Value Based Payment: PPS and Facility Roles in Quality Improvement Program (VBP QIP)

  • Facility Roles is also available in Portable Document Format (PDF, 194KB)

September 2015

Expectations for Today

  1. What is VBP QIP?
  2. VBP QIP Structures and Timelines
  3. VBP QIP Roles: PPS and Facility Role
  4. Next Steps

What is VBP QIP?

VBP QIP Terminology. What is VBP QIP? What´s the difference between VBP QIP and VAPAP?

VBP QIP Terminology

Facilities

  • The hospitals for the VBPQIP program are referred to as ´facilities´

Plans

  • The transformation plans that the Facilities must develop and implement are referred to as the ´plans´

Programs

  • The governing documents of the program run by each MCO will collectively be referred to as that MCO´s VBP QIP ´Program´

MCOs

  • Managed Care Organizations (MCOs) are at times referred to as ´plans.´ To differentiate these entities from the plans being created within this program, they may be capitalized, referred to individually, or identified as ´MCOs,´ and will manage the contracts and payments associated with VBP-QIP

Regional Plans

  • A term used in some initial communications which will be retired to minimize confusion

What is VBP QIP?

  • Funds have been allocated to support the transition of certain struggling facilities to VBP; this is an alternative to the State- administered VAPAP program.
  • VAPAP & VBP QIP are mutually exclusive programs post-September 2015.
  • Separate funds have been allocated for public facilities such as HHC to participate in the VBP QIP program
  • Align qualified facilities to a PPS and PPS to participating MCO via attribution snapshot.

Managed Care Premium Methodology:

  • Limit the number of facility to PPS and PPS to participating MCO combinations in order to alleviate administrative complexities.
  • Calculate the gross dollar target for each MCO including surplus and applicable taxes.
  • Calculate administrative adjustment add-on for participating MCO.
  • Using SFY15-16 projected enrollment, calculate the VBP QIP per member per month (PMPM) add-on for each participating MCO. PMPM will be calculated on a statewide basis.
  • Validate MCO statewide VBP QIP PMPM add-on falls within reasonable range and meets CMS quality threshold requirements.
  • Include the VBP QIP PMPM add-on on MCO specific Schedule B as part of the overall Quality Incentive (QI) portion of the Mainstream Managed Care premium.
  • Provide MCO specific addendum schedule which will breakout the detailed components of the QI premium add-on.
  • Provide MCOs with MMCOR and encounter reporting guidance.

VAPAP vs VBP QIP

VAPAP VBP QIP
Provide funding to allow facilities to implement a financial sustainability transformation Transformation Plan Provide funding to allow facilities to implement a VBP contracting transformation
Provide funding to financially distressed facilities. Purpose Provide funding to financially distressed facilities while pushing the facilities toward longer-term sustainability and improved quality.
OPCHSM Governance OHIP
Department of Health Administering MCO
State Funding MCO

VBP QIP Structure and Timelines

DOH´s VBP QIP Vision: Year-by-Year. VBP QIP: Timeline. DOH´s VBP QIP Structure - What it should look like. DOH´s VBP QIP Structure - What it should NOT look like.

DOH´s VBP QIP Vision: Year-by-Year

Year 1 • Program Planning *
• Pay for Reporting
Year 2 • Program Implementation *
• Pay for Reporting
• Incorporation of DSRIP VBP baseline metrics
Year 3 • Pay for Performance
Year 4 • Pay for Performance
• Sustainability Review
Year 5 • Pay for Performance
• Sustainability review
* In taking an active role in the planning and an oversight role in the implementation of VBP QIP,
   MCOs are moving beyond their traditional contractual relationship.

   Within the bounds of VBP QIP, the MCOs are an active administrator in the facilities´ transformation

VBP QIP: Timeline

qip timeline

DOH´s VBP QIP Structure*- What it should look like

structure should look like
  • MCO A will work with Facilities 1 & 2 under MCO A´s VBP QIP PROGRAM. Facilities 1 & 2 will develop a Transformation PLAN that aligns with this Program, with PPS X input on Facility 1 and PPS Y input on Facility 2
  • MCO B will work with Facilities 3 & 4 under MCO B´s VBP QIP PROGRAM. Facilities 3 & 4 will develop a Transformation PLAN that aligns with this Program, with PPS Y input on Facility 3 and PPS Z input on Facility 4
  • MCO C will work with Facility 5 under MCO C´s VBP QIP PROGRAM. Facility 5 will develop a transformation plan that aligns with this Program, with PPS Z input.

DOH´s VBP QIP Structure*- What it should NOT look like

structure should not look like
  • MCOs A and B will work with Facilities 1 & 2 under MCO A´s and MCO B´s MCO´s VBP QIP PROGRAM, requiring alignment from the MCOs. Facilities 1 & 2 will develop a Transformation PLAN that aligns with this Program, with PPS X input on Facilities 1 & 2
  • MCOs B and C will work with Facility 3 under MCO B´s and MCO C´s VBP QIP PROGRAM, requiring alignment from the MCOs. Facility 3 will develop a Transformation PLAN that aligns with this Program, with PPS Y input on Facility 3.

