2026 Program
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The Physician Distribution Formula will be developed by the Finance Committee of Inspira Health Partners and approved by the Board in the first quarter of 2026. The 2026 Citizenship Metrics were approved in the fourth quarter of 2025 and include the metrics below.
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2025 Program
AmeriHealth’s Total Value of Care (TVOC) program measures quality and costs incurred by commercial health plan members who are assigned to IHP.
Similar to the Medicare ACO, AmeriHealth’s program calculates a total surplus or deficit based on cost of care and quality metric performance adjusts the amount shared by IHP.
- Total costs incurred by attributed members are compared to a target, which is based on the members’ adjusted historical cost on a per member per month (PMPM) basis.
- Weighted two-year timeframe is used to calculate target: earlier year is weighted at 35%, more recent year is weighted at 65%
- Historical cost is trended forward for the performance period using unit cost, risk, and product mix adjustments.
- Commercial HMO and PPO populations are measured separately.
- High-cost members, members under age 18, and members with fewer than 11 months of enrollment are removed from the calculation.
- The base sharing rate is 30%, which can adjust upward to 60% or downward to 15% depending on quality metric performance.
- The program includes 13 Ambulatory Physician Quality Measures (APQM).
The Physician Distribution Formula is developed by the Finance Committee of Inspira Health Partners and approved by the Board.
Components of the formula include:
- Eligible funds will be prorated to primary care practices based on attributed lives.
- Measure performance will condition the payments to the practices
- Key Performance Indicators (KPI) measures (includes quality and care management) condition 75% of the payment
- Citizenship measures condition 25% of the payment
- Treatment of Unearned Dollars
- Re-distributed to practices who achieved a 75% score within the KPI category and 100% score within the citizenship category using a proration based on attributed lives (weighted at 75%)
- Reinvested in clinical integration initiatives (weighted at 25%)
- Quality goals align with the 5-star threshold as outlined.
Citizenship Metrics:
KPI Metrics:
|
KPI |
Category |
Goal |
Weight |
|
Glycemic Status Assessment |
Quality |
72.2% |
15% |
|
Controlling High Blood Pressure |
Quality |
35.14% |
15% |
|
Breast Cancer Screening |
Quality |
80.26% |
15% |
|
Colorectal Cancer Screening |
Quality |
75.55% |
15% |
|
Cervical Cancer Screening |
Quality |
76.46% |
15% |
|
Annual Office Visit |
Care Management |
85% |
25% |
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2024 Program
AmeriHealth’s Total Value of Care (TVOC) program measures quality and costs incurred by commercial health plan members who are assigned to IHP.
Similar to the Medicare ACO, AmeriHealth’s program calculates a total surplus or deficit based on cost of care and quality metric performance adjusts the amount shared by IHP.
- Total costs incurred by attributed members are compared to a target, which is based on the members’ adjusted historical cost on a per member per month (PMPM) basis.
- Weighted two-year timeframe is used to calculate target: earlier year is weighted at 35%, more recent year is weighted at 65%
- Historical cost is trended forward for the performance period using unit cost, risk, and product mix adjustments.
- Commercial HMO and PPO populations are measured separately.
- High-cost members, members under age 18, and members with fewer than 11 months of enrollment are removed from the calculation.
- The base sharing rate is 30%, which can adjust upward to 60% or downward to 15% depending on quality metric performance.
The program has two domains:
- Ambulatory Physician Quality Measures (APQM): HEDIS measures
- Discharge Follow-Up (DFU): visit with PCP within 7 days of discharge
The Physician Distribution Formula is developed by the Finance Committee of Inspira Health Partners and approved by the Board.
Components of the formula include:
- Eligible funds will be prorated to primary care practices based on attributed lives.
- Measure performance will condition the payments to the practices
- Key Performance Indicators (KPI) measures (includes quality and care management) condition 75% of the payment
- Citizenship measures condition 25% of the payment
- Treatment of Unearned Dollars
- Re-distributed to practices who achieved a 75% score within the KPI category and 100% score within the citizenship category using a proration based on attributed lives (weighted at 75%)
- Reinvested in clinical integration initiatives (weighted at 25%)
Citizenship Measures:
- Practice must submit EMR quality reports for continued validation of data harvests according to quarterly schedule (weighted at 15% of citizenship credit for primary care and 40% of citizenship credit for pediatric)
- Each provider must participate on the DoctusTech clinical documentation improvement program (weighted at 60% of citizenship credit for primary care)
- Active program engagement: (weighted at 15% of citizenship credit for primary care and 30% of citizenship credit for pediatric)
- Practice must attend quarterly rounding sessions (office manager and at least one provider per practice)
- Practice must attend the IHP annual meeting (at least one provider per practice)
- Office manager must attend monthly meetings with IHP team to review payer reports and practice opportunities
- Practice must attest to sending EMR direct messages for referrals and pass a quarterly audit (weighted at 10% of citizenship credit for primary care, 30% of citizenship credit for pediatric, and 100% of citizenship credit for specialists)
|
KPI |
Category |
Goal |
Weight |
|
Diabetic Glycemic Status Assessment |
Quality |
29% |
35% |
|
Diabetic Kidney Health Evaluation |
Quality |
||
|
Diabetic Eye Exam |
Quality |
||
|
Breast Cancer Screening |
Quality |
78% |
20% |
|
Colorectal Cancer Screening |
Quality |
69% |
20% |
|
Discharge Follow-Up |
Care Management |
55% |
25% |
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AmeriHealth Commercial Program
2024 Citizenship Metric Performance
C = Compliant
NC = Non-Compliant
NA = Not Applicable
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2023 Program
AmeriHealth’s Total Value of Care (TVOC) program measures quality and costs incurred by commercial health plan members who are assigned to IHP.
