Form CMS-10620 National Data Collection Metrics

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Overview

Introduction
General Info
Comm Metrics
MA Metrics
MCO Metrics
Cross-Checking
Definitions

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Sheet 1: Introduction

Introduction
The Health Care Payment Learning and Action Network's (LAN) goal is to bring together private payers, providers, employers, state partners, consumer groups, individual consumers, and other stakeholders to accelerate the transition to alternative payment models, specifically shifting 30% of health care payments to APMs by 2016 and 50% by 2018. To measure the nation's progress, the LAN launched the National APM Data Collection Effort. This workbook will be used to collect health plan data according to the APM Framework and line of business to be aggregated with other plan responses.
APM Framework
Contents
Tab I	Introduction			Introducing the workbook and providing important instructions
Tab 2	General Information			Background description about health plan data submission
Tab 3	Commercial Metrics			Metrics to report commercial dollars flowing through APMs
Tab 4	Medicare Advantage Metrics			Metrics to report Medicare Advantage dollars flowing through APMs
Tab 5	Medicaid Metrics			Metrics to report Medicaid dollars flowing through APMs
Tab 6	Cross-Checking			Questions to identify whether there are outliers and data needs correction
Tab 7	Definitions			Defines key terms
Instructions
Plans have two options for reporting with different levels of recognition: (1) Premium Level Contributor: full reporting, or (2) Primary Level Contributor: partial reporting. Premium Level Contributor (full details): Plan will report total dollars paid through APMs according to the APM Framework by category and subcategory. This includes Rows 12-32 and 56-71 (questions 1-29) in the tabs for which plan has information (commercial, Medicare Advantage, and/or Medicaid). It is not expected that plans will have dollars in each category and subcategory. For those categories that the plan does not have payments, please report $0. Primary Level Contributor (partial details): Plan will report total dollars paid through APMs according to the APM Framework by higher-level categories 1, 2, 3, and 4. This includes rows 12, 13, 17, 23, 28, 57, 63, 68 and 71 (questions 1, 2, 5, 10, 14, 18, 23, 27, 29) in the tabs for which plan has information (commercial, Medicare Advantage, and/or Medicaid). To easily identify the rows for "partial reporting", they are highlighted yellow.
Please identify which method you are reporting below:
	Premium Level Contributor: Full Reporting (Please report all metrics in the relevant tabs)
	Primary Level Contributor: Partial Reporting (Please report metrics highlighted in yellow only in the relevant tabs)
In addition, plans have the ability to report optional metrics for which there is information. These metrics include the percent of members/beneficiaries attributed to APMs, the percent of providers with APM contracts, and 30-day all-cause readmissions measure.
If you have any questions, please view the Frequently Asked Questions or email Andrea Caballero at [email protected]

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Sheet 2: General Info

General Information
Questions	Responses
Provide contact name, email and phone for the health plan respondent.	Name
	Email
	Phone
What is the total number of members covered by the health plan by line of business?	Comm
	MA
	MCO
In which state(s) does the health plan have business? Please specify which line of business next to the state name. (C - commercial, MA - Medicare Advantage, MCO - Medicaid)		Alabama
		Alaska
		Arizona
		Arkansas
		California
		Colorado
		Connecticut
		Delaware
		Florida
		Georgia
		Hawaii
		Idaho
		Illinois
		Indiana
		Iowa
		Kansas
		Kentucky
		Louisiana
		Maine
		Maryland
		Massachusetts
		Michigan
		Minnesota
		Mississippi
		Missouri
		Montana
		Nebraska
		Nevada
		New Hampshire
		New Jersey
		New Mexico
		New York
		North Carolina
		North Dakota
		Ohio
		Oklahoma
		Oregon
		Pennsylvania
		Puerto Rico
		Rhode Island
		South Carolina
		South Dakota
		Tennessee
		Texas
		Utah
		Vermont
		Virginia
		Washington
		West Virginia
		Wisconsin
		Wyoming
What is the plan's total health care spend (in- and out-of-network) by line of business?	Comm
	MA
	MCO
For the look back metrics, please specify if you are using CY 2015 data or most recent 12 months. Please specify if the time reporting differs by line of business.
If you are using most recent 12 months, please specify the 12 month period.
Does your submission include prescription drug claims data under the pharmacy benefit in the denominator (total spend)? If yes, what percent of the pharmacy benefit spend is included?	Comm
	MA
	MCO
Does your submission include behavioral health claims data in the denominator (total spend)? If yes, what percent of the behavioral health spend is included?	Comm
	MA
	MCO
Please list other assumptions, qualifications, considerations, or limitations related to the data submission.
