2015

Patient Support Plan Incentive

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Patient Support Plan Incentive Program Guide Care Model

HMSA’s Care Model, through its predictive analytics, is able to deliver targeted support to members in the most need—those who are the most sick and who need the most care—and you, the providers who care for them. The Care Model: • Benefits members through targeted, personalized help improving health and coordinating care. • Benefits providers by providing HMSA patient support plans that can be discussed during regular visits. • Benefits the Hawaii health care system by helping control the growth of health care costs. Member data, predictive modeling, and data analysis enable increasingly accurate identification of the best outreach opportunities for high-impact cases in four categories: • Hospital Transitions. • Comprehensive Case Management. • Care Support. • Advanced Care Support. PCPs can also refer members to HMSA’s Care Model; a member of the Hawaii-based Healthways care team will evaluate the member for eligibility. Care team members are a mix of registered nurses (RNs) and social workers with a master of social work (MSW) degree. RNs have patient care experience and MSWs have patient interaction experience. After a patient has been identified, a member of the care team will contact the patient to determine willingness to engage in care and case management. Depending on the category, patients are contacted by phone and may meet with the care team member at the PCP’s office or the patient’s home. Once the patient consents, a care team member will contact the PCP and develop an HMSA patient support plan, which will be implemented and updated until the case is closed.

What are the Care Model categories?

Hospital Transitions

A team of care managers and a hospital-based care transition specialist help targeted members discharged from the hospital. The goal is to reduce the chance of readmission through follow-up care and case management.

Comprehensive Case Management

Care Support

Advanced Care Support

A case manager helps targeted members with chronic care issues (especially those with more than one condition) to coordinate care and prevent conditions from getting worse.

A team of care managers works with members who need short-term help to manage conditions and follow-up care while learning to manage their health challenges.

A care manager helps targeted members at high risk of death within a year who aren’t in hospice care. Members can understand their care choices, learn about advance care directives, and transition to end-oflife care.

Background Concluding in late 2014, pilot studies demonstrated that partnerships with physician organizations (POs) and primary care providers (PCPs) were essential to increase patient enrollment and provide a positive patient experience in HMSA’s Care Model. We’re refining Care Model processes in an effort to strengthen care coordination for members in need of comprehensive case management (CCM) and have identified specific opportunities for PCP involvement. Purpose The Patient Support Plan Incentive Program recognizes and rewards PCPs for their commitment to support CCM members in Care Model by engaging in the member identification and outreach process and to follow up with enrolled members in a three-way case conference (member, Healthways case manager, and PCP). Eligibility The incentive program will include members 18 years of age and older identified by Healthways for CCM who are enrolled in Akamai Advantage and Commercial (HMSA PPO and HMO) health plans. PCPs must be in HMSA’s PCMH program to be eligible to earn the incentives. PCPs with targeted CCM members can earn PCP Incentives 1 and 2; when a PO has targeted CCM members, all PCPs with membership in that PO will be eligible to earn PCP Incentive 3. Incentive activities must be documented in Cozeva as described below. The incentive program will run at least through the end of 2015. Process Overview 1. Healthways generates CCM target list Healthways generates a list of members targeted for CCM using a predictive algorithm at the beginning of each quarter. A “target list” of your identified members will be accessible through Cozeva and refreshed every quarter.

2. PCP reviews target list and excludes inappropriate members To ensure that the right members are targeted for Care Model enrollment, we encourage you to review your target list and exclude members who are inappropriate for the program. In Cozeva, you may exclude members for one of four reasons: • Deceased. • In hospice care. • Not on your patient panel. • Highly sensitive. Healthways won’t contact excluded members. Members who you indicate are deceased or in hospice care will be permanently excluded from your denominator for this measure and from subsequent target lists. Members who you indicate as not on your panel will be excluded from your denominator for the quarter. However, you must remove them from your panel in Cozeva to prevent them from showing up on future target lists. We understand there may be a need to exclude certain members whose conditions or circumstances require extra sensitivity or privacy. If you select the exclusion option "highly sensitive", the member will remain in your denominator for that quarter and won’t be placed in Healthways’ predictive algorithm for one year. Exclusions for this reason should only be used in rare and unique circumstances; overuse of this option will warrant an audit. 3. PCP engages targeted members Members who you don’t exclude from your target list will be released to Healthways for outreach, however, we believe it’s valuable for you to have the opportunity to discuss Care Model with members first. We recommend that you or your office staff call members, briefly explain the comprehensive case management patient support process, and present the potential benefits of the program. A script to guide this conversation is included at the end of this program guide. Reporting Numerator credit: You’ll have four weeks to contact members and submit confirmation through Cozeva. In Cozeva, indicate which targeted member you contacted, validate the member’s preferred phone number, and report the results of communicating the next step of the enrollment process. Healthways will reach out to all members unless you indicate otherwise. If you have concerns about a member with special circumstances or who you think would benefit from a modified approach, you may request that a Healthways case manager contact you before calling the member. Alternately, if members explicitly express that they’re not interested in the program despite your encouragement, you may indicate so; these members won’t be placed in Healthways predictive algorithm for one year. You won’t receive numerator credit for contacting these members. PCP Incentive 1: To acknowledge the time and effort that you and your office staff put into the outreach phone calls, we’ll award you $35 for each targeted member who you successfully contact, release to Healthways, and validate a phone number for within four weeks of the target list being posted on Cozeva. For the purposes of the incentive, a “released” member is anyone who 1) you tell Healthways to call, or 2) cases where you ask Healthways to call you before a

