Office of MaineCare Services: Maine Accountable Communities Initiative Data Book Walk-Through

Office of MaineCare Services: Maine Accountable Communities Initiative Data Book Walk-Through

May 14, 2014

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Agenda

Topic Page

Welcome and Introductions

State Update 2

Recap of the MaineCare Accountable Communities Program 4

Overview of the Data Book 9

Develop of Detailed Adjustments: Policy Adjustment 11

Develop of Detailed Adjustments: Completion Factor 14

Develop of Detailed Adjustments: Prospective Trend 16

Develop of Detailed Adjustments: Claim Cap Adjustment 19

Sample Data Book 21

Outlines of Rule and MOU 23

3

State Update

• Claims cap correction• Additional 3 mo. (6 mo. total) for claims run out• Decision to have interim and final payments• State Plan Amendment• Rulemaking• MaineCare: AC Lead Entity Discussions• Provider agreement/ Rule/ MOU

4

State Authority for AC

1. MaineCare Provider Agreement

2. MaineCare Rule (MaineCare Benefits Manual)

3. Memorandum of Understanding

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Recap of the MaineCare

Accountable Communities

Program

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Recap of Key Elements of the MaineCare AC Program

The initial benchmark, adjusted final benchmark, and the performance PMPM TCOC are key elements in the MaineCare Accountable Communities Program. Below shows the relationship amongst these items.

InitialBenchmark PMPM TCOC

VS.PerformancePMPM TCOC

Relationship of TCOC Elements

InitialBenchmark

PMPM TCOC

Serves as an estimate of the adjusted final benchmark PMPM TCOC

Uses State Fiscal Year 2013 data with 2-months run-out with adjustments for policy change, completion, trend and claims cap

Shared before the performance period begins

Adjusted Final

Benchmark PMPM TCOC

Uses State Fiscal Year 2013 data with 30- months run-out for interim calculation and 41-months run-out for final calculation

Adjusted for policy change, completion (if needed), trend, risk and claims cap

PerformancePMPM TCOC

Uses State Fiscal Year 2015 data with 6-month run-out for interim calculation and 17-month run-out for final calculation

Adjusted for completion (if needed) and claims cap

Interim savings will be determined by May 2016 and final savings by April 2017. Allows 1 month for DHHS to receive data and 3 months for calculations. Payments will be made within 30 days of reports.

Adjusted FinalBenchmark PMPM TCOC

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Recap of Timeline for MaineCare Accountable Communities Program

Performance Period

Benchmark Period

July 2012 July 2014 June 2015June 2013 May 2014

Initial Benchmark PMPM TCOC

Finalized

The timeline for the shared savings calculation in performance year 1 is discussed below.

April 2017

Performance and Adjusted Final

Benchmark PMPM TCOC Final

Payment

Performance Year 1 Timeline:

Rebasing•Benchmark PMPM TCOCs will only be rebased after the initial 3 year test period•The Benchmark PMPM TCOC for Performance Years 2 and 3 will be based on the Base Year TCOC adjusted for policy, risk, trend, and claims cap between the Base Year and the end of each Performance Year.

May 2016

Performance and Adjusted Final

Benchmark PMPM TCOC Interim

Payment

SFY13 Data with 2-months paid run-out is used

for calculation of Initial Benchmark

PMPM TCOC


for calculation of Performance PMPM TCOC


for calculation of Performance PMPM TCOC

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Recap of Steps in Shared Savings Calculation

Adjusted Final Benchmark PMPM

TCOC Development

2

Initial Benchmark PMPM TCOC Development

1

Performance PMPM TCOC Development

3

Shared Savings Calculation

4

• Identify and verify reliability of base period data

• Adjust base period data by performing Incurred But not Reported (IBNR) adjustments

• Apply known policy change adjustments

• Summarize adjusted claim costs for each attributed member

• Develop and apply prospective trend to the data

• Apply high cost claim cap adjustments

• Summarize initial benchmark PMPM TCOC for each AC

• Document aggregate concurrent risk score

• Adjust base period data by performing Incurred But not Reported (IBNR) adjustments, if needed

• Apply policy change adjustments to be reflective of performance period


• Develop and apply actual trend by sub-population to the data using the comparison population

• Adjust data to be on the same risk basis as the performance PMPM TCOC


• Summarize adjusted final benchmark PMPM TCOC for each AC

• Compare adjusted final benchmark PMPM TCOC to performance PMPM TCOC to determine if Min Savings Rate (MSR) is met

• Calculate care management fee PMPM in performance period

• Calculate quality metrics

• Calculate shared savings/losses for eligible ACs (care management fees in the performance period will be subtracted from the shared savings).