How many hours did it take your organization to complete this survey by line of business? Please report your response in hours.	Commercial Hours =
	Medicare Advantage Hours =
	Medicaid Hours =

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Sheet 3: Comm Metrics

Commercial Metrics Look Back Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods (APMs) in calendar year (CY) 2015 or most recent 12 months, as specified. The goal is NOT to gather information on a projection or estimation of where the plan would be if their contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in claims for the specified time period.
Methods
The “look back” metrics (also known as retrospective metrics) should report actual dollars paid to providers through APMs CY 2015 or the most recent 12 months for which the plan has data. For example, if the plan paid a provider $120,000 for the entire year, but entered a shared savings contract with the plan on July 1, 2015, half of the payments the provider received ($60,000) would be reported as fee-for-service (Category 1) and the other half of the payments the provider received ($60,000) would be reported as shared savings (Category 3). An acceptable but less preferable approach to reporting actual dollars paid is annualizing dollars paid in APMs based on a point in time, e.g. on a single day such as December 31, 2015, as long as the APM contract existed for the full 12 month period. For example, a provider in a shared savings arrangement received $300 (a combination of $285 base payment plus $15 in shared savings), which, if multiplied by 365 (annualized), would be reported as $109,500 in shared savings CY 2015. An unacceptable approach is counting all of dollars paid to a provider as being in APMs for the entire year, regardless of when the contract was executed (e.g. counting $120,000 in shared savings even though the contract was only in place for half of the reporting year). NOTE: this method is much more vulnerable to variation from actual spending depending on the representativeness of the time period annualized. Plans should report the total dollars paid, which includes the base payment plus any incentive, such as fee-for-service with a bonus for performance (P4P), fee-for-service and savings that were shared with providers, etc. To the extent payment to a provider includes multiple APMs, the plans should put the dollars in the dominant APM. For example, if a provider has a shared savings contract with a health plan and the provider is also eligible for performance bonuses for meeting quality measures (P4P), the health plan would report the FFS claims, shared savings payments (if any), and the P4P dollars in the shared savings subcategory (Category 3).
Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to providers CY 2015 or most recent 12 months unless another method, such as annualizing, is used. Numerators should not be calculated based on members attributed to APMs unless the provider is held responsible for all care (in network, out of network, inpatient, outpatient, behavioral health, pharmacy) the patient receives.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
Alternative Payment Model Framework - Category 1 (Metrics below apply to total dollars paid for commercial members. Metrics are NOT linked to quality)
1	NA	NA	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Denominator to inform the metrics below	NA
2	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars under legacy payments (including FFS without a quality component, DRGs, and capitation without quality): Percent of total dollars paid through legacy payments (including FFS without a quality component and DRGs) in CY 2015 or most recent 12 months.	#DIV/0!
Alternative Payment Model Framework - Category 2 (All methods below are linked to quality).
3	Dollars paid for foundational spending to improve care (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Foundational spending to improve care: Percent of dollars paid for foundational spending to improve care in CY 2015 or most recent 12 months.	#DIV/0!
4	Total dollars paid to providers through FFS plus P4P payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in P4P programs: Percent of total dollars paid through FFS plus P4P (linked to quality) payments in CY 2015 or most recent 12 months. * CPR historic metric - trend.	#DIV/0!
5	Total dollars paid in Category 2 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS linked to quality: Percent of total dollars paid in Category 2.	#DIV/0!
Alternative Payment Model Framework - Category 3 (All methods below are linked to quality)
6	Total dollars paid to providers through FFS-based shared-savings (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments in CY 2015 or most recent 12 months.	#DIV/0!
7	Total dollars paid to providers through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	#DIV/0!
8	Total dollars paid to providers through procedure-based bundled/episode payments (linked to quality) programs in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments in CY 2015 or most recent 12 months.	#DIV/0!
9	Total dollars paid to providers through population-based payments that are not condition-specific (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments that are not condition-specific in CY 2015 or most recent 12 months.	#DIV/0!
10	Total dollars paid in Category 3 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
Alternative Payment Model Framework - Category 4 (All methods below are linked to quality)
11	Total dollars paid to providers through population-based payments for conditions (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
12	Total dollars paid to providers through condition-specific, bundled/episode payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
13	Total dollars paid to providers through full or percent of premium population-based payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments in CY 2015 or most recent 12 months.	#DIV/0!
