Actively Engaged and the Comprehensive Provider Attribution (CPA)

New York Regional Extension Center (REC) Footprint

  • Presentation is also available in Portable Document Format (PDF)

March 2016

Agenda

Actively Engaged Reporting in IPP

Actively Engaged Reporting Requirements

  • PPS are required to report updates to their Actively Engaged counts in each quarterly report for each project with an Actively Engaged (AE) commitment
    • The quarterly reporting of Actively Engaged counts is cumulative throughout a DSRIP Year (DY), unless specifically noted in the Actively Engaged definition for a project
    • Duplicate counts of members are not allowed, unless specifically noted for a project
      • DY2, Q1 (Medicaid members engaged during DY2, Q1 only) DY2, Q2 (Medicaid members engaged during DY2, Q2 only) DY2, Q2 (AE Count reported on DY2, Q2 Quarterly Report)
        500 800 1,300
  • PPS must engage a minimum of 80% of the Actively Engaged commitment target for a quarter in order to earn the Achievement Value (AV) for this milestone for that quarter.
    • The 80% minimum standard was reduced to 75% for DY1, Q2.

Medicaid Member Registry Requirement

  • PPS must be able to substantiate the Actively Engaged counts reported on the quarterly reports through a registry of Medicaid members maintained by the PPS and submitted through IPP to the Independent Assessor.
    • For each Medicaid member engaged by the PPS and network partners, the registry must include, at a minimum:
      • The Medicaid Client Identification Number (CIN)
      • The Medicaid Managed Care Policy Number
      • For Project 2.d.i – a Unique Individual Identifier
  • An exception has been made to accommodate data sharing concerns associated with Medicaid members with substance use disorder (SUD) under 42 CFR. PPS are able to submit attestations from the SUD providers to support the Actively Engaged counts in lieu of the CIN data.

Actively Engaged Validation

  • Actively Engaged counts will be validated by the Independent Assessor each quarter where the PPS has an Actively Engaged commitment target
    • Actively Engaged supporting documentation must be submitted with the initial submission of the quarterly report
    • Actively Engaged is not subject to the remediation process, however PPS can submit additional documentation to the Independent Assessor through remediation if the PPS identifies an error with the original submission
  • PPS that miss their Actively Engaged commitment targets in Q1 or Q3 may still earn the AV and associated performance payments if the cumulative totals through Q2 and Q4 reach the 80% of commitment target threshold for these quarters.

Double Counting a Medicaid Member

  • PPS cannot "double count" a Medicaid member in their Actively Engaged reporting
    • The ´double count´ applies when multiple PPS are pursuing the same project and share network partners and is intended to ensure that the same Medicaid member is not counted by multiple PPS under the same project.
PPS A and PPS B are implementing project 3.a.i and both have Mental Health Provider 1 in their networks.
↓
Mental Health Provider 1 engages 1,000 Medicaid members for project 3.a.i during DY2, Q2.
↓
PPS A and PPS B must split the 1,000 Actively Engaged Medicaid members from Mental Health Provider 1 for project 3.a.i so the total count from this provider across the two PPS does not exceed 1,000
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Actively Engaged Discount Methodology

Introduction

  • Because of the lack of clarity in previously communicated active patient engagement guidance, a discount factor has been applied to relevant projects
  • To ensure fairness, these Actively Engaged discounts will be applied to the Actively Engaged PPS targets
  • PPSs are required to report non–duplicated numbers in IPP as communicated by the IA

Discussion Points

  • Why is it necessary to discount "by PPS, by project" instead of "by county"?
    • PPSs are not implementing their projects by county
    • Applying a separate discount percentage by county is operationally unfeasible
    • This approach was discussed and agreed upon with the stakeholder community
  • In instances where a PPS is the only PPS to pursue a project in a given county, a 0% discount is factored into the final discount, as opposed to being removed from the final discount calculation entirely

Four Factors in Determining a PPS´ Discount Percentage

  • 4 factors that will be used to determine the final discount percentage a PPS receives by project:
    1. The Percentage of Overlap Factor
  • Discount Factors:
    1. Project 2.a.i Factor
    2. Sole County Factor
    3. Lack of Project Overlap Factor

