Primary Care Alternative Payment Criteria As part of the Department of Health Care Policy & Financing’s (Department) efforts to shift providers from volume to value, the Department is developing a structure to make differential fee-for-service payments to give providers greater flexibility, reward performance while maintaining transparency and accountability, and create alignment across the delivery system. Under the proposed model, providers can earn higher reimbursement (when designated as meeting specific criteria) as they implement and achieve more advanced criteria. Movement along this framework not only encourages higher organizational performance but also helps the Accountable Care Collaborative (ACC) achieve its respective programmatic goals. In developing the proposed framework, the Department cross-referenced with Departmental initiatives, such as the Comprehensive Primary Care Initiative (CPCi), Comprehensive Primary Care Plus (CPC+), Enhanced Primary Care Medical Provider (EPCMP) incentive program, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and State Innovation Model (SIM), as well as with National Committee for Quality Assurance (NCQA) standards for Medical Homes (PCMHs). Please note this is a proposed framework intended for discussion. Also note that additional work is being done to align with CPC+ Track 2 – the framework described does not apply to that methodology. Primary Care Alternative Payment Framework Care Delivery Domain Payment Category Outcomes/ Areas of Impact Level I Level II Level III Access to and Continuity of Care 1. 24 hour phone access 2. Primary care focus 3. Extended hours 4. Same day appts 1. Provider Empanelment (75%) 2. Accept new patients 3. 24 hour EHR access 1. Asynchronous communication 2. Provider Empanelment (95%) 1. Well child care 2. Depression screening 3. ER utilization 4. Other preventive screenings Care Management 1. Preventive health screening 2. Medication management 3. Release of previous records 1. Shared care plan: patient 2. E-prescribing 1. goals 1. Appropriate asthma medications 2. HbA1c testing 3. Well child care 4. Depression screening 5. SUD screening Population Management Population Stratification: Methods
Population Stratification: Care Protocol Registries Team Based Care 1. Care team roles 2. Care team structure 3. Standing orders 1. Care team empanelment (75%) 2. Patient engagement trainings 3. Population health management trainings 4. Care team huddling 1. Care team empanelment (95%) 2. QI trainings 3. Shared care plans: provider 1. HbA1c testing 2. Well child care 3. Depression screening 4. SUD screening 5. ED Visits for ambulatory care-sensitive conditions 6. CAHPS survey 7. ECHO survey 8. National Core Indicators survey Health Neighborhood Care Coordination 1. Care compact: medical providers 1. Referral tracking 2. eConsult 1. Hospital F/U 2. ER F/U 3. Care compact: community partners 1. ED Visits for ambulatory care-sensitive conditions 2. Total cost of care Behavioral Health Integration 1. BH preventive health screening 2. BH referrals 1. BH registry 2. BH share care plan: patient 3. BH shared decision making tool 4. Care compact: behavioral health providers 5. BH agency strategic measures 6. BH referral tracking 1. BH co-location 2. BH providers 1. Well child care 2. Depression screening 3. SUD screening Patient Engagement and Experience 1. Process for soliciting patient feedback 1. Shared decision making tools 2. Patient satisfaction survey 3. Patient advisory group 1. CAHPS survey 2. ECHO survey 3. National Core Indicators Survey Quality Improvement 1. Performs practice improvement activities 1. Agency strategic measures 2. Agency QI plan 1. Agency QI projects 2. Family and patient engagement in QI projects
Access and Continuity Accept new patients Practices will take on new Medicaid patients as their care team capacity permits. Level II Well Child Care; Depression Screening ACC 1.0 Access and Continuity Asynchronous communication Practices will implement at least one form of asynchronous communication (patient portal, email, text messaging, etc.) and will set appropriate and timely follow-up standards. Level III Well Child Care; Depression Screening CPC, SIM 1A3, 1B3, 1C5 Care Management Preventive health screening Practices will regular screen patients for preventive health issues. Level I Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening ACC 1.0 Care Management Medication management Practices will proactively manage and review each patient's respective medications. Level I Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening CPC, CPC+, SIM 4C Care Management Release of previous records Practices will develop protocols and processes whereby they can request, receive, and send patient records from previous providers. Level I Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening 5C Care Management Population stratification: methods Practices will employ data-driven methods and tools (including BDIM) to risk stratify all empaneled patients. Level II Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening CPC, CPC+, SIM, ACC 1.0 3D; 4A1
Care Management Population stratification: care protocols Practices will develop and implement care protocols for the specific risk pools within their population. Level II Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening CPC, CPC+, SIM, ACC 1.0 4A Care Management Registries Practices will develop and implement patient registries to manage the care and outcomes of at least three specific patient populations. Level II Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening SIM, ACC 1.0 4A Care Management Shared care plan: patient Practices will develop and monitor care plans with each patient that address relevant needs and that are shared across each patient's care team members. Level II Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening CPC, CPC+, SIM, ACC 1.0 4B5 Care Management E-prescribing Practices will develop and implement technologies and partnerships that allow for electronic transmission of patients' prescriptions. Level II Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening CPC 4D Care Management goals Practices will develop and monitor goals with their respective patients. Level III Appropriate Asthma medications; HbA1c testing; Well Child Care; Depression Screening; SUD Screening SIM 4B Team Based Care Care team roles Practices will define the specific roles for care teams and integrate patient engagement, population health management, and quality improvement responsibilities in each role. These Level I SIM 2D