14	Total dollars paid in Category 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
15	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Legacy payments not linked to quality: Percent of total dollars paid based through legacy payments (including FFS without a quality component and DRGs).	#DIV/0!
16	Total dollars paid to providers through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 2-4: Percent of total dollars paid through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	#DIV/0!
17	Total dollars paid to providers through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for commercial members in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	#DIV/0!
January 1, 2016 (Point-In-Time) Metrics
Goal/Purpose = Track total dollars paid through APMs in Category 3 and 4 based on contracts in place on January 1, 2016.
This goal is NOT to gather information on a projection or estimation of where the plan expects to be on December 31, 2016. Rather, it is based on actual members and/or dollars paid based on "inked" contracts in place on 1/1/16.
Methods
We understand plans may have different methods to calculate the dollars flowing through APMs based on contracts in place on 1/1/16. Therefore, the plan is free to use a methodology that best suits their data systems and organization to the extent that it answers the question. Two examples of methodologies follow:
		Numerator			Denominator
Example 1		Number of members attributed to [APM] based on contracts in place on 1/1/16	X	Average cost per member per month (annualized)	Total spend as of 1/1/16 annualized
Example 2		Most recent dollars paid through [APM] payments			Most recent total spend
Key Issue To Address
Depending on the methodology used to calculate the numerators, plan must be sure that there is little to no double counting of members or dollars paid. Additional guidance is below.
		Description			Example
Adjust for Double Counting/Overlap		In some cases, the methodology used to calculate the numerator may not account for possible double counting of members or dollars. When double counting occurs, a methodology should be used to "discount" the number of members attributed to the most prominently attributed APM from the less prominently attributed APMs.			A health plan has members attributed to both an ACO (shared savings) and a bundled payment program. In this case, the plan would discount the ACO numerator from the bundled payment program by taking the percent of total dollars paid through shared savings (e.g. 20% of total health spend) and multiplying 1 - that percent (20%) by the total dollars paid through bundled payment ($700 million), which is equal to $560 million. This new numerator is then divided by the denominator above. $700 million (1 - 20%) = $560 million / [denominator]
Metrics
Please note that the dollars paid through the various APMs (numerator) are based on "inked" contracts in place on January 1, 2016. It is NOT a projection for APM spending by December 31, 2016 and does not factor in attrition or growth in membership, contracts, dollars anticipated during CY 2016.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
18	NA	NA	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Denominator to inform the metrics below	0
APM Framework - Category 3 (APMs Built on a Fee-for-Service Architecture)
19	Total dollars paid through FFS-based shared-savings (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments based on contracts in place on 1/1/16.	#DIV/0!
20	Total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	#DIV/0!
21	Total dollars paid through procedure-based bundled/episode payments (linked to quality) programs based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments based on contracts in place on 1/1/16.	#DIV/0!
22	Total dollars paid through population-based payments that are not condition-specific (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments not condition specific based on contracts in place on 1/1/16.	#DIV/0!
23	Total dollars paid in Category 3 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
APM Framework - Category 4 (Population Based Payments that are Condition-Specific or Comprehensive)
24	Total dollars paid through population-based payments for conditions (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
25	Total dollars paid through condition-specific, bundled/episode payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
26	Total dollars paid through full or percent of premium population-based payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments based on contracts in place on 1/1/16.	#DIV/0!
27	Total dollars paid in Category 4 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Category 3 & 4)
28	Total dollars paid through APMs in Categories 3 and 4 based on contracts in place on January 1, 2016.	$0.00	Total dollars paid to providers (in and out of network) for commercial members based on contracts in place on 1/1/16.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through APMs in Categories 3 and 4 based on contracts in place 1/1/16.	#DIV/0!
29	Plan's target percent of spend in alternative payment methods (APMs) Categories 3 & 4 by December 31, 2016:						0.00%
Optional Metrics
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Value
Attributed Consumers
30	Total number of commercial, in-network health plan members attributed to a provider with a payment reform contract in CY 2015 or most recent 12 months.	[Numerator]	Number of commercial, in-network health plan members enrolled in CY 2015 or most recent 12 months.		[Denominator]	Payment Reform Penetration - Attributed Plan Members: Percent of commercial, in-network plan members attributed to a provider participating in a payment reform contract in CY 2015 or most recent 12 months.	#VALUE!
