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Value-Based Incentives

 

Comprehensive Quality Strategy

In accordance with 42 C.F.R. § 438.340, the Mississippi Division of Medicaid (DOM) has developed a Comprehensive Quality Strategy for 2021 – 2024. The Comprehensive Quality Strategy reflects many ongoing and planned quality improvement efforts within the managed care and fee-for-delivery systems.

The Mississippi Division of Medicaid (DOM or Division) requested authority from the Centers for Medicare & Medicaid Services (CMS) for quality initiatives beginning in July 2019. These initiatives cover major sources of Medicaid spending: hospitals (including the state’s academic medical center), physicians, emergency ambulance providers, and coordinated care organizations (CCOs). The programs, as described below, include quality measures, targeted improvement levels and accountability. These programs pertain to the managed care program, Mississippi Coordinated Access Network (MississippiCAN) for the Medicaid Managed Care beneficiaries.

 

External Quality Review (EQR) Protocol 5

The Centers for Medicare & Medicaid Services (CMS) established requirements for states to improve the reliability of encounter data collected from managed care CCOs. In 2016, the Medicaid managed care final rule required states to conduct an independent audit of encounter data reported by each managed care CCO. Revisions to the Medicaid managed care regulations enhanced quality oversight criteria. Under the 2020 final rule, encounter data must include both the allowed and paid amounts and states must annually post on its website CCOs that are exempt from external quality review.

CMS indicated that states could meet the independent audit requirement by conducting an encounter data assessment based on EQR Protocol 55. Protocol 5 evaluates the completeness and accuracy of the encounter data submitted to the State’s fiscal agent contractor (FAC) by the CCOs contracted to provide healthcare services to CAN and CHIP beneficiaries. Although Protocol 5 is a voluntary protocol, CMS strongly encourages states to contract with qualified entities to implement Protocol 5 to meet the audit requirement of the final rule.

Additionally, states are required to provide accurate encounter data to actuaries, as well as CMS, as part of the Transformed Medicaid Statistical Information System (T-MSIS) project. Protocol 5, performed under GAGAS, enables states to meet these data validation and monitoring requirements. Protocol 5 evaluates state/department policies, as well as the policies, procedures, and systems of the CCO, assists states in gauging utilization, identifying potential gaps in services, evaluating program effectiveness, and identifying strengths and opportunities to enhance oversight.

2024 Reports
Magnolia MS EQR P5 Final Report 2024
Molina MS EQR P5 Final Report 2024
UHC MS EQR P5 Final Report 2024

Mississippi Hospital Access Program (MHAP)

The Mississippi Hospital Access Program (MHAP) is a state directed payment arrangement through managed care that is paid monthly to hospitals through the CCOs and is made up of two components: Fee Schedule Adjustment (FSA) and Quality Incentive Payment Program (QIPP). This program is approved by CMS through a preprint that is submitted annually.

 

MHAP by SFY
SFY MHAP-TPP MHAP-FSA MHAP-QIPP Total MHAP
2016 $533,110,956 $ $ $533,110,956
2017 $533,110,956 $ $ $533,110,956
2018 $422,241,632 $110,869,324 $ $533,110,956
2019 $380,017,469 $153,093,487 $ $533,110,956
2020 $215,886,793 $275,000,000 $42,224,163 $533,110,956
2021 $ $317,886,793 $215,224,163 $533,110,956
2022 $ $285,603,168 $247,507,788 $533,110,956
2023 $ $313,053,124 $288,100,478 $601,153,602
2024 $ $733,764,648 $788,549,237 $1,522,313,885
2025 (submitted to CMS) $ $733,317,426 $832,522,898 $1,565,840,324

 

As an example, the payment allocation for the 2023 preprint is based on the hospital inpatient discharges and outpatient payments from managed care encounters paid in calendar year 2021. The final payments will be reconciled to the actual utilization during the rating period (July 1, 2022 through June 30, 2023) in April 2024 to allow for claims runout.

The October 2023 amendment to increase the 2023 preprint was based on a legislative requirement to include a border city university-affiliated pediatric teaching hospital in the payment program. The February 2023 amendment to the 2023 preprint requested an additional $40,245,451 be added to the program based on the outpatient payment average commercial rate (ACR).

To request a copy of the MHAP model, send an email to the QIPP mailbox at QIPP@medicaid.ms.gov.

 

Quality Incentive Payment Program (QIPP)

The Quality Incentive Payment Program (QIPP) is part of the Mississippi Hospital Access Program (MHAP) and is made up of the following components: Potentially Preventable Hospital Returns (PPHR), Potentially Preventable Complications (PPC) and Health Information Network (HIN). For each component, an attestation form is required. The PPHR attestation form and the PPC attestation form require attesting to the receipt of the PPHR and PPC reports provided by DOM. These attestations are associated with the third month of each quarterly MHAP payment for QIPP during the state fiscal year. The HIN attestation indicates the hospital is connected to one of the two statewide HINs. The HIN attestation is associated with the first month of each quarterly MHAP payment for QIPP.

The PPHR baseline for the actual to expected ratio (A/E Ratio) is set at a statewide threshold of 1.04 (1.07 for Cycle 1 and Cycle 2). PPHR calculations include returns to a hospital for readmission or emergency department visit. If the hospitals A/E Ratio is above the statewide threshold, the hospital may be required to submit a Corrective Action Plan (CAP). Each year, the CAP is based on the July report results and is due September 1.

The PPC baseline for the A/E Ratio is set to 1.0 reviewing the hospital’s potentially preventable complications. If the hospital is above the A/E Ratio, the hospital may be required to submit a Corrective Action Plan (CAP). The first CAP submission will be due September 1, using the July report results of the same calendar year.