Percentage of Overlap Factor

  • The count of DSRIP Medicaid members with an interaction with providers in multiple PPS networks was determined ("Overlap"), by PPS by county
    • Using the "Overlap" count by PPS by county, an "Overlap Percentage" was calculated
    • The "Overlap Percentage" is the first component in determining a PPS´ actively engaged discount
      • By PPS By County [A] Overlap Count of Members with Provider Interactions that cross multiple PPSs [B] Non–Overlap Count of Members with Provider Interactions confined to a Single PPS [A] / [A + B] Overlap Percentage
        Forestland PPS Albany 100,000 300,000 25%
        Forestland PPS Saratoga 2,000 8,000 20%
        Forestland PPS Schenectady 30,000 60,000 33.3%

Discount Factors

  • Once an "Overlap Percentage" is calculated, a set of discount factors are applied at the project level as follows:
By PPS By County By Project Overlap Percentage
(Derived from County)
Forestland PPS Albany 2.a.i 25%
Forestland PPS Albany 3.a.ii 25%
Forestland PPS Albany 3.d.iii 25%
Forestland PPS Saratoga 2.a.i 20%
Forestland PPS Saratoga 3.a.ii 20%
Forestland PPS Saratoga 3.d.iii 20%
Forestland PPS Schenectady 2.a.i 33.3%
Forestland PPS Schenectady 3.a.ii 33.3%
Forestland PPS Schenectady 3.d.iii 33.3%

Discount Factor 1: 2.a.i

  • Once an "Overlap Percentage" is calculated, a set of discount factors are applied at the project level as follows:
    • 2.a.i–Because project 2.a.i´s objectives are to create an Integrated Delivery System, no discount will be applied to this project
By PPS By County By Project Overlap Percentage
 
Forestland PPS Albany 3.a.ii 25%
Forestland PPS Albany 3.d.iii 25%
 
Forestland PPS Saratoga 3.a.ii 20%
Forestland PPS Saratoga 3.d.iii 20%
 
Forestland PPS Schenectady 3.a.ii 33.3%
Forestland PPS Schenectady 3.d.iii 33.3%

Discount Factor 2: Sole County

  • Once an "Overlap Percentage" is calculated, a set of discount factors are applied at the project level as follows:
    • Sole County Factor–If a PPS is the only PPS active in a county, then the "Overlap Percentage" for that county does not factor into the final discount calculation
By PPS By County By Project Overlap Percentage
 
Forestland PPS Albany 3.a.ii 25%
Forestland PPS Albany 3.d.iii 25%
 
  Saratoga    
  Saratoga    
 
Forestland PPS Schenectady 3.a.ii 33.3%
Forestland PPS Schenectady 3.d.iii 33.3%

Assume that Forestland is the only
PPS active in Saratoga County

Discount Factor 3: Lack of Project Overlap

  • Once an "Overlap Percentage" is calculated, a set of discount factors are applied at the project level as follows:
    • Lack of Project Overlap Factor–If a PPS is the only PPS pursuing a project in a given county, then the "Overlap Percentage" is set to 0% (but it is still factored into the discount)
By PPS By County By Project Overlap Percentage
 
Forestland PPS Albany 3.a.ii 25%
Forestland PPS Albany 3.d.iii 25%
 
       
       
 
Forestland PPS Schenectady 3.a.ii 33.3%
Forestland PPS Schenectady 3.d.iii 0%

Assume that Forestland is the only
PPS pursuing 3.d.iii in Schenectady County

Weighted Average–Discount by Project

  • After the application of the business rules, the "Overlap Percentage" by county by project is weighted by the utilizing members attributed to the PPS in a given county
award

Final Actively Engaged Discounts

  • This weighted average result is rounded UP to the nearest 5% integer
  • This percentage is the discount factor applied to the actively engaged targets by PPS, by project
  • Actively engaged targets will be communicated to the PPS next week, and will have the discount percentages applied, where applicable
By PPS By Project As a
Percentage		 ↓