one behavioral health practice, to grant access to their respective EHRs and their patients' respective medical records and care plans. testing; Well Child Care; Depression Screening; SUD Screening Health Neighborhood Care Coordination Care compact: medical providers Practices will enact care compacts with 1-3 relevant partner providers to track and coordinate care. Level I ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 4C; 5B Health Neighborhood Care Coordination Referral tracking Practices will monitor the status of patient referrals between the practice and its respective partners. Level II ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care SIM, ACC 1.0 5B2 Health Neighborhood Care Coordination Hospital F/U Practices will follow up with 75% of hospitalized patients within 72 hours of discharge. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 5C Health Neighborhood Care Coordination ER F/U Practices will follow up with 75% of emergency room patients within one week of discharge. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care CPC, CPC+, SIM 5C Health Neighborhood Care Coordination Care compact: community partners Practices will enact care compacts with 1-3 relevant community partners to refer and coordinate care. Level III ED Visits for Ambulatory Care Sensitive Conditions; Total Cost of Care ACC 1.0? 4E Behavioral Health Integration BH preventive health screening Practices will regular screen patients for behavioral health issues using a nationally recognized screening tool. Level I Well Child Care; Depression Screening; SUD Screening SIM 3C
Behavioral Health Integration BH referrals Practices will provide access to behavioral health services through referrals to partner providers or internal services. Level I Well Child Care; Depression Screening; SUD Screening SIM 5B/C Behavioral Health Integration BH registry Practices will develop and implement patient registries to manage the care and outcomes of patients with behavioral health needs. Level II Well Child Care; Depression Screening; SUD Screening SIM 4A Behavioral Health Integration BH shared care plan: patient Practices will develop and monitor care plans with each patient that address behavioral health needs and that are shared across each patient's care team members. Level II Well Child Care; Depression Screening; SUD Screening SIM 4B5 Behavioral Health Integration BH shared decision making tool Practices will employ shared decision making tools for patients with behavioral health needs. Level II Well Child Care; Depression Screening; SUD Screening SIM 4E Behavioral Health Integration Care compact: behavioral health providers Practices will enact care compacts with relevant behavioral health providers to track and coordinate care. Level II Well Child Care; Depression Screening; SUD Screening SIM 4C; 5B Behavioral Health Integration BH agency strategic measures Practices will identify and monitor at least one clinical quality measure relevant to behavioral health. Level II Well Child Care; Depression Screening; SUD Screening 6A Behavioral Health Integration BH referral tracking Practices will monitor the status of patient referrals between the practice and its respective behavioral health partners. Level II Well Child Care; Depression Screening; SUD Screening SIM 5B Behavioral Health Integration BH co-location Practices will provide on-site behavioral health services through a contracted or in-house provider. Level III Well Child Care; Depression Screening; SUD Screening SIM 2
Behavioral Health Integration BH providers Practices will employ behavioral health providers as part of their service portfolio. Level III Well Child Care; Depression Screening; SUD Screening SIM? 2 Patient Engagement and Experience Solicit patient input Practices will gather feedback from their patients using a post-visit question or brief set of questions. Level I CAHPS Survey; ECHO Survey; National Core Indicators Survey CPC, SIM Patient Engagement and Experience Patient satisfaction survey Practices will enact and publish results from a patient satisfaction survey on a bi-annual basis. Level II CAHPS Survey; ECHO Survey; National Core Indicators Survey CPC, SIM 6C Patient Engagement and Experience Shared decision making tools Practices will employ shared decision making tools for at least two primary care conditions. Level II CAHPS Survey; ECHO Survey; National Core Indicators Survey CPC, CPC+, SIM 4E Patient Engagement and Experience Patient advisory group Practices will convene a patient and family advisory council and publish relevant minutes on a quarterly basis. Level III CAHPS Survey; ECHO Survey; National Core Indicators Survey CPC, CPC+, SIM 6C4 Quality Improvement Performs practice improvement activities Practices will identify a change area and work on specific activities that will advance progress in that area. Level I 6 Quality Improvement Agency QI plan Practices will develop and implement an agency quality improvement plan that is reviewed annually and linked to the strategic and operational direction of the practice. Level II ACC 1.0 6
Quality Improvement Agency strategic measures Practices will identify and monitor at least three clinical quality measures relevant to their specific patient populations or the RAE's strategic initiatives and goals or the State's designated key performance indicators. Level II CPC, CPC+ 6A Quality Improvement Agency QI projects Practices will implement 1-3 performance improvement projects, using relevant performance improvement tactics and clinical and operational data, to improve their respective clinical quality measures. Level III CPC, CPC+, SIM 6D Quality Improvement Family and patient engagement in QI projects Practices will solicit and include feedback from patients and families regarding the development and implementation of QI projects. Level III CPC, CPC+, SIM 6C Quality Improvement QI project progress and communication Practices will publicly publish their progress and outcomes from their respective quality improvement initiatives. Level III CPC, CPC+, SIM 6E/F