Provider Participation
31	Number of providers who participate in at least one APM contract in Categories 3 and 4.	[Numerator]	Total number of providers with whom plan has contracts.		[Denominator]	Percent of plan's contracted providers who have at least one APM contract in Categories 3 or 4.	#VALUE!
Benchmarks for Trend: All Cause Readmissions
32	Number of observed acute readmissions for any diagnosis within 30 days, for members 18 years of age and older.	[Numerator]	Total number of acute inpatient stays during the measurement year.		[Denominator]	Readmission Rate: Percent of total hospital admissions that are readmissions for any diagnosis within 30 days of discharge for members 18 years of age and older. NCQA Plan All Cause Readmissions (PCR) measure.	#VALUE!

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Sheet 4: MA Metrics

Medicare Advantage Metrics Look Back Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods (APMs) in calendar year (CY) 2015 or most recent 12 months, as specified. The goal is NOT to gather information on a projection or estimation of where the plan would be if their contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in claims for the specified time period.
Methods
The “look back” metrics (also known as retrospective metrics) should report actual dollars paid to providers through APMs CY 2015 or the most recent 12 months for which the plan has data. For example, if the plan paid a provider $120,000 for the entire year, but entered a shared savings contract with the plan on July 1, 2015, half of the payments the provider received ($60,000) would be reported as fee-for-service (Category 1) and the other half of the payments the provider received ($60,000) would be reported as shared savings (Category 3). An acceptable but less preferable approach to reporting actual dollars paid is annualizing dollars paid in APMs based on a point in time, e.g. on a single day such as December 31, 2015, as long as the APM contract existed for the full 12 month period. For example, a provider in a shared savings arrangement received $300 (a combination of $285 base payment plus $15 in shared savings), which, if multiplied by 365 (annualized), would be reported as $109,500 in shared savings CY 2015. An unacceptable approach is counting all of dollars paid to a provider as being in APMs for the entire year, regardless of when the contract was executed (e.g. counting $120,000 in shared savings even though the contract was only in place for half of the reporting year). NOTE: this method is much more vulnerable to variation from actual spending depending on the representativeness of the time period annualized. Plans should report the total dollars paid, which includes the base payment plus any incentive, such as fee-for-service with a bonus for performance (P4P), fee-for-service and savings that were shared with providers, etc. To the extent payment to a provider includes multiple APMs, the plans should put the dollars in the dominant APM. For example, if a provider has a shared savings contract with a health plan and the provider is also eligible for performance bonuses for meeting quality measures (P4P), the health plan would report the FFS claims, shared savings payments (if any), and the P4P dollars in the shared savings subcategory (Category 3).
Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to providers CY 2015 or most recent 12 months unless another method, such as annualizing, is used. Numerators should not be calculated based on members attributed to APMs unless the provider is held responsible for all care (in network, out of network, inpatient, outpatient, behavioral health, pharmacy) the patient receives.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
Alternative Payment Model Framework - Category 1 (Metrics below apply to total dollars paid for Medicare Advantage members. Metrics are NOT linked to quality)
1	NA	NA	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Denominator to inform the metrics below	NA
2	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars under legacy payments (including FFS without a quality component and DRGs): Percent of total dollars paid through legacy payments (including FFS without a quality component and DRGs) in CY 2015 or most recent 12 months.	#DIV/0!
Alternative Payment Model Framework - Category 2 (All methods below are linked to quality).
3	Dollars paid for foundational spending to improve care (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Foundational spending to improve care: Percent of dollars paid for foundational spending to improve care in CY 2015 or most recent 12 months.	#DIV/0!
4	Total dollars paid to providers through FFS plus P4P payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in P4P programs: Percent of total dollars paid through FFS plus P4P (linked to quality) payments in CY 2015 or most recent 12 months. * CPR historic metric - trend.	#DIV/0!
5	Total dollars paid in Category 2 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS linked to quality: Percent of total dollars paid in Category 2.	#DIV/0!
Alternative Payment Model Framework - Category 3 (All methods below are linked to quality)
6	Total dollars paid to providers through FFS-based shared-savings (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments in CY 2015 or most recent 12 months.	#DIV/0!
7	Total dollars paid to providers through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	#DIV/0!
8	Total dollars paid to providers through procedure-based bundled/episode payments (linked to quality) programs in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments in CY 2015 or most recent 12 months.	#DIV/0!
9	Total dollars paid to providers through population-based payments that are not condition-specific (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments that are not condition-specific in CY 2015 or most recent 12 months.	#DIV/0!
