Common use of ACO Improvement Clause in Contracts

ACO Improvement. a. For each composite within a domain, compare ACO BP1 actual rates to BP2 performance rates i. For composites where an ACO demonstrates improvement (i.e., reaches the improvement target), the ACO earns improvement points ii. For composites where an ACO fails to demonstrate improvement, then Step 2 is implemented a. If the State sets individual ACOs’ BP2 and BP3 performance rates to be the higher of their actual BP1 or BP2 rates, then for each composite within a domain, compare BP1 statewide median rates to BP2 statewide median rates. If the State sets ACOs’ BP2 and BP3 performance rates to be the higher of their BP2 or BP3 actual rates, then for each composite within a domain, compare BP1 statewide median rates to the higher of BP2 statewide median rates or BP3 statewide median rates. i. For composites where the State demonstrates improvement (i.e., reaches the improvement target), the ACO earns improvement points ii. For composites where the State fails to demonstrate targeted improvement, the ACO does not earn improvement points Note: In order to prevent such cases where an ACO’s performance would improve excessively through the use of the statewide median, the number of composites by which an ACO may use Step 2.a.i to earn improvement points is capped at one Note: This example assumes each composite has the same Improvement Target across composites A- D, and that the State is comparing BP1 rates to BP2 rates. Measure Improvement Target = 1.0 State Improvement Median = 1.0 A – Willingness to Recommend (Adult Survey) 75.1% 75.9% 0.8 (target not met by ACO) State Med = 1.0 YES (Step 2 applied) B - Willingness to Recommend (Child Survey) 85.1% 87.0% 1.9 (target met by ACO) ACO = 1.9 YES (Step 2 not needed) C - Communications (Adult Survey) 89.5 88.7% -0.8 (target not met by ACO) State Med = 1.0 NO (Capped at 1: Composite A already received points) D - Communications (Child Survey) 78.1% 78.5% 0.4 (target not met by ACO) State Med = 0.8 (target not met by State) NO EOHHS will establish the attainment threshold and goal benchmark for each Quality Measure. EOHHS anticipates establishing these performance benchmarks as follows: • For Quality Measures based on NCQA HEDIS measures, EOHHS anticipates using NCQA Quality Compass percentile benchmarks where possible • For non-HEDIS claims-based Quality Measures, EOHHS anticipates using existing MassHealth data sources such as MassHealth historical claims or encounter data • For non-HEDIS Clinical Quality Measures, or other Quality Measures where EOHHS does not have access to applicable data, EOHHS anticipates using MassHealth benchmarks based on the ACO-attributed population EOHHS will calculate the Contractor’s Quality Score by multiplying the unweighted domain scores for each domain by the domain weights detailed in Exhibit 1, and then summing the resulting weighted domain scores together. The Contractor’s Quality Score will be a number between zero (0) and one (1), inclusive. The amount of at-risk DSRIP funds a Contractor earns will be determined by its DSRIP Accountability Score. The Contractor’s DSRIP Accountability Score will be based on the ACO’s TCOC achievement, as well as their quality performance on the same four (4) Quality Measure domains used for the Contractor’s Quality Score. The Contractor’s TCOC achievement will be calculated as described in Section 3.2 below; the Contractor’s quality performance will be calculated as described in Section 3.3 below. The relative contributions of the Contractor’s TCOC achievement and quality performance are detailed in Exhibit 10: EXHIBIT 10 – ACO DSRIP Accountability Domains DSRIP Accountability Domain % Contribution to DSRIP Accountability Score This domain reflects a Contractor’s TCOC performance for its Enrollees, relative to the Contractor’s TCOC Benchmark as described in Section 4 of the Contract. The Contractor’s TCOC component of its DSRIP Accountability Score will be calculated in the following manner: • If the Contractor’s TCOC Performance is lower than the Contractor’s TCOC Benchmark (i.e., the Contractor has Savings), as described in Section 4 of the Contract, the Contractor’s TCOC component of its DSRIP Accountability Score equals 100% • If the Contractor’s TCOC Performance exceeds the Contractor’s TCOC Benchmark by more than 5% of the Contractor’s TCOC Benchmark, as described in Section 4 of the Contract, the Contractor’s TCOC component of its DSRIP Accountability Score equals 0% • If the Contractor’s TCOC Performance exceeds the Contractor’s TCOC Benchmark by less than 5% of the Contractor’s TCOC Benchmark, the Contractor’s TCOC component of its DSRIP Accountability Score equals: one (1) minus (the Contractor’s TCOC Performance minus the Contractor’s TCOC Benchmark / (5% of the Contractor’s TCOC Benchmark) The Contractor’s quality component of the DSRIP Accountability Score will be the exact same number as the Contractor’s Quality Score, as described in Section 2. DSRIP Accountability Score‌‌ EOHHS will calculate the Contractor’s DSRIP Accountability Score by multiplying the Contractor’s TCOC component of its DSRIP Accountability Score (as calculated in Section 3.2 above) and the Contractor’s quality component of its DSRIP Accountability Score (as described in Section 3.3 above) by the domain weights in Exhibit 10 above, and summing the resulting amounts together. The resulting number is the Contractor’s DSRIP Accountability Score, which will be a number between zero (0) and one (1), inclusive. Listed below are the Per Member Per Month (PMPM) TCOC Benchmarks and Administrative Payments for Contract Year 5 (January 1, 2022, through December 31, 2022), subject to state appropriation and all necessary federal approvals.