Rounded Up to
the Nearest 5%
Forestland PPS 3.a.ii 27.08% 30%
Forestland PPS 3.d.ii 18.75% 20%

Application of Actively Engaged Discounts

  • The Final Actively Engaged Discounts have been applied, where applicable, to the quarterly Actively Engaged commitment targets from the DY1, Q1 Quarterly Report to determine the new Actively Engaged commitment targets.
    • PPS will need to engage of minimum of 80% of the new Actively Engaged commitment target to earn the Achievement Value for respective quarter.
PPS Project Original Actively
Engaged Commitment
DY1, Q4		 Actively Engaged
Discount Factor		 New Actively
Engaged Commitment
DY1, Q4		 Minimum Actively
Engaged to earn AV
Forestland PPS 3.a.ii 8,500 30% 5,950 4,760
Forestland PPS 3.d.ii 2,100 20% 1,680 1,344
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Interpreting the Comprehensive Provider Attribution (CPA) Report

Purpose

  • The purpose of the Comprehensive Provider Attribution (CPA) report is to:
    • Provide the PPS with the member level detail of their attributed cohort
    • Catalog all Medicaid providers who performed a service on a PPS´ attributed member
    • Display the number of visits by provider for each attributed PPS member

Providers in the CPA

  • The CPA:
    • Includes only a PPS´ attributed members
    • Does not include members attributed to another PPS
    • Includes member interactions with all Medicaid providers, not just member interactions with the PPS´ in–network providers
  • Each record within the CPA will include a field denoting the provider that was responsible for an attribution, as well as a field denoting a servicing provider that did not result in an attribution
  • A flag will be included for each provider to identify whether the provider is:
    1. In the PPS network being reported on
    2. In a PPS network not being reported on
    3. Not in any PPS network
    4. In PPS and in Other PPS

CPA Service Types

  • For each member, the method of attribution that will be disclosed align with the DSRIP Attribution Loyalty Assignment (i.e. DSRIP Attribution Swimlane)
Attributed Provider
Service Type		 Non–Attributed
Provider Service Type		 CPA Service Type Full Name
DD–R DDL1 Developmental Disabilities–Residential (Waiver and IID)
DD–DVS DDL2 Developmental Disabilities–Day/Vocational Services
DD–CM DDL3 Developmental Disabilities–Care Management
DD–A16 DDL4 Developmental Disabilities–Article 16 Clinic
DD–OWS DDL5 Developmental Disabilities–Other OPWDD Waiver Services
LTC–NH LTCL1 Long Term Care–Nursing Home
BH–HH BHL1 Behavioral Health–Health Home TC, or ACT or HCBS Waiver (kids)
BH–IRC BHL2 Behavioral Health–Intermediate or Intensive Residential Care (RTF, RRSY, Rehab Services to CR Residents, etc.)

CPA Service Types

Designation for provider
that resulted in attribution		 Designation for provider
that a member saw but did
not result in attribution		 DSRIP Attribution Loyalty
Assignment (i.e. DSRIP
Attribution Swimlane)
Attributed Provider
Service Type		 Non–Attributed
Provider Service Type		 CPA Service Type Full Name
DD–R DDL1 Developmental Disabilities–Residential (Waiver and IID)
DD–DVS DDL2 Developmental Disabilities–Day/Vocational Services
DD–CM DDL3 Developmental Disabilities–Care Management
DD–A16 DDL4 Developmental Disabilities–Article 16 Clinic
DD–OWS DDL5 Developmental Disabilities–Other OPWDD Waiver Services
LTC–NH LTCL1 Long Term Care–Nursing Home
BH–HH BHL1 Behavioral Health–Health Home TC, or ACT or HCBS Waiver (kids)
BH–IRC BHL2 Behavioral Health–Intermediate or Intensive Residential Care (RTF,
BH–OC BHL3 Behavioral Health–OMH/OASAS Outpatient Clinic, CDT, PROS, Day Treatment, MMTP, Outpatient Rehab
BH–FMD BHL4 Behavioral Health–Freestanding MD psychiatrist, psychologist treating BH
BH–SM BHL5 Behavioral Health–Specialty Medical or Inpatient/ED for BH
AO–HH OTHL1 All Other–Health Home (Members meeting HH standard and Utilizing HH)
AO–PCP OTHL2 All Other–Primary Care Provider
AO–OPCP OTHL3 All Other–Other Primary Care Provider or Outpatient Clinic
AO–ED OTHL4 All Other–Emergency Department
AO–IP OTHL5 All Other–Inpatient
OTH CAT (blank) Other Category (not in any of the 16 Service Types defined above)