10	Total dollars paid in Category 3 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
Alternative Payment Model Framework - Category 4 (All methods below are linked to quality)
11	Total dollars paid to providers through population-based payments for conditions (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
12	Total dollars paid to providers through condition-specific, bundled/episode payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
13	Total dollars paid to providers through full or percent of premium population-based payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments in CY 2015 or most recent 12 months.	#DIV/0!
14	Total dollars paid in Category 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
15	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Legacy payments not linked to quality: Percent of total dollars paid based through legacy payments (including FFS without a quality component and DRGs).	#DIV/0!
16	Total dollars paid to providers through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 2-4: Percent of total dollars paid through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	#DIV/0!
17	Total dollars paid to providers through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	#DIV/0!
January 1, 2016 (Point-In-Time) Metrics
Goal/Purpose = Track total dollars paid through APMs in Category 3 and 4 based on contracts in place on January 1, 2016.
This goal is NOT to gather information on a projection or estimation of where the plan expects to be on December 31, 2016. Rather, it is based on actual members and/or dollars paid based on "inked" contracts in place on 1/1/16.
Methods
We understand plans may have different methods to calculate the dollars flowing through APMs based on contracts in place on 1/1/16. Therefore, the plan is free to use a methodology that best suits their data systems and organization to the extent that it answers the question. Two examples of methodologies follow:
		Numerator			Denominator
Example 1		Number of members attributed to [APM] based on contracts in place on 1/1/16	X	Average cost per member per month (annualized)	Total spend as of 1/1/16 annualized
Example 2		Most recent dollars paid through [APM] payments			Most recent total spend
Key Issue To Address
Depending on the methodology used to calculate the numerators, plan must be sure that there is little to no double counting of members or dollars paid. Additional guidance is below.
		Description			Example
Adjust for Double Counting/Overlap		In some cases, the methodology used to calculate the numerator may not account for possible double counting of members or dollars. When double counting occurs, a methodology should be used to "discount" the number of members attributed to the most prominently attributed APM from the less prominently attributed APMs.			A health plan has members attributed to both an ACO (shared savings) and a bundled payment program. In this case, the plan would discount the ACO numerator from the bundled payment program by taking the percent of total dollars paid through shared savings (e.g. 20% of total health spend) and multiplying 1 - that percent (20%) by the total dollars paid through bundled payment ($700 million), which is equal to $560 million. This new numerator is then divided by the denominator above. $700 million (1 - 20%) = $560 million / [denominator]
Metrics
Please note that the dollars paid through the various APMs (numerator) are based on "inked" contracts in place on January 1, 2016. It is NOT a projection for APM spending by December 31, 2016 and does not factor in attrition or growth in membership, contracts, dollars anticipated during CY 2016.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
18	NA	NA	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Denominator to inform the metrics below	0
APM Framework - Category 3 (APMs Built on a Fee-for-Service Architecture)
19	Total dollars paid through FFS-based shared-savings (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments based on contracts in place on 1/1/16.	#DIV/0!
20	Total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	#DIV/0!
21	Total dollars paid through procedure-based bundled/episode payments (linked to quality) programs based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments based on contracts in place on 1/1/16.	#DIV/0!
22	Total dollars paid through population-based payments that are not condition-specific (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments not condition specific based on contracts in place on 1/1/16.	#DIV/0!
23	Total dollars paid in Category 3 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
APM Framework - Category 4 (Population Based Payments that are Condition-Specific or Comprehensive)
24	Total dollars paid through population-based payments for conditions (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
25	Total dollars paid through condition-specific, bundled/episode payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
26	Total dollars paid through full or percent of premium population-based payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments based on contracts in place on 1/1/16.	#DIV/0!
27	Total dollars paid in Category 4 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Category 3 & 4)
28	Total dollars paid through APMs in Categories 3 and 4 based on contracts in place on January 1, 2016.	$0.00	Total dollars paid to providers (in and out of network) for Medicare Advantage members based on contracts in place on 1/1/16.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through APMs in Categories 3 and 4 based on contracts in place 1/1/16.	#DIV/0!
29	Plan's target percent of spend in alternative payment methods (APMs) Categories 3 & 4 by December 31, 2016:						0.00%
Optional Metrics
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Value
Attributed Consumers
30	Total number of Medicare Advantage, in-network health plan members attributed to a provider with a payment reform contract in CY 2015 or most recent 12 months.	[Numerator]	Number of Medicare Advantage, in-network health plan members enrolled in CY 2015 or most recent 12 months.		[Denominator]	Payment Reform Penetration - Attributed Plan Members: Percent of Medicare Advantage, in-network plan members attributed to a provider participating in a payment reform contract in CY 2015 or most recent 12 months.	#VALUE!
