Changes to Priority Health 2019 PCP Incentive Program Manual

Administrative details – (pg. 11)

Measure rounding – PIP measures round up if the score is within 0.5% of the target.

Example: If the score is 89.4, it will round to 89. Alternatively, if the score is 89.5, it will round to 90.

PPACA – (pg. 12)

The Patient Protection and Affordable Care Act (PPACA), which is also known as The Affordable Care Act (ACA), is considered healthcare law. Some of our measures have applicable product lines listed as PPACA. This line of business can include individual and small group lines of business.

Cervical cancer screening – (pg. 25)

Case definition
For PPACA Individual (HMO/POS) and Medicaid, continuously enrolled with Priority Health in the measurement year. No more than one gap in enrollment of up to 45 days during each measurement year.

Breast cancer screening – (pg. 27)

Case definition
Women must be continuously enrolled with Priority Health from October 1, two years prior to the measurement year. No more than one gap in enrollment of up to 45 days during each year of continuous enrollment. No enrollment gap from October 1, 2017, through December 31, 2017.
Applicable product line – HMO/POS, ASO/PPO, Medicare, Medicaid.

Measure code set – (pg. 120)

Measure code – Mammography now listed as MAM
Value Domain -N/A added
Measure code – Bilateral mastectomy now listed as BILAT MAST

Colorectal cancer screening – (pg. 29)

Case definition
Members continuously enrolled in 2018 and 2019, with no more than one gap in continuous enrollment of up to 45 days during each year of continuous enrollment.

Applicable product line – HMO/POS, ASO/PPO, Medicare

MTM – (pg. 61)

Reporting
OutcomesMTM has the most up to date list of target members. Use OutcomesMTM to identify members that need a comprehensive medication review (CMR).

Your Performance Specialist can supply a report that includes the score and remaining opportunity at each participating practice site.

PIP_011J – PIP Medication Therapy Management Worksheet. This report outlines member level detail of who had received a CMR, when it occurred, and who performed it.

PCMH – (pg. 62)

Method of measurement
Completion of the State Preferred Patient-Centered Medical Home application offered by The Michigan Department of Health and Human Services (MDHHS) will meet the requirements of the PCMH attestation. Eligible practices will not need to submit additional PCMH attestation documentation for the 2019 or 2020 incentive program performance years.

Risk adjustment – (pg. 65)

Method of measurement
Preventive targets for Medicare and Individual (HMO/POS)

  • ACA Individual (HMO/POS) – 20% target
  • Medicare – 30% target

Healthy Michigan Plan – (pg. 68)

Notes
Each member is eligible for only one HRA incentive payment per measurement year.

Acute hospital utilization – (pg. 70)

Reporting – PIP_021 – PIP Acute Hospital Utilization (TAB)

ED PCP Treatable – (pg. 73)

Target and payout

Filemart report inventory (pgs. 123 and 125)

PIP_011J – PIP Medication therapy management worksheet (TAB)
PIP_021 – PIP Acute hospital utilization (TAB)

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