State BlueCare Prime Plus POS

BlueCare Prime Network Criteria

A cost index is calculated by dividing the actual risk-adjusted allowed PMPM for all members associated with that provider by an expected risk-adjusted market allowed PMPM comparison.
The market allowed comparison is based on members with the same mix of members by market (Medicare fee locality, typically county divisions), member age group, product swim lane (e.g. PPO, HMO), and product drug coverage
A lower cost index is favorable
Providers are ranked by cost index, forming percentiles, and the 50th percentile (median) value is determined.

A provider quality index is constructed by comparing a provider group’s compliance rate to a market compliance rate.
A market quality comparison of the line of business, provider state, and mix of quality measures for all participating providers is used.
The quality index is the average of all of the compliance rates on the various metrics compared to the market value, it is not a weighted average based on membership
An individual measure must have a denominator of 5 in order to be scored. A provider must have 2 scoreable measures and a combined denominator of 30 to receive a quality score.
Not all providers have all quality metrics.
Providers have an average of 33 quality metrics (range 2 – 109)
A higher quality index is favorable

Thresholds

Baseline threshold values of cost and quality indices were established using claims 4/1/2018-3/31/2019, paid through 6/30/2019
A provider with a cost and quality index that meets the thresholds aforementioned is considered a high performing provider

Inclusion

All Anthem commercial members in CT
For primary care, Only members with affinity to primary care provider are measured for participation
Cooperative Care providers are considered high performing
No special adjustments were made for downside risk contracts

Exclusion

Anthem participating specialist and within two percentile of quality and affordability
In good standing with Anthem provider participation agreement
Participants in the State of CT Episodes of Care Program

Anthem HPP or within two percentile of quality and affordability benchmarks
In good standing with Anthem provider participation agreement
Utilization of a referral management program
Commitment to the tenets of value-based care and a patient centered practice model consistent with the shared principles of high performing primary care
Adoption of e-consult platform
Participation in at least two education meetings each year and good citizenship
Open panel with same day appointment slots; evening and weekend appointments or equivalent coverage