IRIS (Integrated Resourcing and Incentive System)

1. IRIS(Integrated Resourcing and Incentive System) Richard Meyer Management Division, OACSRM/G8 October 2013 UNCLASSIFIED

2. BLUF Purpose: To align funding and incentive mechanisms to enhance MTF value production • Starting in FY14 : Integrated Resourcing & Incentive System (IRIS) • Funding for Primary Care will be moved from Core Funding to a model based primarily on Capitation. • Performance Plan links to the above funding and incentive models • IRIS will include metrics from PBAM and include new incentives to support strategic metrics • Periodic reconciliation and budget adjustments • Incremental implementation

3. Overview Unless specifically addressed, the metrics currently in PBAM will be used in IRIS in their current structure. • FY14 Funding model will have 25 modifications or additions • 1 Major Modification: Primary Care Capitation • 7 Other Modifications • 11 New Metrics • 6 Metrics Under Development • Five Metrics for FY15 • 1 will be monitored and displayed as Information Only in FY14 • 4 are still under development • Model is a Work in Progress

4. Primary Care Capitation • Capitated amount based on Prime Enrollees from M2 identified using the ACV Group “Prime” • An enrollee will be considered under capitation if any care is provided with the enrolled PDMIS hierarchy. • All Non-Prime will be paid using FFS • MTFs paid FFS for Prime Enrollees if the Enrollee is seen outside the Enrollment PDMIS • an Evans ACH Prime Enrollee seen at SAMMC – SAMC received FFS • Specialty Care done within a PC MEPRS are paid FFS • Identified using Appointment Type “SPEC” or “$SPEC” for Primary Care Providers such as Internal Medicine and Pediatrics • Identified using Provider Specialty for non Primary Care such as PT • PT work Identified using PT Provider Spec and Tech HIPAA Taxonomy code • BH not included • Business Plan data used to calculate the Baseline for Primary Care Capitation

5. Modifications • Primary Care Leakage • This metric is currently on the Administrative Report under “Network Primary Care” with a -$5.00 penalty per RVU. • Will move to the Capacity Report • Working on adjusting to ensure MTFs are not charged for non-PC work. Some providers doing specialty and sub-specialty care but are identified in the claims under their base HIPAA Taxonomy code • Example is: Internal Medicine doing Chemo • Additional exclusions may be identified by Provider Spec and procedure code. This exclusion process is already in use but will need new codes identified. • Will reduce Capitation dollars by -$39 per RVU for Prime enrollee care provided within the enrollment area • Change to rolling 12-month data, refreshed monthly

6. Modifications • Inpatient Nurse Staffing Efficiency - Permitted Inefficiency structure • Directed to review and account for the ”permitted” inefficiency. • Those facilities that have low nursing care hour requirements but must maintain minimum staff levels to keep a unit open which may force them to exceed the metric upper limit. • Minimum Staff levels were determined for 2 types of Units: LDRP and All Others • LDRP routinely require 3 nurse staff members on per Shift or 2,160 hours per month • All Others routinely require 2 nursing staff members or 1,440 hours per month • Identified four MTFs that are minimally staffed, by ward. • Keller, Weed, Ireland, and B. Allgood • If an MTF is permitted to be inefficient they may be rewarded as per the current standard process by staying within 90-120% of minimal staffing levels. The amount of the bonus is determined using the WMSNi hours. • All Inpatient Efficiency will be done by Unit Type beginning in FY14

7. Modifications • Healthy Weight • Modification of current BMI metric. Will keep current methodology and change data set to use Healthy Weight (HW) Status based on CDC Standards • Bonus: • Pay +$1.00 per Prime Enrollee, per month, with a Healthy Weight • Pay +$0.50 per Prime Enrollee, per month, when over weight but within 2 index points of Healthy Weight status • Network Primary Care: Non-Emergent ER Care • Penalty: Change to -$10.00 per RVU • MILPAY Reduction – No Longer a flat percentage • MILPAY *GPCI * CIVPAY Equivalency Factor (CEF) • MILPAY: MTF specific using A & B MEPRS Direct Expenses • MTF Specific Capitation GPCI • CEF = 1.4

8. Modifications • Non-DoD Workload • Exclusion of Veterans Affairs (VA) and Coast Guard (CG) Workload • VA: Excluded using Patient Category K61 • CG: Excluded Using Sponsor Service “C” • Patient Categories C28, C29, & C44 are not part of the Exclusion • Removed from both Baseline and Performance • Current Associated Dollars Remain – No Funding Reductions • Workload (RVUs, RWPs, etc.) will remain visible but no IRIS dollars amounts will be shown • Ambulatory Efficiency Adjustment • No longer applied to Professional Services Earnings

