A Guide for Primary Care Physicians

OPTIMUM PHYSICIAN ALLIANCE CONTACT PO Box 90 MERI NOTARO Buffalo, New York opawny.com 14240 1-844-769-5879 OPA 2017 NETWORK + INCENTIVE GUIDE Prepared For: Date Issued: A GUIDE FOR 10.31.2016 PRIMARY CARE PHYSICIANS Valid To: 12.31.2017 OPA PHYSICIAN PARTNERS Table of Contents CONTENTS 1 2 3 Take a look at what you'll find inside this guide. INTRODUCTION TIERING PROGRAM STANDARD INCENTIVE OPA Overview 3 OPA Primary Care 12 Standard Incentive Overview 17 Physician Tiering Overview 2017 Network Standards 5 Primary Care Metrics 19 2017 PCP 13 OPA Resources 7 Tiering Structure Pediatric Care Metrics 22 Network Incentive and 9 Standard Incentive Metrics 23 PCP Tiering Overview 4 5 6 CENTERS OF EXCELLENCE PRACTICE OPTIMIZATION APPENDICES PROGRAM (POP) Centers of Excellence 25 Practice Optimization 31 Standard Incentive 45 Overview Program (POP) Guidelines Code Lists Activity Based 27 Sample POP Application 39 Performance Measures Utilization Based 28 Performance Measures Centers of Excellence Metrics 29 1 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 2 [ the platform that simplifies the practice of medicine ] Optimum Physician Alliance (OPA), formed in 2012, is the platform that simplifies the practice of medicine. It consists of approximately 600 physicians in the areas of primary and specialty care, Organization located mainly in Erie and Niagara counties. OPA is committed to promoting prac- meaningful engagement among healthcare tice transformation, with a patient-centered partners. OPA provides key resources to reduce Overview approach, and understands the importance administrative burdens and offers incentive pro- of leveraging healthcare data to support high grams designed to promote the type of practice quality outcomes for patients. This systematic transformation necessary for success in this OPA is an organization committed to excellence. Learn a little bit approach to healthcare is anchored by the pri- evolving industry. more about us. mary care physician and driven by collaboration This handbook is for you, our physician between primary and specialty care physicians, partner, to navigate and explore the benefits of hospitals, a health plan and most importantly, being an OPA physician, and provide you with patients. an understanding of OPA's Network Standards, This collaborative relationship sets OPA Resources, Incentive Programs and more! apart as a unique organization which facilitates We accelerate smart, patient-centered and value based care. Take a look at the values that help us achieve our vision and define our culture. WHY CHOOSE US? PATIENT FOCUSED INTEGRITY COMMITMENT RESPECT FORWARD-THINKING 3 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 4 [ 2017 network standards ] As an Optimum Physician Alliance (OPA) provider you have agreed to actively participate in, and * The Network Standards are reviewed on an to adhere to, the Network Standards.* intermittent basis, and revised if warranted Standard No. 4 Each OPA practice must identify and commit a physician champion (solo physicians are champion by default), and an administrative champion. Standard No. 1 Standard No. 5 Physicians must be credentialed through BlueCross BlueShield of Western New York Each OPA physician and administrative champion must have a unique functioning (BCBSWNY) in order to participate in OPA. email address. Standard No. 2 Standard No. 6 Participating OPA providers must have privileges at Kaleida Health or an agreement in place All champions (as stated in #5) must meet with their OPA Physician Advisor on a regular basis with a hospital group that has privileges at Kaleida. throughout the year. Standard No. 3 Standard No. 7 Participating OPA practice must have an operational EMR. Each OPA provider practice must be compliant with the HEALTHeLINK Consent Process AND have an effective workflow in place to obtain HEALTHeLINK consents from patients 5 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 6 [ resources that we provide ] The way you practice medicine has changed drastically in the last few years. On top of your clinical responsibilities there are greater administrative burdens placed on your practice. OPA understands the need to focus on healthcare, and not just administration. As a member of Integrated Care EMR Support Specialist Variation Analysis OPA, you can receive comprehensive support through the following services: for Kids (Inc/K) Review and analysis of care OPA physicians, within the Behavioral Health (BH) support management platforms, same specialty type, are for children and their families, predictive modeling tools, brought together to examine therapy and psychiatry services EMR systems and network unwarranted variations in conveniently provided at the connectivity to illustrate the care and develop