Hypothetical Walk–Through

The following slides will walk users through a hypothetical example, using John Doe, a Medicaid Member in the State of New York. When reading through the example, please refer to the table at the bottom of each slide, which describes and defines the columns used throughout the CPA report.

  • Medicaid member John Doe [MBR_ID = XYZ123] is attributed to the Forestland PPS [PPS_ID = FL2] and lives in Saratoga County [MBR_RES_COUNTY_CD = 41].
Report Column Name Description Example
MBR_ID The Member attributed to the PPS listed in column 'PPS ID' XYZ123
PPS_ID The Performing Provider System (PPS) ID Forestland PPS (FL2)
MBR_RES_COUNTY_CD The member´s residence county code 41

Hypothetical Walk–Through

(DSRIP Attributed Provider)

  • John Doe is attributed to a DSRIP provider based on his claims volume [MBR_CATEGORY = Attributed Through Total Claims]. The attribution by provider service type is left blank in the CPA since the attribution resulted from total claims versus a specific qualifying service type [ATTR_PROV_SRV_TYPE = blank].
  • The provider that led to John´s attribution–Maple Leaf [ATTR_PROV = 1930163744–Maple Leaf Recovery Inc.]–will appear on every record where John exists in the CPA.
Report Column Name Description Example
MBR_CATEGORY The Member´s attribution category. It will either contain one of the 16 CPA Service Types or one of the following reasons: – ´Attributed Through Total Claims´ – ´PCP Attributed´ Attributed Through Total Claims
ATTR_PROV The ´Attributed by´ provider´s NPI or MMIS Provider ID + Provider Name. When the Attr_Prov_Ind = ´Y´ in the source, this is the Attributed by provider for the member 1930163744–Maple Leaf Recovery Inc.
ATTR_PROV_SRV_TYPE The Attributed by provider Service Type blank

Hypothetical Walk–Through

(Non–Attributed Provider)

  • John Doe also has an interaction with an Inpatient provider that belongs to one of the DSRIP Attribution Loyalty Assignments [Diag_Srv_Catg_CD = AO–IP].
  • The Inpatient provider that John interacted with–[Prov_id = 1730686743] Dr. Sheryl Silverstein [Prov Name = Dr. Sheryl Silverstein]–did not lead to an attribution.
  • Both the provider that led to attribution (Maple Leaf), and this specific provider (Dr. Sheryl Silverstein) will have relevant information listed on the same CPA record.
Report Column Name Description Example
Prov id CPA Service Type Provider ID related to the member within the PPS. Can either be an Entity ID or NPI. 1730686743
Prov Name Service Type Provider Name related to the member within the PPS. Can either be an Entity ID or NPI. Dr. Sheryl Silverstein
Diag_Srv_Catg_Cd CPA Service Type. When this column is blank, this will be ´OTH CAT´. AO–IP
  • Dr. Sheryl Silverstein processes 4 claims related to John Doe´s visits [Tot_Claim_Cnt = 4]. This is the provider to which John Doe has interacted with the second most [Prov_Seq = 2].
  • Dr. Sheryl Silverstein is in the Forestland PPS and the Riverside PPS [Netwk_Ind = In PPS and Other PPS] networks.
Report Column Name Description Example
Tot_Claim_Cnt The total claims/encounters related to the Service Type Provider for the member within the PPS 4
Prov_Seq The provider sequence number within the CPA Service Type. The providers are ranked by number of claims. Sequence 1 is ranked the highest 2
Netwk_Ind Identifies whether the provider is:
  • In the PPS network being reported on (´In PPS´)
  • In a PPS network not being reported on (´In Other PPS´)
  • Not in any PPS network (´Not in any PPS´)
  • In the PPS being reported on and in another PPS (´In PPS and Other PPS´)
 In PPS and Other PPS

