Horizon Blue Cross Blue Shield of New Jersey and Inspira Health Partners entered into value-based program agreement on January 1, 2023 for the Braven Health (Medicare Advantage) population. The goal of this agreement is for IHP to improve the coordination, clinical performance and cost of care for its attributed members. Horizon will compensate IHP for improved performance. Please see program details below.
2024 Program
Medicare Advantage (MA) has two main funding sources: CMS which is the larger of the tow, and monthly plan premiums paid by enrollees. The amount the MA plan receives from CMS depends on the county where the beneficiary lives, demographics (age and gender), and expected cost of the beneficiary based on acuity (risk-adjustment factor).
Horizon’s MA program sets a target for the Medical Loss Ratio (MLR) that decreases incrementally over a four-year contract period. Risk scores have a significant impact on this model, which are driven by hierarchical condition category (HCC) coding.
- The MLR target is set for 89% for the 2024 performance year.
- Targets are set based on overall market performance and expected future year trends.
The base allocation between Horizon and IHP is 70/30. IHP is eligible to receive up to 30% of gross savings.
Quality metric gap incentives are paid at $15-$45 per closure depending on the metric. Incentives are paid at the practice TIN level on a quarterly basis for care gaps closed within the previous quarter. The final Star rating incentive is a lump-sum annual incentive payment at the IHP level based on overall Stars rating performance and chart chase targets achieved.
In addition to overall Stars rating performance, IHP has an opportunity to earn an additional financial reward based on the Annual Wellness Visit completion rate: 75% completion earns a 120% multiplier and 90% completion earns a 150% multiplier.
Coding compliance measures must be met in order to quality for the year-end Star rating incentive program. 80% of annual chart chase must be completed successfully for Braven members included in risk adjustment and HEDIS chart chase activities.
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 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 |
|
Medication Adherence for Diabetes |
Quality |
90% |
15% |
|
Medication Adherence for Hypertension |
Quality |
91% |
15% |
|
Medication Adherence for Cholesterol |
Quality |
91% |
15% |
|
Controlling High Blood Pressure |
Quality |
82% |
15% |
|
Glycemic Status Assessment > 9% |
Quality |
13% |
15% |
|
Annual Wellness Visits/Annual Physical Exam |
Care Management |
75% |
25% |
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2023 Program
Medicare Advantage (MA) has two main funding sources: CMS which is the larger of the tow, and monthly plan premiums paid by enrollees. The amount the MA plan receives from CMS depends on the county where the beneficiary lives, demographics (age and gender), and expected cost of the beneficiary based on acuity (risk-adjustment factor).
Horizon’s MA program sets a target for the Medical Loss Ratio (MLR) that decreases incrementally over a four-year contract period. Risk scores have a significant impact on this model, which are driven by hierarchical condition category (HCC) coding.
- The MLR target is set for 95% for the 2023 performance year.
- Targets are set based on overall market performance and expected future year trends.
The base allocation between Horizon and IHP is 70/30. IHP is eligible to receive up to 30% of gross savings.
Quality metric gap incentives are paid at $15-$45 per closure depending on the metric. Incentives are paid at the practice TIN level on a quarterly basis for care gaps closed within the previous quarter. The final Star rating incentive is a lump-sum annual incentive payment at the IHP level based on overall Stars rating performance and chart chase targets achieved.
In addition to overall Stars rating performance, IHP has an opportunity to earn an additional financial reward based on the Annual Wellness Visit completion rate: 75% completion earns a 120% multiplier and 90% completion earns a 150% multiplier.
Coding compliance measures must be met in order to quality for the year-end Star rating incentive program. 80% of annual chart chase must be completed successfully for Braven members included in risk adjustment and HEDIS chart chase activities.
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.
- 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 |
| Flu Vaccine | Quality | 79% | 25% |
| Controlling High Blood Pressure | Quality | 80% | 25% |
| Diabetic A1c Poor Control >9% | Quality | 21% | 25% |
| Annual Wellness Visits/Annual Physical Exam | Care Management | 90% | 25% |
Horizon Braven 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 MLR was 97.9%, higher than the target MCF of 95.0%, resulting in no savings.
The Horizon MA program also includes 11 quality metrics that are rewarded separately from the MCF calculation. IHP scored 4.16 Stars on the quality portion, resulting in a quality payment from Horizon. Please see the Quality Performance section for additional details.
IHP Quality Metric Summary Files