Incentives and Rewards
Incentive and reward value
Total eligible incentive payments for practices participating in the Primary Care VBP Model should equal at least 10% of the value of annual projected practice service payments (capitated + fee-for-service) for the practice’s attributed patients. This doesn’t mean a participating practice will earn the full 10%, but that it would do so if it met all incentive metrics in the Primary Care VBP Model.
Reward timing
Payers should make certain reward payments to participating primary care practices during the performance period if feasible, rather than at the end of the performance period, to ensure sufficient and sustainable resources for performance improvement investments. For example, some payers may tie certain reward payments to delivery of specific services, such as bonus payment for each claim related to a prescribed screening. Note: Different methods and timing may be used for different metrics within the primary care model. Payers might assess some practice performance metrics, such as alignment with Total Cost of Care (TCOC) targets and overall HEDIS-related metrics for a panel, after the performance year is complete if that is the most appropriate method. Learn more about different approaches to timing of provider rewards in Section II Step 4 Assess, interpret and leverage data.
Total cost of care
While a TCOC shared risk arrangement between larger provider organizations and payers is not part of the primary care VBP model, it may be employed as a complement to the primary care payment model if mutually agreeable to the parties. For primary care practices with large attributed adult populations, the methodology used to determine performance incentive payments should incorporate a measure of primary care practice performance managing total cost of care for the attributed adult population. In addition, payers should employ mechanisms to protect practices against the impact of random variation in medical expenditures over time.
Performance criteria used in HEDIS measures, such as continuous enrollment, needs to be recognized in benchmark setting, and adjusted, depending upon the source of data.
Improvement rewards for practices should be equivalent to high performance rewards to provide a strong incentive for practices with lower performance scores to improve. Improvement targets should represent meaningful improvement and be reasonably attainable by primary care practices.
Practices identified by payers as serving patient populations with unusually high medical and/or social risk may be held accountable only for improvement if the payer and practice agree that external benchmarks are not applicable.
Total Cost of Care (TCOC): Total spending on services from which shared savings and shared risk rates are based. TCOC benchmarks approximate the costs and resources used to treat identified populations for a defined set of health care services, such as all professional, pharmacy, hospital, ancillary care and administrative payments. TCOC does not always include all services, as some plans may carve out high-cost services or rarely used services to protect providers from costs they may not be able to control.
HEDIS: Healthcare Effectiveness Data and Information Set is a tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care and service.