Provider Participation
31	Number of providers who participate in at least one APM contract in Categories 3 and 4.	[Numerator]	Total number of providers with whom plan has contracts.		[Denominator]	Percent of plan's contracted providers who have at least one APM contract in Categories 3 or 4.	#VALUE!
Benchmarks for Trend: All Cause Readmissions
32	Number of observed acute readmissions for any diagnosis within 30 days, for members 18 years of age and older.	[Numerator]	Total number of acute inpatient stays during the measurement year.		[Denominator]	Readmission Rate: Percent of total hospital admissions that are readmissions for any diagnosis within 30 days of discharge for members 18 years of age and older. NCQA Plan All Cause Readmissions (PCR) measure.	#VALUE!

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Sheet 5: MCO Metrics

Medicaid Metrics Look Back Metrics
Goal/Purpose = Track total dollars paid through legacy payments and alternative payment methods (APMs) in calendar year (CY) 2015 or most recent 12 months, as specified. The goal is NOT to gather information on a projection or estimation of where the plan would be if their contracts were in place the entire calendar year. Rather it is based on what the plan actually paid in claims for the specified time period.
Methods
The “look back” metrics (also known as retrospective metrics) should report actual dollars paid to providers through APMs CY 2015 or the most recent 12 months for which the plan has data. For example, if the plan paid a provider $120,000 for the entire year, but entered a shared savings contract with the plan on July 1, 2015, half of the payments the provider received ($60,000) would be reported as fee-for-service (Category 1) and the other half of the payments the provider received ($60,000) would be reported as shared savings (Category 3). An acceptable but less preferable approach to reporing actual dollars paid is annualizing dollars paid in APMs based on a point in time, e.g. on a single day such as December 31, 2015, as long as the APM contract existed for the full 12 month period. For example, a provider in a shared savings arrangement received $300 (a combination of $285 base payment plus $15 in shared savings), which, if multiplied by 365 (annualized), would be reported as $109,500 in shared savings CY 2015. An unacceptable approach is counting all of dollars paid to a provider as being in APMs for the entire year, regardless of when the contract was executed (e.g. counting $120,000 in shared savings even though the contract was only in place for half of the reporting year). NOTE: this method is much more vulnerable to variation from actual spending depending on the representativeness of the time period annualized. Plans should report the total dollars paid, which includes the base payment plus any incentive, such as fee-for-service with a bonus for performance (P4P), fee-for-service and savings that were shared with providers, etc. To the extent payment to a provider includes multiple APMs, the plans should put the dollars in the dominant APM. For example, if a provider has a shared savings contract with a health plan and the provider is also eligible for performance bonuses for meeting quality measures (P4P), the health plan would report the FFS claims, shared savings payments (if any), and the P4P dollars in the shared savings subcategory (Category 3).
Metrics
Please note that the dollars paid through the various APMs (numerator) are actual dollars paid to providers CY 2015 or most recent 12 months unless another method, such as annualizing, is used. Numerators should not be calculated based on beneficiaries attributed to APMs unless the provider is held responsible for all care (in network, out of network, inpatient, outpatient, behavioral health, pharmacy) the patient receives.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
Alternative Payment Model Framework - Category 1 (Metrics below apply to total dollars paid for Medicaid beneficiaries. Metrics are NOT linked to quality)
1	NA	NA	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Denominator to inform the metrics below	NA
2	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars under legacy payments (including FFS without a quality component and DRGs): Percent of total dollars paid through legacy payments (including FFS without a quality component and DRGs) in CY 2015 or most recent 12 months.	#DIV/0!
Alternative Payment Model Framework - Category 2 (All methods below are linked to quality).
3	Dollars paid for foundational spending to improve care (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Foundational spending to improve care: Percent of dollars paid for foundational spending to improve care in CY 2015 or most recent 12 months.	#DIV/0!
4	Total dollars paid to providers through FFS plus P4P payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in P4P programs: Percent of total dollars paid through FFS plus P4P (linked to quality) payments in CY 2015 or most recent 12 months. * CPR historic metric - trend.	#DIV/0!
5	Total dollars paid in Category 2 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS linked to quality: Percent of total dollars paid in Category 2.	#DIV/0!
