider's episodes and are not relatable to any individual
			 provider claim for payment.
G.
			 Medicaid establishes episode definitions, levels of incentives and appropriate
			 quality measures based on evidence-based practices. To identify evidence-based
			 practices, Medicaid shall consider clinical practices information furnished by
			 Arkansas providers of the care and services typically rendered during the
			 episode of care, and may also consider input from quality measurement
			 organizations, peer-reviewed medical literature or any combination
			 thereof.
H. Principal Accountable
			 Providers
The Principal Accountable Provider(s) (PAPs) for each episode
				is/are identified in the section defining the episode. In some cases, Medicaid
				may identify PAPs after an episode is complete using algorithms described in
				the episode definition.
I.
			 Incentives
For each PAP for each applicable episode type:
1. Performance will be aggregated and
			 assessed over a specified period of time ("performance period"). For each PAP,
			 the average reimbursement across all valid episodes completed during the
			 performance period will be calculated, based on the set of services included in
			 the episode definition. Please refer to the Episodes of Care Medicaid Manual
			 for information about specific Episodes of Care.
2. Some episodes may be excluded based on
			 clinical factors derived from paid claims. Other exclusions may be determined
			 from coverage factors for each individual patient.
3. Reimbursement for some episodes may be
			 adjusted as described in the definition of each episode. The average adjusted
			 reimbursement of all episodes for the PAP during the performance period will be
			 compared to thresholds which are established by Medicaid in consultation with
			 providers.
4. If a PAP's average
			 adjusted episode reimbursement is lower than the commendable threshold and the
			 PAP has met the quality measures established by Medicaid for each episode type,
			 the PAP is eligible for gain share and Medicaid will make a positive incentive
			 to the PAP. This will be equal to the difference between the average adjusted
			 episode reimbursement and the commendable threshold, multiplied by the number
			 of episodes included in the calculation and multiplied by a gain-sharing
			 percentage for the episode. Where necessary, a gain-sharing limit will be
			 established to avoid incentives for underutilization. PAPs with average
			 adjusted episode reimbursement lower than the gain-sharing limit will receive
			 an incentive calculated as though their average adjusted episode reimbursement
			 were equal to the gain-sharing limit.
5. If the average adjusted episode
			 reimbursement is higher than the acceptable threshold, the PAP will incur a
			 negative (risk-share) incentive. This incentive to Medicaid will be equal to
			 the difference between the acceptable threshold and the average adjusted
			 episode reimbursement, multiplied by the number of episodes included in the
			 calculation and multiplied by a risk-sharing percentage defined by Medicaid for
			 the episode.
J.
			 Principles for Determining "Thresholds"
1. The
			 threshold process aims to incentivize high-quality clinical care delivered
			 efficiently and to consider several factors including the potential to improve
			 patient access, the impact on provider economics and the level and type of
			 practice pattern changes required for performance improvement.
2. The acceptable threshold is set such that
			 average cost per episode above the acceptable threshold reflects unacceptable
			 performance, which could result from a large variation from typical performance
			 without clinical justification (e.g., individual provider variation) or from
			 system-wide variance from widely accepted clinical standards.
3. The commendable threshold is set such that
			 outperforming the commendable threshold represents quality care provided at a
			 lower total reimbursement, which would result from care at meaningfully better
			 than current average reimbursement in Arkansas, consistent with good medical
			 outcomes. Medicaid may take into consideration what a clinically-feasible
			 target would be, as demonstrated by historical reimbursement variance in
			 Arkansas.
4. The gain-sharing limit
			 is set to avoid the risk of incentivizing care delivery at a cost that could
			 compromise quality.
5. The gain-
			 and risk-sharing percentages aim to recognize required provider investment in
			 practice change and will be set at a sustainable level for Medicaid.
K. Outlier Patient Exclusions
Calculation of average adjusted episode reimbursement for each
				PAP will exclude outlier patients who have extraordinarily high or low cost
				episodes and/or comorbid conditions so that one or a few cases do not
				misrepresent a provider's overall performance across the provider's broader
				patient population.
L.
			 Provider-Level Adjustments
1. Incentives for
			 each PAP take into account provider-level adjustments, which may include
			 stop-loss provisions, adjustments for cost-based facilities, adjustments or
			 exclusions for providers with low case volume or any combination
			 thereof.
2. Stop-loss protection:
			 Unless provided otherwise for a specific episode of care, a provider's net
			 negative incentive adjustment (total positive adjustments minus total negative
			 adjustments) for all Episodes of Care adjustments made during any calendar year
			 shall not exceed ten percent (10%) of the provider's gross Medicaid
			 reimbursements received by the provider during that calendar year.
3. Temporary stop-loss provisions may apply
			 when necessary to ensure access to care.
4. Providers that receive cost-based or
			 PPS-based reimbursement are reimbursed as specified in the corresponding
			 provider manual(s), but are subject to positive (gain-share) and negative
			 (risk-share) incentives in order to achieve statewide improvement in quality
			 and efficiency. For episodes including services furnished by providers who
			 receive at exceptional reimbursement levels, reimbursements attributed to PAPs
			 for the purpose of calculating performance are computed as if the provider did
			 not receive exceptional reimbursement.
5. Each episode has a designated minimum case
			 volume that must be reached in order for the PAP to be eligible for incentives.
			 PAPs who do not meet the minimum case volume for an episode type will not be
			 eligible for positive (gain-share) or negative (risk-share) incentives for that
			 episode type.
M. Quality
			 Measures
1. For each episode type, there is a
			 set of quality measures "to pass" and/or a set of quality measures "to track."
			 These quality measures are based on paid claims data or based on additional
			 data when specified by Medicaid and which PAPs are required to report through
			 the Advanced Health Information Network (AHIN) provider portal.
2. To qualify for positive (gain-share)
			 incentives, PAPs must report required data and meet specific quality measures
			 "to pass."
3. Providers who do not
			 report data or who do not meet minimum quality measures may still incur
			 negative (risk-share) incentives if their average adjusted episode
			 reimbursement exceeds the acceptable threshold.
N. Consideration of the aggregate cost and
			 quality of care is not a retrospective review of the medical necessity of care
			 rendered to any particular patient, nor is such consideration intended to
			 supplant any retrospective review or other program integrity
			 activity.