Many Medi-Cal managed care plans (MCPs) have introduced quality incentive programs (QIP) for Enhanced Care Management (ECM) providers. These QIP bonus payments are valuable incentives that encourage ECM providers to improve the quality of care they provide. By meeting specific quality metrics, ECM providers can earn a significant amount of money that can be used to enhance their programs and services.

QIP Enrollment

Under most QIP programs, contracted ECM providers are automatically enrolled and eligible for incentive payments. These incentives are paid to ECM providers who meet specific quality measures. The quality measures are designed to assess:

  • The extent to which ECM providers provide comprehensive care coordination services
  • The ability of ECM providers to improve the health outcomes of their patients
  • The ability of ECM providers to reduce the costs of care for their patients.

The specifics of the quality measures vary depending on the individual MCPs. The California Department of Health Care Services (DHCS) sets the overall goals and requirements for the QIP, but each MCP has its own specific targets and performance measures for QIP payments.

Incentive Amount

The amount of the CalAIM QIP bonus payment can vary depending on the specific MCP and program. The bonus payment may be a percentage of the total reimbursement received by the ECM provider from the MCP or a fixed dollar amount. The exact amount of the bonus payment may also depend on the provider’s performance on the established quality metrics. Providers who meet or exceed the target goals for the quality metrics may receive a higher bonus payment than those who do not meet the target goals.

Payment Methodology

The most common model used by MCPs to pay providers for meeting quality metrics is pay-for-performance. Under this model, providers are rewarded for meeting specific quality metrics, such as reducing readmission rates or improving patient satisfaction. The amount of money that providers receive is typically based on their performance on a set of quality metrics.

The payment methodology varies by MCPs. In one model, an MCP may base its QIP payment methodology on:

  • Timeliness of reporting: The RTF and OTF reports that are submitted on time are counted in the calculations.
  • The number of eligible members: These are members that a provider reports on RTF.
  • The number of measures: Each measure may have a predefined percentage.

If the provider submits the report on time, the members on the report are counted for that month, and based on their success rate (for each measure), an amount is calculated based on a pre-defined formula.

In another model, an MCP establishes a set of quality metrics and assigns a point value to each metric based on its importance. The provider is then measured on their performance on each metric and assigned a score based on their level of performance. The total score is used to calculate a bonus payment, which is typically a percentage of the provider’s total reimbursement from the MCP. For example, an MCP may establish a set of quality metrics worth a total of 100 points. The provider is measured on their performance on each metric and assigned a score out of 100 based on their level of performance. If the provider scores 90 out of 100 points, they will receive a bonus payment equal to a percentage of their total reimbursement from the MCP, such as 5% or 10%.

Improving QIP Performance

Achieving higher QIP bonus payments requires ECM providers to proactively engage in quality improvement initiatives and consistently meet the performance goals established by the managed care plan. The following steps can help ECM providers achieve this objective:

  1. Gain an in-depth understanding of the metrics: The first step is for providers to thoroughly review the quality metrics set by the managed care plan and understand the performance expectations for each metric. They should be aware of the target goals for each metric and the consequences of not meeting them.
  2. Monitor Performance: Providers should track their performance on each quality metric and identify areas to improve. This may involve collecting and analyzing data related to patient care and outcomes, including readmission rates, medication adherence, and patient satisfaction.
  3. Adopt Evidence-Based Practices: ECM providers should adopt evidence-based practices and interventions to improve patient outcomes and meet quality metrics. This may include implementing new care processes or interventions that have been proven effective in enhancing patient outcomes.
  4. Foster Patient Engagement: Providers should work towards enhancing patient engagement and participation in their care. This may involve providing education and resources to help patients better understand their health conditions and treatment options. When patients are engaged in their care, they are more likely to comply with their care plans, resulting in better outcomes.
  5. Provide comprehensive care coordination services: ECM providers should provide comprehensive care coordination services, which may include coordinating referrals to specialists, scheduling appointments, and ensuring that patients receive appropriate follow-up care.
  6. Utilize technology: ECM providers can utilize technology to improve the quality of care they provide and track their performance on quality metrics. This may involve using a whole-person care management platform to manage patient care, using Telehealth services to improve access to care, or using data analytics tools to identify areas where they can improve patient outcomes.

Connect with us to learn how our technology can help you improve the quality of care you provide to your patients while earning the QIP bonus established by the managed care plans.