• Apply shared savings / loss caps (10% TCOC for Model I)

• Verify the reliability of the performance period data

• Perform IBNR adjustments to complete the performance period data, if needed



• Summarize performance PMPM TCOC for each AC

• Document aggregate concurrent risk score

Shared Savings Calculation Steps

The main steps to calculate shared savings are listed below.

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Recap of Initial Benchmark PMPM TCOC Development

The initial benchmark PMPM TCOC is developed using Medicaid claims data with various adjustments applied to provide the AC Lead Entities with the best estimate available at the start of the Performance Year.

Benchmark periodJuly 2012 – June 2013

Performance periodJuly 2014 – June 2015

Benchmark Period Base Data:

•Data with incurred dates between 7/1/2012 and 6/30/2013 and paid through 8/31/2013 will be used

•Data checks will be completed

•Only Medicaid specific claim costs for fully Medicaid eligible members will be used (including the dual population)

•Only core and optional services, if applicable, will be included in the base data

•Only claim costs for members attributed to each AC will be used

Goal: Develop Benchmark PMPM TCOC to be Reflective of

Performance Period

Adjustments

In order to calculate the initial benchmark PMPM TCOC, the following formula is applied:

Initial Benchmark PMPM TCOC = ( X ) with an adjustment of X X

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Items Description

Step 1: Policy Change Adjustments

Policy change adjustments are made to account for rate, and benefit or eligibility changes that occur after the base period in order to bring base data to the effective period

Step 2: Completion Factor Adjustments

Completion factor adjustments account for claims that may still be outstanding in the base data

Step 3: Prospective Trend Adjustments

Prospective trend will be applied to project the base data in the benchmark period to the performance period based on projected PMPM TCOC trend.

Step 4: Claim Cap Adjustments

Claim cap adjustments smooth any potential volatility as a result of an abnormal distribution of catastrophic claims

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3

4

5

1 2 3 4 5

Note: Aggregate risk score is documented for each AC in the benchmark period

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Overview of the Data Book

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Overview of the Data Book

The data book shows the adjustments performed to the base data in the development of the initial benchmark PMPM TCOC. Below is an overview of the data book structure.

Exhibit Name Description

1 Base Data

• Directly summarized from the claims system with no adjustments• Data elements include attributed membership, gross payment amount,

units, utilization, and PMPM. • Shown by high-level service category as well as population.

2 Policy Change Adjustment• One adjustment factor is developed for each policy change and applied to

the claims with the corresponding policy sections• Shown by high-level service category as well as population

3 Completion Factor

• Developed based on available historical claims data• One completion factor is developed for each high-level service category

and each month• Shown by high-level service category as well as population

4 Prospective Trend• Developed based on 30-months of historical claims data with completion

factor, policy and risk adjustments applied• Developed and shown by population group

5 Claim Cap Adjustment Factor• Medicaid paid amount is summarized for each attributed member and the

dollar amount above the corresponding claim cap threshold for the AC is removed

6Initial Benchmark PMPM Summary

• Documents each adjustment applied to base data • Data elements include the PMPM before and after the adjustment as well

as the adjustment factor• Detailed adjustment steps are shown by service category and by population

group

Appendix 1 Service Category Mapping• Documents which Accountable Communities program services are included

in each service category

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Development of

Detailed Adjustments:

Policy Adjustment

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Accountable Community A

Total Dollar Amount

Policy Change Adjustment Factor

$100,0001.000

=$100,000/$100,000

$55,0001.100

=$55,000/$50,000

Development of Detailed Adjustments: Policy Adjustment

Methodology

• All policy changes that occurred in SFY13 and SFY14 with a fiscal impact will be summarized by the impacted policy sections.

