P4P - Individual Health Plan Bonus Programs

P4P - Individual Health Plan Bonus Programs

HEALTH PLAN

USE OF P4P COMMON MEASURES

OTHER MEASURES IN BONUS PLAN

DATA SOURCE FOR BONUS

MAX. BONUS POTENTIAL or SIZE OF BONUS POOL

PAYMENT THRESHOLD FOR

CLINICAL & PAT. SAT. SCORES

PAYMENT

TYPE &

FREQUENCY

CONTRACTUAL ISSUES OR

OTHER REQUIREMENTS

Aetna

Pay for Performance Program

YES – all

Clinical – 50%

Pt Sat – 40%

IT – 10%

NO

Aggregated data

Up to 3.5% of cap

Performance at75th percentile & up on each measure (6 clinical, 4 pt. satis. and 2 IT) earns payment up to 3.5% cap

Annual payment based on previous CY performance

Not in contract. Groups must have 12,000 Aetna member months in 2003, sign up for CAS, and have signed, delegated agreements for patient mgt, claims, & credentialing.

Blue Cross (CA)

Physician Quality Incentive Program (PQIP)

Mammograms,

pap smears, & asthma (7.5%); essentially same pt. sati.s. (20%); no IT investment but enc. data is in bonus

YES – 72.5% of bonus keyed to non-P4P measures: grievances, audit, transfers, PCP bonus, enc. data, UM requirements, care mgt.

Blue Cross data

$4.50 pmpm (and $2.50 pmpm for separate generic prescribing bonus)

Performance at 20th, 40th, 60th, & 80th percentile earns increasing payment up to $4.50 pmpm max.

Annual payment based on previous CY performance

In contract. No special P4P strategy around contracting. About 70% of contracts have been amended, but only for BCC program.

Blue Shield (CA)

Quality Incentive Program III

YES – all

Clinical – 50%

Pt Sat – 40%

IT – 10%

NO

Aggregated data

$2.00 pmpm

[$1.00 clinical

.80 pt sat

.20 IT]

Performance at 30th, 50th, & 75th percentile earns 25%-50%-100% payment for each of 6 clinical measures; Pt Sat earns 50% for avg. and

Annual payment based on previous CY performance

Incentive program to be decoupled from contracting. New groups, and existing groups with no incentive plan, will be automatically enrolled. Existing groups with prior incentive plans will

HEALTH PLAN USE OF P4P COMMON MEASURES OTHER MEASURES IN BONUS PLAN DATA SOURCE FOR BONUS MAX. BONUS POTENTIAL or SIZE OF BONUS POOL PAYMENT THRESHOLD FOR CLINICAL & PAT. SAT. SCORES PAYMENT TYPE & FREQUENCY CONTRACTUAL ISSUES OR OTHER REQUIREMENTS

100% for above avg for each of 4 areas; IT earns 50% credit for one activity, 100% for two

have pro-rated payments as they transition to this plan. Measurement year is CY2003.

Encounter data submission threshold is 2.7 E&M codes pmpy to qualify for payment.

CIGNA

2003 Provider Group Rewards Program

YES – all

Clinical – 50%

Pt Sat – 40%

IT – 10%

YES – (1) encounter data rewards of $.05 pmpm for each of 3 areas if group meets annual threshold of procedures per 1000: lab (1,500), radiology (530) & professional outpatient (6,500); and (2) open panel reward of $.10 pmpm if group maintains at least 90% PCP panels open to assignment of CIGNA members

(1) Monthly CIGNA specific encounter data submission to DDD for the encounter rewards

(2)) quarterly HP Open Panel reports for accessibility (3) aggregated data for P4P measures

$.15 max for encounter data

$.10 for open panel rewards

Minimum of $1.60 pmpm for the top performing groups in all components of the PGRP

Performance above the 50th percentile for each clinical measure & each pt sat domain earns a payment, with higher scores earning higher payments

For CIGNA specific measures, payout is quarterly or annual depending upon the measure (the same as 2002 CIGNA PGRP program).

Annual payment based on previous CY performance for P4P measures

N/A – Bonus plan was never in CIGNA contracts.

Groups must meet 2.7 encounters pmpy to participate in P4P measures.

Group must be signed up for CAS to participate in P4P measures.

HEALTH PLAN USE OF P4P COMMON MEASURES OTHER MEASURES IN BONUS PLAN DATA SOURCE FOR BONUS MAX. BONUS POTENTIAL or SIZE OF BONUS POOL PAYMENT THRESHOLD FOR CLINICAL & PAT. SAT. SCORES PAYMENT TYPE & FREQUENCY CONTRACTUAL ISSUES OR OTHER REQUIREMENTS

Health Net (CA)

Quality of Care Incentive Program (QCIP)

YES – all

Clinical – 50%

Pt Sat – 40%

IT – 10%

NO (other measures in Health Net report but only P4P measures in bonus program)

Aggregated data

$2.25 pmpm + 10% bonus if group has individual physician bonus plan

Breast cancer – 66%

Cervical cancer – 58%

Immun MMR – 69%

Immun VZV – 64%

Asthma – 73%

Diabetes HbA1c– 56%

CAD LDL – 54%

Pt. Sat: timely – 75%

Pt. Sat: Dr.-Pt – 80%

Pt. Sat: specialty – 70%

Pt. Sat: overall– 75%

Annual payment based on previous CY performance

Groups must be contracted for both 2003 and 2004; have submitted 3.0 encounters pmpy (E&M codes); and sign amendment removing QCIP from the contract.

Bonus payment will not be offset against risk pools.

PacifiCare

Quality Index® profiles and Quality Incentive Program

Same clinical; same pt. sat. domains but from plan survey, not CAS; no IT

YES – 4 other hospital measures & 6 other clinical measures collected for PacifiCare Quality Index profiles

PacifiCare data, , OSHPD, MedPAR, PEP-C, Leapfrog

$21 million pool

Max bonus of $3.00 pmpm if Secure Horizons contract; $2.00 pmpm max if commercial only

Performance at 75th percentile earns 50% of payment; 85th percentile earns 100%

Absolute value based on percentiles for each measure as of 1Q03

Quarterly pmpm adjustment based on previous 4 quarters performance

Program is in PacifiCare contracts.