case manager contacts the member. You cannot earn the incentive for members who you report aren’t interested in the program and are therefore not released to Healthways. 4. Healthways contacts members for enrollment Healthways will first reach out to members you contacted and released from your target list, then to any members whom you didn’t exclude or contact within four weeks of the target list’s posting on Cozeva. Healthways will enroll interested members and help them develop a patient support plan. A Healthways case manager will send you an eReferral in Cozeva with the patient support plan attached. The case manager will continue to work with the member on the goals in their patient support plan. 5. PCP follows up with a three-way case conference To ensure that the goals and strategies in the members support plan align with and supplement the member’s clinical care needs, we encourage you to schedule a case conference visit with the member and Healthways case manager in your office to review the patient support plan. The case manager’s contact information will be included in the eReferral. PCP Incentive 2: To acknowledge the time you spend with the member and the Healthways case manager, we’ll award you $165 for the first three-way case conference you have with each CCM member and Healthways case manager. Reporting completion of the three-way case conference In Cozeva, a new measure will enable you to submit confirmation of the three-way case conference. You’ll attest the case conference was completed and report the date of service. Please document the presence of the case manager and member in the patient's medical record. We recommend that you schedule the case conference with the member and their case manager as soon as possible, however, you’ll be eligible to earn the incentive from the date that the case manager sends you the patient support plan through eReferral until the date the member drops out or graduates from the program, at which time the eReferral case will be closed by the case manager. You’ll have a one-month run-out period at the end of the quarter to submit supplemental data for case conferences that occurred during that quarter. You may earn PCP Incentive 2 for one visit per member per enrollment in Care Model. You don’t need to submit a claim for the case conference. Payments will be issued on a quarterly basis. 6. Continual engagement with CCM members in Care Model We hope that the three-way case conference will enable member-centered care coordination and that it may initiate ongoing communication between you and the Healthways case manager on the member’s status. If the patient support plan is updated, the case manager will send it to you as an attachment to the original eReferral. We recommend that you use the eReferral functions to continue communication and provide updates to the case manager. If you schedule any other follow-up visits with the member, please use standard Evaluation and Management procedure codes when filing claims.

Physician Organization Performance Incentive and PCP Incentive 3 In addition to your individual engagement with CCM targeted members, we’d like to reward PCPs and POs for the PO’s collective performance in contacting and releasing members to Healthways. Each PO will be scored and rewarded for the percentage of targeted members they contact and release each quarter. Each PCP in the PO, regardless of the number of CCM members they have during the quarter, is eligible to receive PCP Incentive 3 based on their PO’s performance that quarter. This means that even if a PCP has no members eligible for the patient support plan, all PCPs will benefit from the overall group’s performance. POs will earn a separate, additional payment per PCP in the PO, based on the PO’s aggregate performance (see table below). Denominator: All CCM targeted members attributed to a PCP in the PO who aren’t excluded by their PCP within four weeks of the target list’s posting on Cozeva. Excluded members are those identified as deceased, not on the PCPs panel, or in hospice care. Numerator: Members who are contacted by their PCP and released to Healthways for outreach within four weeks of the target list’s posting on Cozeva and with validated contact information. PO’s aggregate performance: % Contacted and Released

PCP Incentive 3 (Per PCP per Quarter)

PO Incentive (Per PCP in PO Per Quarter)

≥80%

$150

$250

70%-79.99%

$125

$225

60%-69.99%

$100

$200

50.00%-59.99%

$75

$175