Alternative Payment Model Framework - Category 3 (All methods below are linked to quality)
6	Total dollars paid to providers through FFS-based shared-savings (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments in CY 2015 or most recent 12 months.	#DIV/0!
7	Total dollars paid to providers through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments in CY 2015 or most recent 12 months.	#DIV/0!
8	Total dollars paid to providers through procedure-based bundled/episode payments (linked to quality) programs in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments in CY 2015 or most recent 12 months.	#DIV/0!
9	Total dollars paid to providers through population-based payments that are not condition-specific (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments that are not condition-specific in CY 2015 or most recent 12 months.	#DIV/0!
10	Total dollars paid in Category 3 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
Alternative Payment Model Framework - Category 4 (All methods below are linked to quality)
11	Total dollars paid to providers through population-based payments for conditions (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
12	Total dollars paid to providers through condition-specific, bundled/episode payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality in CY 2015 or most recent 12 months.	#DIV/0!
13	Total dollars paid to providers through full or percent of premium population-based payments (linked to quality) in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments in CY 2015 or most recent 12 months.	#DIV/0!
14	Total dollars paid in Category 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Comparison between Category 1 and Categories 2-4)
15	Total dollars paid to providers through legacy payments (including FFS without a quality component and DRGs) payments in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Legacy payments not linked to quality: Percent of total dollars paid based through legacy payments (including FFS without a quality component and DRGs).	#DIV/0!
16	Total dollars paid to providers through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 2-4: Percent of total dollars paid through payment reforms in Categories 2-4 in CY 2015 or most recent 12 months.	#DIV/0!
17	Total dollars paid to providers through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries in CY 2015 or most recent 12 months.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through payment reforms in Categories 3 and 4 in CY 2015 or most recent 12 months.	#DIV/0!
January 1, 2016 (Point-In-Time) Metrics
Goal/Purpose = Track total dollars paid through APMs in Category 3 and 4 based on contracts in place on January 1, 2016.
This goal is NOT to gather information on a projection or estimation of where the plan expects to be on December 31, 2016. Rather, it is based on actual beneficiaries and/or dollars paid based on "inked" contracts in place on 1/1/16.
Methods
We understand plans may have different methods to calculate the dollars flowing through APMs based on contracts in place on 1/1/16. Therefore, the plan is free to use a methodology that best suits their data systems and organization to the extent that it answers the question. Two examples of methodologies follow:
		Numerator			Denominator
Example 1		Number of beneficiaries attributed to [APM] based on contracts in place on 1/1/16	X	Average cost per beneficiary per month (annualized)	Total spend as of 1/1/16 annualized
Example 2		Most recent dollars paid through [APM] payments			Most recent total spend
Key Issue To Address
Depending on the methodology used to calculate the numerators, plan must be sure that there is little to no double counting of beneficiaries or dollars paid. Additional guidance is below.
		Description			Example
Adjust for Double Counting/Overlap		In some cases, the methodology used to calculate the numerator may not account for possible double counting of beneficiaries or dollars. When double counting occurs, a methodology should be used to "discount" the number of beneficiaries attributed to the most prominently attributed APM from the less prominently attributed APMs.			A health plan has beneficiaries attributed to both an ACO (shared savings) and a bundled payment program. In this case, the plan would discount the ACO numerator from the bundled payment program by taking the percent of total dollars paid through shared savings (e.g. 20% of total health spend) and multiplying 1 - that percent (20%) by the total dollars paid through bundled payment ($700 million), which is equal to $560 million. This new numerator is then divided by the denominator above. $700 million (1 - 20%) = $560 million / [denominator]
Metrics
Please note that the dollars paid through the various APMs (numerator) are based on "inked" contracts in place on January 1, 2016. It is NOT a projection for APM spending by December 31, 2016 and does not factor in attrition or growth in beneficiaries, contracts, dollars anticipated during CY 2016.
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
18	NA	NA	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Denominator to inform the metrics below	0
APM Framework - Category 3 (APMs Built on a Fee-for-Service Architecture)
19	Total dollars paid through FFS-based shared-savings (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Dollars in shared-savings (linked to quality) programs: Percent of total dollars paid through FFS-based shared-savings payments based on contracts in place on 1/1/16.	#DIV/0!
20	Total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Dollars in shared-risk programs: Percent of total dollars paid through FFS-based shared-risk (linked to quality) payments based on contracts in place on 1/1/16.	#DIV/0!