Hypothetical Walk–Through

(Health Home Enrollment)

  • John Doe does not have an open Health Home enrollment record [HH_IND = N]. For illustration purposes, if John Doe did have an open Health Home enrollment record, then [HH_IND = Y].
Report Column Name Description Example
HH_IND If member has an open Health Home enrollment record then this will be set to ´Y´. Otherwise, the indicator will be set to ´N´. N

Hypothetical Walk–Through

(Managed Care and PCP Assignment)

  • John is enrolled with a Managed Care Organization [MCO = 01183019] called Spruce Health First [MCO_NAME = Spruce Health First].
  • His MCO has assigned him a primary care provider [PCP_NPI = 1380008249], of which he regularly uses–Dr. Brown [PCP_NAME = Dr. Brown and Associates].
Report Column Name Description Example
MCO The provider ID of the member´s managed care organization (MCO) 01183019
MCO_NAME The name of the member´s managed care organization Spruce Health First
PCP_NPI The NPI of the member´s MCO assigned primary care provider 1380008249
PCP_NAME The name of the member´s MCO assigned primary care provider Dr. Brown and Associates

Hypothetical Walk–Through

(Summary)

Report Column Name Example Used
MBR_ID XYZ123
PPS_ID Forestland PPS (FL2)
MBR_RES_COUNTY_CD 41
MBR_CATEGORY Attributed Through Total Claims
ATTR_PROV 1930163744–Maple Leaf Recovery Inc.
ATTR_PROV_SRV_TYPE blank
Prov_id 1730686743
Prov Name Dr. Sheryl Silverstein
Diag_Srv_Catg_Cd AO–IP
Tot_Claim_Cnt 4
Prov_Seq 2
Netwk_Ind In PPS and Other PPS
HH_IND N
MCO 01183019
MCO_NAME Spruce Health First
PCP_NPI 1380008249
PCP_NAME Dr. Brown and Associates

CPA Release Information

  • The CPA reports will be sent to the PPS through the CMA Secure File Transfer Protocol (SFTP), where they will remain on–site at the location approved through the DEAA Agreement
  • Because the CPA contains Member–Level data, the report can only be released to PPS currently cleared for data receipt, and can only be accessed by PPS users that had a User Identity Attestation
    • PPS should hold the report centrally and redact once the opt–out process is complete
Cleared for Data Receipt  
Albany Medical Center Finger Lakes Alliance CNYC C
Nassau Queens Stony Brook Bassett Adirondack Health Institute
Montefiore Refuah Advocate Community Providers Bronx Lebanon
Westchester Medical Center NYU Lutheran Maimonides St. Barnabas Health
Mt. Sinai NY Presbyterian–Queens NY Presbyterian Care Compass
Staten Island Millennium Collaborative Care Samaritan Sisters of Charity
NYC Health & Hospitals Corp      
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Future Attribution Reports

Overlap Report

  • Purpose: The Overlap Report will show the count and percentage of overlapping members. These counts and percentages will be shown by provider, by PPS, by region.
  • Release Date: ASAP
  Attribution Count % of Total Attribution Count % of Total Attribution Count % of Total Provider Total
  PPS 1 PPS 2 PPS 3 …  
Provider 1 400 14% 2,000 69% 500 17% 2,900
Provider 2 680 26% 750 29% 1,200 46% 2,630
Provider 3 45 26% 62 36% 66 38% 173
Provider 4 502 64% 49 6% 238 30% 789
PPS Total 1,627 2,861 2,400  

The Individual Provider Attribution (IPA) Report

  • Purpose: The IPA will show each PPS how many attributed member counts their providers had at the individual provider level. Results have been de–duplicated
  • Release Date: The IPA report is scheduled for release the week of March 21st, 2016.
  • This report will contain no PHI and be available to all PPSs
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Questions?

DSRIP Email:
dsrip@health.ny.gov

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