PCP Incentive Program
Initially a risk sharing program, PCPs were paid via shared surpluses generated through appropriate utilization management. CenCal Health chose to adopt a methodology to compute financial incentives for utilization and quality management.
This model, in existence today, uses financial incentives based primarily upon a PCP’s utilization and quality performance relative to peers who share the same provider type and incorporates process measures more indicative of quality of care.
Some characteristics of this Incentive methodology are that it:
Includes timely incentive payments
- Allows for monthly status reporting
- Provides an adaptable framework to easily incorporate criteria
- Improves case mix risk adjustment techniques
Funding for the program is obtained from the CenCal Health reserve funds and from the withhold contributed by all PCPs from the Full Capitation.
Please view the PCP Incentive Program Protocols.
CenCal Health offers PCPs a $75 incentive per member per year for each comprehensive assessment that is completed during the member’s initial encounter with a selected or assigned PCP within the first 120 day of enrollment into the plan.
Initial Health Assessment (IHA) Components:
In addition to monthly capitation, PCPs who submit Claims for readmission follow-up visits will be paid a flat rate of $100.00 per qualified visit.
Though reported through a Claim form as described above, the Claim will be paid at $0.00 because reimbursement will be issued through a separate payment to be provided on a monthly basis for services rendered in the prior month.
The payment timeframe will be the 15th of each month.
CenCal Health’s Diabetes SMART Program is a program for members diagnosed with diabetes. The goal of the program is to identify diabetic members and provide their PCP with tools to improve their quality of life by ensuring that they receive clinically appropriate care to manage their diabetes. The objective of the program is to promote and facilitate patient-physician communication utilizing an interactive approach toward the treatment of diabetes by assuring receipt of appropriate medical services in accordance with established clinical practice guidelines.
Program Components: The Diabetes SMART Program is structured to support the management of members’ diabetes care by their PCP. The components of the program include:
Diabetes education materials for members upon request
- Notification to PCPs of members newly enrolled in the Diabetes SMART program
- Notification to PCPs of members’ need for clinically appropriate screenings related to diabetes care
- Notification to PCPs of high risk diabetic members
- PCP quality performance reporting regarding their diabetic population
- An online tool to submit clinical data and to manage members enrolled in the Diabetes SMART Program via the web portal
Reports: All provider notifications regarding members enrolled in the Diabetes SMART program and PCP quality performance is communicated through quarterly reports submitted to PCPs.
Pay for Performance:
A $50 incentive is paid to PCPs for each assigned member identified with diabetes who annually completes all three minimum clinical services (MCS):
Hemoglobin A1c testing (HbA1c)
- Diabetic eye exam treatment
- Screening for nephropathy (Micro albumin urine test or total urine protein, ACE/ARB Rx, dialysis or referral to nephrologist.)
An additional $25 incentive is paid for each clinical improvement:
Hemoglobin A1c tests that show a 10% reduction from 1st baseline test within a calendar year (maximum of 3)
CenCal Health’s Breathe SMART Program is a program for members diagnosed with persistent asthma. The goal of the program is to increase PCPs knowledge of members with persistent asthma and improve adherence to recommended treatment to reduce exacerbations, ED visits and hospitalizations. The objective of the program is to promote and facilitate patient-physician communication utilizing an interactive approach to better assure receipt of appropriate medical services in accordance with established clinical practice guidelines.
Program Components: The Breathe SMART Program is structured to support the management of members’ asthma by their PCP. The components of the program include:
- Promotion of Asthma Action Plans for all members with persistent asthma
- Informing Primary Care Providers with reports on preferred and rescue medication usage to assist coordination of care
- Reporting to providers to identify patients with Emergency Department or Inpatient Stays, to enable intensive interventions to prevent readmissions
Reports: All provider notifications regarding members enrolled in the Breathe SMART program and PCP quality performance is communicated via quarterly reports to PCPs.
Pay for Performance: A $100 Incentive Bonus is paid to providers for each patient who meets the goal of filling 8 or more preferred asthma medications in a calendar year.
An additional $75 incentive is paid for an Asthma Action Plan for each member annually.
Click here for more information about how to fill out an Asthma Action Plan.
Spirometry tests are encouraged for Asthma patients as they may identify the degree of airflow obstruction that is poorly recognized or perceived by the patient, establish a diagnosis of asthma, and assess reversibility, severity or prediction of future adverse events.