AETNA BETTER HEALTH®
Pay for Performance program
You may be able to earn more compensation with new Pay for Performance (P4P) program
We’re introducing our 2014 P4P program for participating primary care and Ob/Gyns in Pennsylvania. Under this program, you may be eligible for more compensation.
We base this on practice-specific data tied to a variety of clinical quality and utilization guidelines. We’ll make payments for the P4P program based on patient encounters from January 1, 2014 through December 31, 2014. Individuals and/or practices that qualify for program compensation will receive payment during the second quarter of 2015.*
Guidelines of the P4P Program
· Only PCPs and OB/GYNs are eligible
· 25 member minimum panel size requirement
· Metrics have quality and utilization parameters
· Dental visits require that the PCP include the “YD” code outlined in the EPSDT periodicity schedule when billing the plan
Refer to the attached document for more information about measures, thresholds and dollar amounts.
We’re here to help and answer your questions
Our goal is to help support your patients with access to the highest quality medical care. If you have questions, call us at 1-866-638-1232.
Sincerely,
John Robinson, MD
Chief Medical Officer
Enclosure: P4P Program measures
*Payment for the P4P program is dependent on the funding that the Pennsylvania Department of Public Welfare provides. Aetna Better Health reserves the right to end the P4P program if funding becomes unavailable.
2014 Pay for Performance Measures
Adolescent well-care visits (ages 12-21 years)
Targeted providers: Primary care providers
This measure includes members ages 12 – 21 years who receive one adolescent well visit according to HEDIS Technical Specifications between January 1, 2014 and December 31, 2014 shown through claims data.
Providers must meet the minimum threshold of 49.65% (HEDIS 2013 50th percentile) in order to receive payment for services given to members. PCPs that meet the minimum threshold of 49.65% will receive a one-time payment of $4.50 for each member aged 12 – 21 years that received an adolescent well-care visit between January 1, 2014 – December 31, 2014.
Annual dental visit (ages 2–21 years)
Targeted providers: Primary care providers
This measure includes members ages 2 – 21 years who receive one annual dental visit according to HEDIS Technical Specifications between January 1, 2014 and December 31, 2014 shown through claims data.
PCPs will receive payment for each member who has an annual dental care visit according to HEDIS Technical Specifications. Providers must meet the minimum threshold of 50.32% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 50.32% will receive a one-time payment of $6.75 for each member aged 2 – 21 years who receives a dental visit between January 1, 2014 – December 31, 2014.
Cholesterol management for patients with cardiovascular conditions: LDL-C control (<100 mg/dL) (ages 18-75 years)
Targeted providers: Primary care providers
This measure includes members 18-75 years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1, 2013–November 1, 2013 or, who had a diagnosis of ischemic vascular disease (IVD) during 2014 and 2013, and their most recent LDL-C level during 2014 is <100 mg/dL. This is shown through claims data by services that Quest Labs obtains (Aetna Better Health’s lab vendor).
Providers must meet the minimum threshold of 41.82% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 41.82%will receive a one-time payment of $4.50 for each member aged 18 – 75 years that received an LDL-C screening with a result <100 mg/dL between January 1, 2014 – December 31, 2014.
Payment will be made to providers once after the completion of the full calendar year of 2014, as the member may have more than one LDL-C level and, the most recent level performed before December 31, 2014 will be used to determine compliance.
Comprehensive diabetes care: Cholesterol management for people with diabetes (LDL-C control <100 mg/dL)
Targeted providers: Primary care providers
This measure includes members 18–75 years of age with diabetes (type 1 and type 2) whose most recent 2014 LDL-C level is <100 mg/dL. Providers must meet the minimum threshold of 34.89% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 34.89% will receive a one-time payment of $4.50. This will be for each member aged 18 – 75 years who received an LDL-C screening with a result <100 mg/dL between January 1, 2014 – December 31, 2014. This is shown through claims data by services that Quest Labs obtains (Aetna Better Health’s lab vendor).
Comprehensive diabetes care: Hemoglobin A1c (HbA1c) control (<8%)
Targeted providers: Primary care providers
This measure includes members 18–75 years of age with diabetes (type 1 and type 2) whose most recent 2013 HbA1c level is <8mg/dL. Providers must meet the minimum threshold of 48.57% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 48.57% will receive a one-time payment of $4.50 for each member aged 18 – 75 years that received an HbA1c Screening with a result <8mg/dL between January 1, 2014 – December 31, 2014. This is shown through claims data by services that Quest Labs obtains (Aetna Better Health’s lab vendor).