Similar to the Medicare ACO, AmeriHealth’s program calculates a total surplus or deficit based on cost of care and quality metric performance adjusts the amount shared by IHP.
- Total costs incurred by attributed members are compared to a target, which is based on the members’ adjusted historical cost on a per member per month (PMPM) basis.
- Weighted two-year timeframe is used to calculate target: earlier year is weighted at 35%, more recent year is weighted at 65%
- Historical cost is trended forward for the performance period using unit cost, risk, and product mix adjustments.
- Commercial HMO and PPO populations are measured separately.
- High-cost members, members under age 18, and members with fewer than 11 months of enrollment are removed from the calculation.
- The base sharing rate is 30%, which can adjust upward to 60% or downward to 15% depending on quality metric performance.
The program has two domains:
- Ambulatory Physician Quality Measures (APQM): HEDIS measures
- Discharge Follow-Up (DFU): visit with PCP within 7 days of discharge
The Physician Distribution Formula is developed by the Finance Committee of Inspira Health Partners and approved by the Board.
Components of the formula include:
- Eligible funds will be prorated to primary care practices based on attributed lives.
- Measure performance will condition the payments to the practices
- Key Performance Indicators (KPI) measures (includes quality and care management) condition 75% of the payment
- Citizenship measures condition 25% of the payment
- Treatment of Unearned Dollars
- Re-distributed to practices who achieved a 75% score within the KPI category and 100% score within the citizenship category using a proration based on attributed lives (weighted at 75%)
- Reinvested in clinical integration initiatives (weighted at 25%)
- Citizenship Measures:
- Practice must submit EMR quality reports for continued validation of data harvests according to quarterly schedule (weighted at 15% of citizenship credit)
- Each provider must participate on the DoctusTech clinical documentation improvement program (weighted at 60% of citizenship credit)
- Active program engagement: (weighted at 15% of citizenship credit)
- Practice must attend quarterly rounding sessions (office manager and at least one provider per practice)
- Practice must attend the IHP annual meeting (at least one provider per practice)
- Practice must attest to sending EMR direct messages for referrals and pass a quarterly audit (weighted at 10% of citizenship credit)
| Key Performance Indicator | Category | Goal | Weight |
| Diabetic A1c Control <8% Diabetic Kidney Health Evaluation Diabetic Eye Exam |
Quality | 21% | 35% |
| Breast Cancer Screening | Quality | 82% | 20% |
| Colorectal Cancer Screening | Quality | 68% | 20% |
| Transitional Care Management | Care Management | 55% | 25% |
Note - the three diabetic metrics are considered a composite metric. All three items must be achieved for each patient.
IHP showed improvement against historical performance for 4 out of the 5 quality measures. IHP’s performance on the Discharge Follow-up metric decreased significantly compared to the historical measurement period.
AmeriHealth Commercial Program
2023 Citizenship Metric Performance
C = Compliant
NC = Non-Compliant
NA = Not Applicable
Utilization data includes claims incurred from January through December 2023, paid through March 2024.
IHP’s per member per month (PMPM) spend was $24.69 PMPM lower than target for HMO attributed lives and $33.22 PMPM lower than target for PPO attributed lives, resulting in savings of $611,909.
IHP Quality Metric Summary Files
2022 Program
AmeriHealth’s Total Value of Care (TVOC) program measures quality and costs incurred by commercial health plan members who are assigned to IHP.
Similar to the Medicare ACO, AmeriHealth’s program calculates a total surplus or deficit based on cost of care and quality metric performance adjusts the amount shared by IHP.
- Total costs incurred by attributed members are compared to a target, which is based on the members’ adjusted historical cost on a per member per month (PMPM) basis.
- Weighted two-year timeframe is used to calculate target: earlier year is weighted at 35%, more recent year is weighted at 65%
- Historical cost is trended forward for the performance period using unit cost, risk, and product mix adjustments.
- Commercial HMO and PPO populations are measured separately.
- High-cost members, members under age 18, and members with fewer than 11 months of enrollment are removed from the calculation.
- The base sharing rate is 30%, which can adjust upward to 60% or downward to 15% depending on quality metric performance.
The program has two domains:
- Ambulatory Physician Quality Measures (APQM): HEDIS measures
- Discharge Follow-Up (DFU): visit with PCP within 7 days of discharge
Since the AmeriHealth program was launched late in 2022, the IHP Board approved a distribution formula that combines reinvesting a portion of any savings earned towards clinical integration activities and distributing the remaining savings to practices based on a proration of attributed lives. The percentage to be reinvested will be determined using a tiered approach based on the overall savings amount.
|
Savings Amount |
% Reinvested in Initiatives |
% Distributed to Practices |
|
< $50k |
100% |
0% |
|
Between $50k and $100k |
40% |
60% |
|
> $100k |
20% |
80% |
IHP showed improvement against historical performance for 4 out of 5 APQM metrics and score higher than peers on the DFU metric.
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Utilization data includes claims incurred from January through December 2022, paid through March 2023.
For the 2022 performance year, IHP performed better than target, resulting in net savings of approximately $2 million. IHP’s per member per month (PMPM) spend was $55.46 PMPM lower than target for HMO attributed lives and $40.25 PMPM lower than target for PPO attributed lives.
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