common patient's PCP office, assistance value of care coordination and standards that improve quality with medication management, outcomes achieved in care and access to care and help linking families to management initiatives other BH support services PCMH/PCSP Consulting Nutrition Education Health Coach Pharmacist Patient Centered Medical Home Outreach Associate Patient Centered Specialty Practice One-on-one nutrition Support for weight manage- Pharmacy support services Supports practices in achieving Communication assistance to education for adults and ment, physical activity, stress include high level practice PCMH or PCSP recognition keep patients up-to-date on children, nutrition education management, smoking cessa- analysis to improve both the appointments and necessary for those with chronic diseases, tion, disease prevention and quality and efficiency of care milestones, training for staff to follow-ups by phone or in free wellness education classes as well as patient specific improve efficiency and better office, electronic medical record education with a focus on meet the needs of patients, (EMR) documentation for each best practice and therapeutic and assistance streamlining one-on-one visit with BlueCross efficacy organizational workflows BlueShield of Western New York (BCBSWNY) members 7 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 8 [ 2017 PCP incentive program overview ] Standard Incentive The standard incentive is broken down into two (2) components - the Network Incentive and the At-Risk Incentive. These NETWORK INCENTIVES incentives will be evaluated based on the performance of the overall OPA network. • It is a well-known fact that early detection is key to preventing and/or lessening the impact of chronic conditions and illnesses, however screening rates for common diseases have not changed much year after year. TheNetwork AND OPA TIERING Incentives were designed to engage our OPA partners in developing population management techniques, which will be critical to future success in healthcare. • The At-Risk Incentive is designed to facilitate coordination and cooperation among physicians to improve the quality PROGRAM OVERVIEW of care for patients and reduce unnecessary costs. Additional information will be available about this incentive in the coming weeks. OPA is excited to offer several incentive programs for 2017, giving practices the opportunity to earn additional revenue through quality focused initiatives, network Centers of Excellence engagement and improvements in the quality and coordination of patient care. The objectives, structure, and reimbursement methodologies vary across incentive This incentive focuses on engagement and encourages physicians to attend local events, network with peers in the programs, but are all tied to OPA’s goal to be the platform that simplifies the practice community, and allows for the opportunity to share and receive information on both local and national healthcare trends. of medicine. To qualify for each incentive, physicians must be active OPA The specific benchmarks are described in more detail within the Centers of Excellence section of this guide. Payment of this incentive is distributed quarterly and will be based on practice performance. providers and practice a minimum of twelve (12) clinical hours per week. In addition, starting January 1, 2017, OPA will be launching a new PCP Tiering Program. The Tiering Program is an initiative aimed at improving the quality, Practice Optimization Program efficiency, and overall engagement of the OPA primary care physician network and will impact eligibility for OPA’s incentive program. For more information on the The Practice Optimization Program (POP) is designed to provide the necessary support and resources to prepare physicians Tiering Program, please see the Tiering section of this guide. and their practices for the next decade of healthcare evolution. It is an incentive opportunity designed to empower OPA practices to determine how they would like their incentive dollars applied within their practice. In order to receive incentive dollars, practices must submit the POP application within the designated time-frames and identify a project that will help transform their practice. Payment of this incentive is distributed quarterly. 9 OPTIMUM PHYSICIAN ALLIANCE OPTIMUM PHYSICIAN ALLIANCE 10 OPA Primary Care Physician Tiering TIERING Program [ 2017 PCP tiering program overview ] Effective, January 1, 2017, OPA will be imple- The program is also linked to OPA’s Network menting a Tiering Program designed to improve Standards, which were developed to encourage the quality, efficiency, and cooperation among engagement within OPA. The more OPA aligns as OPA physicians. The Tiering Program will

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