2016 Care Based Incentives
For complete information on the Care Based Incentives (CBI) Program, please see Section 18 of the Alliance Provider Manual.
What's New for 2016
New Fee-For-Service Incentives
The Alliance is excited to introduce three new Fee-For-Service (FFS) incentives to the CBI program for 2016:
• Post-Discharge Care: In an effort to reduce hospital readmissions, the Alliance will pay PCPs an additional $100 for the first post-discharge visit provided to eligible members that occurs within 14 days of discharge or an additional $150 if the first post-discharge visit occurs within 7 days of discharge.
• Patient Centered Medical Home (PCMH) Recognition: In support of our provider network, the Alliance will begin incentivizing providers’ achievement of either NCQA or The Joint Commission PCMH recognition. Incentive amounts are based on the level of PCHM recognition achieved and range from $2,000 to $3,500. Providers may receive additional payments achieving subsequent levels of recognition. During the 2016 CBI Term, providers are eligible to receive this incentive for recognition earned in prior years.
• Initial Visit Incentive: This new FFS incentive is replacing the Primary Care Initial Visit Incentive offered by the Alliance during 2015. Under this incentive, the Alliance will pay providers an additional $100 for initial visits with eligible members for visits that occur within 120 days of the members’ enrollment in the Medi-Cal Program.
Good News, Fewer Forms!
The Alliance is eliminating the requirement that providers must submit a Post-Partum Care Form in order to receive the $25 Post-Partum Care incentive. Instead, eligibility for this incentive will be determined based on claims data.
Changes to Diabetes-Related Measures
Beginning in 2016, Diabetic Retinal Exams will replace LDL-C Screenings as a Quality of Care measure under which providers may earn CBI points. In addition, the LDL-C Screening will no longer be a required element of care for the Composite Diabetes Services Incentive. For the 2016 CBI Term, this $100 FFS incentive will be paid to providers for each eligible member who receives the following three elements of care between January 1, 2016 and December 31, 2016:
• HbA1c testing
• Diabetic retinal exam
• Medical attention for nephropathy
Introduction of Benchmark Rankings
The Alliance is introducing a “Benchmark Ranking” system in 2016 to award CBI points for eight programmatic measures, including all Care Coordination measures and four of the Quality of Care measures.
Point allocations for “Benchmark Ranking” measures will be determined differently for the Care Coordination Measure and Quality of Care Measures, as explained below.
• Care Coordination Measures: PCPs will earn points if their performance exceeds a threshold based on the PCP’s Comparison Group’s median score for the 2014 measurement period. Measures include:
– Ambulatory Care Sensitive Readmissions
– Rate of Readmissions
– Rate of Generic Prescriptions
– Preventable ED Visits
• Quality of Care Measures: PCPs will be awarded points based on their performance relative to NCQA’s national benchmarks for HEDIS reporting. Measures include:
– Asthma Medication Ratio
– Avoidance of Antibiotic Treatment in Acute Bronchitis
– Use of Spirometry Testing in the Assessment and Diagnosis of COPD
– Appropriate Testing for Children with Pharyngitis
Benchmark ranking sets target scores for the entire year which do not fluctuate quarterly. Relative ranking targets fluctuate quarterly based on the provider’s peer group performance. The remaining six Quality of Care measures will continue to be ranked using the relative ranking methodology.
The Performance Improvement measure has changed in that the plan goal for Care Coordination Measures is now comparison group specific. The CBI provider comparison groups are Family Practice, Pediatrics and Internal Medicine. The Plan Goal for Quality of Care measures remains a single target for all comparison groups. As a reminder, providers can receive points for the Performance Improvement measure by either:
• Meeting the plan goal (which is now comparison group specific) or,
• Achieving either a 5% improvement (Care Coordination measures) or a five percentage point improvement (Quality of Care measure) compared to the prior year.
For questions regarding the CBI program, please contact your Provider Services Representative at (800) 700-3874 ext. 5504.