ACO Improvement. a. For each composite within a domain, compare ACO BP1 actual rates to BP2 performance rates i. For composites where an ACO demonstrates improvement (i.e., reaches the improvement target), the ACO earns improvement points ii. For composites where an ACO fails to demonstrate improvement, then Step 2 is implemented a. If the State sets individual ACOs’ BP2 and BP3 performance rates to be the higher of their actual BP1 or BP2 rates, then for each composite within a domain, compare BP1 statewide median rates to BP2 statewide median rates. If the State sets ACOs’ BP2 and BP3 performance rates to be the higher of their BP2 or BP3 actual rates, then for each composite within a domain, compare BP1 statewide median rates to the higher of BP2 statewide median rates or BP3 statewide median rates. i. For composites where the State demonstrates improvement (i.e., reaches the improvement target), the ACO earns improvement points ii. For composites where the State fails to demonstrate targeted improvement, the ACO does not earn improvement points Note: In order to prevent such cases where an ACO’s performance would improve excessively through the use of the statewide median, the number of composites by which an ACO may use Step 2.a.i to earn improvement points is capped at one Note: This example assumes each composite has the same Improvement Target across composites A- D, and that the State is comparing BP1 rates to BP2 rates. Measure Improvement Target = 1.0 State Improvement Median = 1.0 A – Willingness to Recommend (Adult Survey) 75.1% 75.9% 0.8 (target not met by ACO) State Med = 1.0 YES (Step 2 applied) B - Willingness to Recommend (Child Survey) 85.1% 87.0% 1.9 (target met by ACO) ACO = 1.9 YES (Step 2 not needed) C - Communications (Adult Survey) 89.5 88.7% -0.8 (target not met by ACO) State Med = 1.0 NO (Capped at 1: Composite A already received points) D - Communications (Child Survey) 78.1% 78.5% 0.4 (target not met by ACO) State Med = 0.8 (target not met by State) NO EOHHS will establish the attainment threshold and goal benchmark for each Quality Measure. EOHHS anticipates establishing these performance benchmarks as follows: • For Quality Measures based on NCQA HEDIS measures, EOHHS anticipates using NCQA Quality Compass percentile benchmarks where possible • For non-HEDIS claims-based Quality Measures, EOHHS anticipates using existing MassHealth data sources such as MassHealth historical claims or encounter data • For non-HEDIS Clinical Quality Measures, or other Quality Measures where EOHHS does not have access to applicable data, EOHHS anticipates using MassHealth benchmarks based on the ACO-attributed population EOHHS will calculate the Contractor’s Quality Score by multiplying the unweighted domain scores for each domain by the domain weights detailed in Exhibit 1, and then summing the resulting weighted domain scores together. The Contractor’s Quality Score will be a number between zero (0) and one (1), inclusive. The amount of at-risk DSRIP funds a Contractor earns will be determined by its DSRIP Accountability Score. The Contractor’s DSRIP Accountability Score will be based on the ACO’s TCOC achievement, as well as their quality performance on the same four (4) Quality Measure domains used for the Contractor’s Quality Score. The Contractor’s TCOC achievement will be calculated as described in Section 3.2 below; the Contractor’s quality performance will be calculated as described in Section 3.3 below. The relative contributions of the Contractor’s TCOC achievement and quality performance are detailed in Exhibit 10: EXHIBIT 10 – ACO DSRIP Accountability Domains DSRIP Accountability Domain % Contribution to DSRIP Accountability Score This domain reflects a Contractor’s TCOC performance for its Enrollees, relative to the Contractor’s TCOC Benchmark as described in Section 4 of the Contract. The Contractor’s TCOC component of its DSRIP Accountability Score will be calculated in the following manner: • If the Contractor’s TCOC Performance is lower than the Contractor’s TCOC Benchmark (i.e., the Contractor has Savings), as described in Section 4 of the Contract, the Contractor’s TCOC component of its DSRIP Accountability Score equals 100% • If the Contractor’s TCOC Performance exceeds the Contractor’s TCOC Benchmark by more than 5% of the Contractor’s TCOC Benchmark, as described in Section 4 of the Contract, the Contractor’s TCOC component of its DSRIP Accountability Score equals 0% • If the Contractor’s TCOC Performance exceeds the Contractor’s TCOC Benchmark by less than 5% of the Contractor’s TCOC Benchmark, the Contractor’s TCOC component of its DSRIP Accountability Score equals: one (1) minus (the Contractor’s TCOC Performance minus the Contractor’s TCOC Benchmark / (5% of the Contractor’s TCOC Benchmark) The Contractor’s quality component of the DSRIP Accountability Score will be the exact same number as the Contractor’s Quality Score, as described in Section 2. DSRIP Accountability Score‌‌ EOHHS will calculate the Contractor’s DSRIP Accountability Score by multiplying the Contractor’s TCOC component of its DSRIP Accountability Score (as calculated in Section 3.2 above) and the Contractor’s quality component of its DSRIP Accountability Score (as described in Section 3.3 above) by the domain weights in Exhibit 10 above, and summing the resulting amounts together. The resulting number is the Contractor’s DSRIP Accountability Score, which will be a number between zero (0) and one (1), inclusive. Community Care Cooperative Listed below are the Per Member Per Month (PMPM) TCOC Benchmarks and Administrative Payments for Contract Year 5 (January 1, 2022, through December 31, 2022), subject to state appropriation and all necessary federal approvals.