Both the PPHR and PPC components run in three-year cycles. As of January 2023, cycle two (2) has completed its three-year cycle for PPHR. The January 2023 PPHR report determined the results for those hospitals who were under a CAP for Cycle Two. If the required improvement was not met for the hospitals under a CAP, the hospital forfeited a percentage of the PPHR portion of QIPP funds for the 2023 state fiscal year based on the “at-risk” ratio tied to the hospital’s actual A/E Ratio. Those funds will be reallocated among the other hospitals in the MHAP program at the end of SFY 2023 along with any forfeited funds due to hospitals who did not submit an attestation form for PPHR, PPC and HIN or if a hospital did not participate in a HIN.

See the PPHR and PPC Training Webinar presentation under SFY 2024 QIPP Resources for more detailed information about each of the QIPP components.

DOM will offer the annual QIPP Provider training webinar in July 2024. See the following dates and times:

• Tuesday, July 23, 2024, 10:00 AM – 11:30 AM
• Wednesday, July 24, 2024, 1:30 PM – 3:00 PM

For any further questions regarding this program, email the QIPP mailbox at QIPP@medicaid.ms.gov.

 

SFY 2025 QIPP Resources

SFY 2024 QIPP Resources

SFY 2023 QIPP Resources

SFY 2022 QIPP Resources

SFY 2020 QIPP Resources

 

Transforming Reimbursement for Emergency Ambulance Transportation (TREAT)

In the 2022 regular legislative session, House Bill 657 authorized the additional payment program for ground emergency ambulance services to be funded with a health care provider fee. This state directed payment arrangement through managed care will be made quarterly to the eligible ground ambulance providers for SFY 2023. For more information regarding the TREAT program, please visit the following DOM site: https://medicaid.ms.gov/transforming-reimbursement-for-emergency-ambulance-transportation-treat/.

TREAT by SFY
SFY Status Amount
2023 Approved by CMS $14,740,472
2024 Approved by CMS $20,616,966

 

The quality measures associated with this program are the following:

  • Maintain ground emergency ambulance providers in all of the Mississippi 82 counties;
  • Managed care utilization of ground emergency services; and
  • Identify existing sources of data for emergency ambulance provider performance measures to be able to identify future opportunities for quality improvement initiatives.

If you are a provider and have any questions regarding the TREAT program, email the TREAT mailbox at TREAT@medicaid.ms.gov.

 

Mississippi Medicaid Access to Physician Services (MS MAPS)

Mississippi Medicaid Access to Physician Services (MAPS) is a directed payment program developed in conjunction with the University of Mississippi Medical Center (UMMC). DOM received approval from CMS for the MAPS payments beginning in November 2019, and this program requires CMS approval annually. Much like MHAP, CCOs will be responsible for disbursing this additional funding to certain provider groups based on utilization of services.

The program is intended to increase access and quality of care for Medicaid beneficiaries to primary and specialty care services by increasing payments made to qualified practitioners employed by or affiliated with UMMC. UMMC will submit an Intergovernmental Transfer (IGT) for the state share of the payment.

MS MAPS by SFY
SFY Status Amount
2020 Payment $35,195,007
2021 Payment $37,239,856
2022 Approved by CMS $38,783,002
2023 Approved by CMS $38,018,361
2024 Approved by CMS $39,420,290

 

This program is subject to six (6) quality measures for SFY 2023 and is to be monitored by UMMC. The SFY 2023 payment is 5% at-risk meaning if the target for each measure is not met, that pro-rata portion of the at-risk portion for that 5% of the payment will be subject to not being paid. The following are the quality measures for the MS MAPS program:

  1. Follow-Up After Hospitalization for Mental Illness – Adult (30-day)
  2. Follow-Up After Hospitalization for Mental Illness – Child (30 day)
  3. Tobacco Use: Screening and Cessation – Ages 18 and older
  4. Well Child Visits in the First 30 Months (Rate 1 only, First 15 months)
  5. Comprehensive Diabetes Care: Hemoglobin (HbA1c) Poor Control (>9.0%)
  6. Controlling High Blood Pressure (Hypertension)

 

Hospital Physician Directed Payment Arrangement

The Mississippi Division of Medicaid is working on the development of a new directed payment for physician services. This state directed payment arrangement would require a preprint approval by CMS. This program is authorized in Mississippi Code Section 43-13-117(A)(18)(b)(i) which allows DOM to pay additional payments for physician services for physicians who are either employed by or contracted with a hospital.

For any further questions regarding this program, email the QIPP mailbox at QIPP@medicaid.ms.gov.

 

Managed Care Value-Based Withhold Program

DOM has implemented a Managed Care Value-Based Withhold on MississippiCAN capitation rate payments. This quality withhold is based on established quality metrics, such as Healthcare Effectiveness Data and Information Set (HEDIS) measures, which are already being reported by the CCOs.

DOM has set a 1.0% withhold of capitation rates that began in SFY 2020 and requests approval annually for this program as part of the capitation rate certification performed yearly by CMS. These measures consist of mostly HEDIS measures which are based on prior Calendar Year and other measures including Hospital Readmissions for the respective CCO beneficiaries. For more information regarding the CCOs performance including a list of these performance metrics and results for each CCO for each year, please visit https://medicaid.ms.gov/programs/managed-care/measuring-managed-care-performance/.

 

Physician Quality Incentive Payment Program (PQIPP)

The PQIPP program development process did not result in a new payment program request to CMS.

 

Medicaid Presentations

 

Preprints

MHAP

MS MAPS

TREAT

Autism Spectrum Disorder

 

 

Posted byMatt Westerfield
November 12, 2019
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