9. DRAFT Capacity Report

10. New Metrics • Partnership for Patients (P4P) Readmissions • Penalty: -$1,000 per each identified readmission in Direct Care • Will Target 3 admission types: AMI, Heart Failure, & Pneumonia • Identified in M2 using Diagnosis 1 = 410%% or 428%% or 486%% • Readmission for same diagnosis within 30 days of discharge • Administrative Cost Efficiency (ACE) • Uses ACE Expense Target compared to ACE Expenses • The difference (excess expenses) is used to calculate a penalty • Penalty: -0.5% per month of excess expenses; ~6% Annual • NCQA Medical Home Enrollment • Bonus: Pay +$1.00 per Prime and Plus enrollee, per month, that is enrolled at an MTF in an NCQA recognized medical home with an approved PCMH 4th level functional cost code

11. New Metrics • Secure Message Usage • From CMS: “% Messages Responded to Within 24 Hours” • Bonus: +$1.00 per message using the “Total Transaction Volume” • Bonus per Secure Message (SM) initiated by the patient • TOL Booked Appointments • Bonus: +$5.00 per appoint booked via TRICARE Online • TOL currently uses Primary Care and Optometry appointments • AHRQ Preventable Admissions • Penalty: -$2,000 per Preventable Admission • M2: “Preventable Adm Indicator, AHRQ” different from “O” • OR Utilization • Bonus for Prime Minutes OR Utilization • 80% Prime Minute minimum Threshold • +$1.00 per Patient Minute

12. New Metrics • Inpatient Occupancy • Uses current Identified Operational Beds (as of July 2013) • Uses a “2 MTF type” structure: ACH & MEDCEN • Upper threshold is different: ACH = 85%, MEDCEN = 90% • Incentive Structure • Amount is per Operational Bed • PMPM Percent Change • Uses Prime Enrollees and PMPM % Change to calculate a Quarterly incentive • Percent change from the prior year, same quarter • Uses a 4 Tier structure similar to Patient Satisfaction • Amount is per Prime Enrollee

13. New Metrics • Medical Readiness • Soldiers: Compo 1, Non-Trainee, non-deployed • At start of year $30 per Soldier removed from Core • -$2.50 per Soldier per month • Bonus: • MRC1 = +$5.00 per Soldier per month • MRC 2 = +$2.00 per Soldier per month • Bed Days Per 1,000 Enrollees • Uses Direct and Network bed Days for PRIME enrollees within catchment and compares current Rolling-12 total Bed Days / Enrollee to a Baseline. • Incentive: +$100 per reduced Bed Day when less than the rolling-12 average.

14. New Metrics (Delayed) • MEB Phase Cases Completed within Standard • 100 days • Carve out funding for staffing • Total cases x rate per staff = total staff • Earnings/Incentive for completed volume within standard (MTF portion only): TBD • Cases completed within standard/Total cases = $ • Leadership Incentive – Under Development • Carve out from core based on size of budget • Earn funding based on minimum submission/quality threshold • Incentive $ based on higher quality threshold • Civilian Development – Under Development • Bonus per Civilian Employee with a an IDP

15. New Metrics (Delayed) • Military Development – Under Development • Bonus per Military Member that attends their Appropriate Career Development Course. i.e. (CPT to CPT Career Course) • Retail Pharmacy Expenses • Prime Enrollees only (ACV Group = Prime) • Incentive Structure being re-worked: TBD

16. FY15 • ROFR Take Rate • Postponed to FY15 but will display the data during FY14, • There are problems with getting accurate data reliably. • Intent: Encourage MTFs to sustain effective and timely ROFR review practices by effectively communication with respective TRICARE contractors regarding clinical capabilities to reduce unnecessary network leakage • Incentive: 5-Tier structure similar to APLSS Q20

17. FY15 • Low Back Pain & Diabetes Management CPGs • There is currently an IT constraint of not being able to data mine off the CPG AIM forms out of AHLTA. This is a major problem regarding the capability to pull data to monitor provider compliance pertaining to the CPG recommendations embedded into the CPG AIM forms. • Wartime Clinical Skills Sustainment: All components of this metric still TBD at this time. • Specialty Care Deferrals to Network: HA & Services still working on this metric. • Voluntary Protection Program – Army Star Strong • Bonus for achieving Army VPP Star status or OSHA VPP Star status • MEDCOM VPP CONOPS available – Currently Under Revision

18. Timeline • Significant Hours required to implement • Primary Care Capitation is priority and will be completed first. • What is not competed by October will be brought on line as programming is finished. We will not wait for everything to be done before we begin making information available.

19. Questions?