VBP QIP Roles

General Roles, PPS´ Roles, Facility´s Roles

VBP QIP Roles

PPS Role
  • Consult with Facilities and MCOs to ensure facility plan submitted by facilities aligns with PPS DSRIP goals
  • Provide support (non-financial) and guidance to the participating facilities
  • Flow funds from MCO to Facility
  • Document and report quarterly on the payments made to the facilities under VBP QIP.
  • Document and report quarterly on facility performance.
MCO Role
  • Design VBP transition program in accordance with DOH-provided criteria
  • Administer program and distribute funds
  • Approve facility plans
Facility Role
  • Adhere to plan submitted to MCO, including any application and reporting requirements
  • Become financially sustainability by transitioning to VBP
DOH Role
  • Provide MCOs with criteria for funds distribution and program administration that aligns with NYS VBP Roadmap
  • Fund program through MCO rate increase which includes administrative fee

PPS´ Role

Inputs   PPS Role   Output
  1. Facility submits VBP QIP plan
  2. MCO sends funds
  3. MCO and PPS Contract
 +
  1. Consult with Facilities and MCOs to ensure and approve the plan submitted by facilities aligns with PPS DSRIP goals
  2. Relay funds to facilities
  3. Provide support (non- financial) and guidance to the participating facilities
 = Facility is operating on VBP contracts and is sustainable.
Resulting in improved population health and improved VBP baseline metric achievement for the PPS. Thus increased shared savings

Facility´s Role

Inputs   Facility Role   Outputs
  1. PPS Guidance
  2. Funds from MCOs, via PPSs
  3. MCO Contract
 +
  1. Design and submit a plan to MCOs (with PPS approval) that will ensure a successful transformation to VBP and in turn a sustainable future
  2. Adhere to plan submitted to MCO, including any application and reporting requirements
 = Facility is operating on VBP contracts and is sustainable.
Resulting in improved population health and improved VBP baseline metric achievement for the PPS.

MCO-PPS Contracting for VBP QIP

ASO Agreements

  • The most promising vehicle for enabling contracting between PPSs & MCOs for VBP QIP is by recognizing PPSs Administrative Services Organizations (ASOs), and using ASO Agreements
  • ASO Agreements can be used as a contracting vehicle so long as provider/medical services and/or management relationships are not involved in the resulting agreement

Other Potential Contracting Solutions

  • Since ASO Agreements cannot be used for medical service contracts, they can be used for VBP QIP but not for the entirety of the VBP programs required by DSRIP
  • One solution to this is for PPSs to be registered as IPAs and/or ACOs, giving them the required regulatory status
  • An unlikely but possible solution is that PPSs will become established in statute, giving them the waiver extension from corporate practice that would enable them to engage in medical service contracts

The Department is actively engaged in developing contracting guidance for the purposes of VBP QIP. Greater detail will be made available as the process progresses. It should be noted that the Department will not be reviewing the contracts established for VBP QIP.

VBP QIP "Draft" Plan Pairings

MCO PPS Facility
Fidelis Maimonides Medical Center Interfaith Medical Center Kingsbrook Jewish Medical Center
Montefiore Hudson Valley Collaborative Montefiore – Mount Vernon Nyack Hospital
Nassau Queens Performing Provider System, LLC St. John´s Episcopal
Refuah Community Health Collaborative Good Samaritan Hospital Suffern
Westchester Medical Center Bon Secours Charity Health Good Samaritan Hospital Suffern
Healthfirst Advocate Community Providers (AW Medical) Brookdale Hospital
New York City Health and Hospitals Corporation Secondary Lead
HIP/Emblem New York City Health and Hospitals Corporation Secondary Lead
MetroPlus New York City Health and Hospitals Corporation Primary Lead
MVP/Hudson Health Montefiore Hudson Valley Collaborative Montefiore – New Rochelle
United Health Plan Westchester Medical Center Health Alliance (Benedictine)

What´s Next?

What can Start Now? Next Steps.

What can Start Now?

Below are the priority actions that can and should commence following today´s discussion

  1. Facilities to begin developing facility plans with PPS guidance
    • Review the VBP Roadmap and hold discussions with PPSs on what needs to take place to meet the DSRIP VBP baseline expectations
  2. Continue contracting conversations
    • While guidance for conducting VBP QIP contracting is being developed by the state, MCOs will use this time and the information currently available to build the framework for future contracting discussions with PPSs & Facilities
  3. Develop contracting guidance
    • The Department is actively creating guidance to assist all involved parties in upcoming MCO-PPS VBP QIP contract negotiations. It should be noted that the Department will not review the contracts established for VBP QIP.

Next Steps

Activity Date
DOH to hold webinar on Equity Programs By Sept 16th
DOH to hold next discussion with MCOs on VBP QIP programs By Sept 18th
DOH to provide further guidance on VBP QIP PMPM add-on timing By Sept 18th
DOH to provide contractual guidance to MCOs TBD

Questions?

Comments?

For any further questions, please contact the VBP QIP inbox: vbp_qip@health.ny.gov