Comprehensive diabetes care: HbA1c screening for people with diabetes
Targeted providers: Primary care providers
This measure includes members ages 18 – 75 years who receive one HbA1c screening according to HEDIS Technical Specifications between January 1, 2014 and December 31, 2014. This is shown through claims data of services that Quest Labs obtains (Aetna Better Health’s lab vendor).
Providers must meet the minimum threshold of 83.16% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 83.16% will receive a one-time payment of $2.50. This is for each member aged 18 – 75 years who received an HbA1c screening between January 1, 2014 – December 31, 2014.
Controlling high blood pressure (ages 18-85)
Targeted providers: Primary care providers in Philadelphia, PA
(Zip codes included are: 19019 – 19092; 19099; 19101 – 19116; 19118 – 19129; 19130 – 19139; 19140 – 19149; 19150 – 10155; 19160 – 19162; 19170 -119173; 19175 – 19179; 19181 – 19185; 19187 – 19188; 19190 – 19197; 19244; 19255)
This measure includes members 18-85 years of age whose most recent BP reading during the measurement year (as long as it occurred after the diagnosis of hypertension was made) is <140/90. If multiple BP measurements occur on the same date, or are noted in the chart on the same date, the lowest systolic and lowest diastolic BP reading will be used. If there is no BP recorded during the measurement year, we will assume that the member is “not controlled.”
PCPs will be required to send documentation by fax or mail, and photocopied from the member’s medical record. It should indicate a diagnosis of hypertension before the date of the blood pressure reading and the member’s blood pressure reading on that date. We will keep a database of all documentation we have. We’ll also use an RN to review the documentation to determine compliance.
Providers must meet the minimum threshold of 56.2% (HEDIS 2013 50th percentile). PCPs who meet the minimum threshold of 56.2% will receive a one-time payment of $4.50. This is for each member aged 18 – 85 whose most recent BP reading during the measurement year (as long as it occurred after the diagnosis of hypertension was made) is <140/90 between January 1, 2013 – December 31, 2013. Payment will be made to providers before
June 30, 2014.
We’ll make payment to providers after the completion of the full calendar year of 2014, as the member may have more than one blood pressure reading and, the most recent reading performed before December 31, 2014 will be used to determine compliance.
Providers in the above listed Philadelphia zip codes please fax or mail a copy of the member’s visit that includes the date, diagnosis of hypertension prior to the date of the blood pressure reading and the actual blood pressure reading to:
ATTN: QUALITY MANAGEMENT
Aetna Better Health®
2000 Market Street, Suite 850
Philadelphia, PA 19103
FAX: 1-860-754-0337
Frequency of ongoing prenatal care: > 81% of expected visits
Targeted providers: OB/GYNs
This measure includes members who deliver between November 6, 2013 and November 5, 2014. And, for those members who complete 81% or more of expected prenatal visits according to HEDIS Technical Specifications shown through claims data.
Providers must meet the minimum threshold of 64.7% (HEDIS 2013 50th percentile). OB/GYNs who meet the minimum threshold of 64.7% will receive a one-time payment of $2.50. This is for each member who delivered between November 6, 2013 and November 5, 2014, and who completes 81% or more of expected prenatal visits.
Prenatal care in the first trimester
Targeted providers: OB/GYNs
This measure includes members who deliver between November 6, 2013 and November 5, 2014 who receive one prenatal visit in the first trimester or, within 42 days of enrollment according to HEDIS Technical Specifications shown through claims data. OB/GYNs must meet the minimum threshold of 85.88% (HEDIS 2013 50th percentile). OB/GYNs who meet the minimum threshold of 85.88% will receive a one-time payment of $2.50. This is for each member who delivered between November 6, 2013 and November 5, 2014, and who receive one prenatal visit in the first trimester, or within 42 days of enrollment.
Postpartum care
Targeted providers: OB/GYNs
This measure includes members who deliver between November 6, 2013 and November 5, 2014 who receive one postpartum visit 21 – 56 days post-delivery according to HEDIS Technical Specifications shown through claims data. OB/GYNs must meet the minimum threshold of 63.99% (HEDIS 2013 50th percentile). OB/GYNs will receive a one-time payment of $4.50 for each member who delivered between November 6, 2013 and November 5, 2014 who has one postpartum visit 21 to 56 days post-delivery. Providers must meet the minimum threshold of 63.99%.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
www.aetnabetterhealth.com/pennsylvania
PA-13-01-04