• An adjustment factor will be calculated for each policy change with fiscal impact based on the estimated dollar impact by the State and the total claims dollars for the affected policy section after the change was implemented.

• The adjustment factor for each policy change will only be applied to the claims for the associated policy section prior to the corresponding policy change effective date to put that data on the current policy basis.

Policy adjustments are made to the claims data to make sure data in prior periods are on the current policy basis.

Example Calculation


Service Category

Total Dollar Amount

Inpatient $100,000

Physician $50,000

Policy Change: 10% Rate Increase on

Physician Claims

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Development of Detailed Adjustments: Policy Adjustment - Continued

The actual policy adjustment factors for the total attributed population by each service category for the development of the initial benchmark PMPM TCOC are shown below.

The adjusted final benchmark PMPM TCOC will be further adjusted by policy changes in SFY2015 to be reflective of the performance period policy basis

Illustrative Policy

Adjustments by Service Category

Note: Policy change factors vary by community at the service category level, the population level, and in total based on the varying dollar distribution of claims by service category and population. The factors in the table above are illustrative only.

Eligibility Group Service Category Policy Change AdjustmentInpatient 1.0020 Outpatient 1.0020 Physician 1.0023 Physician Behavioral Health 0.9979 Other 1.0000 Pharmacy 0.9883 Subtotal - Core 0.9984 Children PNMI 0.9649 Long Term Care (Optional) 0.9990 Dental 1.0000 Total - Core & Optional 0.9976

Total AC Attributed Population

Maine Accountable Communities

Accountable Community AExhibit 2 - Policy Change Adjustment FactorsFFS Incurred July 1, 2012 to June 30, 2013 and Paid Through

August 31, 2013

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Development of


Completion Factor

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Development of Detailed Adjustments: Completion Factor

Methodology

• From June 2011 to August 2013, the Medicaid paid amount and members were summarized for each service category by incurred and paid month.

• Historical payment patterns were analyzed in the Deloitte reserve model using the summarized data and ultimate completion factors were estimated for each incurred month.

• Claims were adjusted by the completion factor with the corresponding service category and incurred month for the 12 month benchmark period.

Illustrative Completion Factor by Service

Category

Completion factor adjustments account for any claims incurred but not yet paid.

Different completion factors will be developed for the adjusted final benchmark PMPM TCOC based on the additional run-out available

Note: Completion factors vary by community at the service category level, the population level, and in total based on the varying dollar distribution for incurred month by service category and population. The factors in the table on the left are illustrative only.

Eligibility Group Service Category Completion FactorInpatient 1.1173 Outpatient 1.0806 Physician 1.0914 Physician Behavioral Health 1.0202 Other 1.0674 Pharmacy 1.0003 Subtotal - Core 1.0568 Children PNMI 1.0122 Long Term Care (Optional) 1.0297 Dental 1.0214 Total - Core & Optional 1.0478


Maine Accountable Communities

Accountable Community AExhibit 3 - Completion FactorsFFS Incurred July 1, 2012 to June 30, 2013 and Paid Through

August 31, 2013

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Development of


Prospective Trend

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Development of Detailed Adjustments: Prospective Trend

Methodology

• 30-months of claims data was limited to only members who met the attribution criteria statewide and adjusted for completion, policy changes, and risk score.

• Utilization and unit cost trends were analyzed under various trending techniques

• Final prospective trend was based on an equal weighting of four trend techniques

Monthly linear regression

Quarterly linear regression with seasonality adjustment

Six month rolling trend

12 month rolling trend

• Total PMPM TCOC trends by population group were developed by multiplying the utilization and unit cost trends together

Developing trends by population group is consistent with the trend development for the Medicare Shared Savings Program

Prospective trend is applied to project the base data from the base period to the performance period.

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Development of Detailed Adjustments: Prospective Trend - Continued

Illustrative PMPM TCOC

Trend by Population

Group

Prospective trend will be replaced by the actual retrospective trend from the comparison population in the development of the adjusted final benchmark PMPM TCOC


Eligibility Group Service CategoryProspective PMPM

TrendSubtotal - Core 5.2%Total - Core & Optional 4.2%Subtotal - Core 5.8%Total - Core & Optional 5.5%Subtotal - Core 4.7%Total - Core & Optional 4.0%Subtotal - Core 6.2%Total - Core & Optional 6.7%Subtotal - Core 4.3%Total - Core & Optional 1.6%

Maine Accountable CommunitiesExhibit 4 - Annualized Prospective PMPM Trend

FFS Incurred July 1, 2012 to June 30, 2013 and Paid Through August 31, 2013

Adult

Aged or Disabled Non-Dual

Child

Fully MaineCare Eligible Dual


Note: Trend factors will not vary at the sub-population level by community. The total trend factor will vary by community based on the varying distribution of dollars by population. The factors in the table above are illustrative only.

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Development of


Claim Cap Adjustment

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Development of Detailed Adjustments: Claim Cap Adjustment

Methodology

• The catastrophic claim cap threshold is:

$50,000 for accountable community group sizes of 1,000 to 1,999;

$150,000 for accountable community group sizes of 2,000 to 4,999;

$200,000 for accountable community group sizes of 5,000 +

• The Medicaid paid amount (after applying the previous adjustments) is summarized for each attributed member and the dollar amount above the threshold corresponding to the member’s community is removed.

Example Calculation

Catastrophic claim adjustments are made to smooth the data for outlier claims.

The claim cap adjustment will be refreshed in development of adjusted final benchmark PMPM TCOC after updates are made for completion, policy changes, retrospective trend, and risk

Accountable Community AWith 5,500 Members and $200,000 Claim Cap Threshold

MemberBefore Adjustment After Adjustment

Total Dollar Amount Total Dollar Amount

A $250,000 $200,000B $100,000 $100,000C $210,000 $200,000

Total $560,000 $500,000

Adjustment Factor 0.8929= $500,000 / $560,000

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Sample Data Book

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Sample Data Book

The final data book sent to each accountable community will only contain that community’s data.

Microsoft Excel Worksheet

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Outlines of Rule and MOU

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MaineCare AC Rule content: Chapter II

• Provider Requirements• RFA, MaineCare Provider, quality measurement, learning activities• PCCM• Contractual relationships: Providers of care coordination for members with Chronic

Conditions, Developmental or Intellectual Disabilities, and Behavioral Health Issues• Invitations to CCT and BHHO partners of HHPs to contract• Partnerships or policies with all hospitals in service area, public health entity

• Covered services: locating, coordinating and monitoring of core and any optional services selected

• Member eligibility: minimum MaineCare eligibility and attribution methodology• Quarterly notification by DHHS to members assigned to AC• Member freedom of choice• Quality framework (actual measures in MOU)• Governance: transparency, MaineCare member participation• Performance bond required for Model II• Termination: Pro-ration if state terminates the AC without cause, or if the Department or

legislature eliminates the AC program. Other provisions under discussion with AAG.

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MaineCare AC Rule content: Chapter III

• Shared Savings Methodology

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Memorandum of Understanding (MOU) Purpose

• To formalize an agreement to engage in a partnership.

• On an individual AC basis, to allow for the selection of key elements of the program that the Lead Entity has chosen on behalf of the Accountable Community and for which the Lead Entity will be held accountable.

• To specify Quality measures that will not be a part of rulemaking due to the likelihood of modifications for each Performance Year.

• To outline deliverables and deadlines on the part of the Department and the Lead Entity.

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MOU Key Elements

• 1 year Term of Agreement with up to two (2) renewals = 3 years• Risk Sharing Model Selection • Service Area• Optional Services • Quality Measures

• Core Measures• Elective Measures• Authorization for Department to directly access quality data (HbA1c, CG-CAHPS, etc)

• Reports and Due Dates• Department to Lead Entity• Lead Entity to Department

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MOU: Commitment to Provide Reports

Provider to Department:

•AC Provider Organization•AC Primary Care Physician (for non FQHC or RHCs)•Member Assignment Reconciliation

Department to Provider:

•Initial Benchmark Total Cost of Care•Quarterly:

– Member Assignment– Quality Performance– Total Cost of Care Tracking

•Monthly Utilization Dashboard Reports (PHI)

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Q&A

Questions?

Office of MaineCare Services: Maine Accountable Communities Initiative Data Book Walk-Through

Documents

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