21	Total dollars paid through procedure-based bundled/episode payments (linked to quality) programs based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Dollars in procedure-based bundled/episode payments (linked to quality) programs: Percent of total dollars paid through procedure-based bundled/episode payments based on contracts in place on 1/1/16.	#DIV/0!
22	Total dollars paid through population-based payments that are not condition-specific (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Population-based payments to providers that are not condition-specific and linked to quality: Percent of total dollars paid through population-based (linked to quality) payments not condition specific based on contracts in place on 1/1/16.	#DIV/0!
23	Total dollars paid in Category 3 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Payment Reform - APMs built on FFS architecture: Percent of total dollars paid in Category 3.	#DIV/0!
APM Framework - Category 4 (Population Based Payments that are Condition-Specific or Comprehensive)
24	Total dollars paid through population-based payments for conditions (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Population-based payments for conditions (linked to quality): Percent of total dollars paid through condition-specific population-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
25	Total dollars paid through condition-specific, bundled/episode payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Dollars in condition-specific bundled/episode payment programs (linked to quality): Percent of total dollars paid through condition-specific bundled/episode-based payments linked to quality based on contracts in place on 1/1/16.	#DIV/0!
26	Total dollars paid through full or percent of premium population-based payments (linked to quality) based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Dollars in full or percent of premium population-based payment programs (linked to quality): Percent of total dollars paid through full or percent of premium population-based payments based on contracts in place on 1/1/16.	#DIV/0!
27	Total dollars paid in Category 4 based on contracts in place on 1/1/16.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Payment Reform - Population-based APMs: Percent of total dollars paid in Category 4.	#DIV/0!
Aggregated Metrics (Category 3 & 4)
28	Total dollars paid through APMs in Categories 3 and 4 based on contracts in place on January 1, 2016.	$0.00	Total dollars paid to providers (in and out of network) for Medicaid beneficiaries based on contracts in place on 1/1/16.		$0.00	Payment Reform Penetration - Dollars in Categories 3 and 4: Percent of total dollars paid through APMs in Categories 3 and 4 based on contracts in place 1/1/16.	#DIV/0!
29	Plan's target percent of spend in alternative payment methods (APMs) Categories 3 & 4 by December 31, 2016:						0.00%
Optional Metrics
#	Numerator	Numerator Value	Denominator		Denominator Value	Metric	Metric Calculation
Attributed Consumers
30	Total number of Medicaid, in-network health plan beneficiaries attributed to a provider with a payment reform contract in CY 2015 or most recent 12 months.	[Numerator]	Number of Medicaid, in-network health plan beneficiaries enrolled in CY 2015 or most recent 12 months.		[Denominator]	Payment Reform Penetration - Attributed Plan Beneficiaries Percent of Medicaid, in-network plan beneficiaries attributed to a provider participating in a payment reform contract in CY 2015 or most recent 12 months.	#VALUE!
Provider Participation
31	Number of providers who participate in at least one APM contract in Categories 3 and 4.	[Numerator]	Total number of providers with whom plan has contracts.		[Denominator]	Percent of plan's contracted providers who have at least one APM contract in Categories 3 or 4.	#VALUE!
Benchmarks for Trend: All Cause Readmissions
32	Number of observed acute readmissions for any diagnosis within 30 days, for beneficiaries 18 years of age and older.	[Numerator]	Total number of acute inpatient stays during the measurement year.		[Denominator]	Readmission Rate: Percent of total hospital admissions that are readmissions for any diagnosis within 30 days of discharge for beneficiaries 18 years of age and older. NCQA Plan All Cause Readmissions (PCR) measure.	#VALUE!

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Sheet 6: Cross-Checking

Cross-Checking
Questions	Responses
For the look back metrics only, what payment models were in effect during specified the period of reporting? Please specify the line of business (Comm, MA, MCO).	Select all that apply:
		Foundational spending to improve care
		FFS plus Pay for Performance
		FFS-based Shared Savings
		FFS-based Shared Risk
		Procedure-based Bundled/Episode Payments
		Population-based Payments not condition-specific
		Population-based Payments condition-specific
		Condition-Specific Bundled/Episode Payments
		Full or Percent of Premium Population-based Payment
For each program identified in the prior question, indicate when the program was launched. Please specify the line of business (Comm, MA, MCO).	Launch Date (Month/Year in Column B)
		Foundational spending to improve care
		FFS plus Pay for Performance
		FFS-based Shared Savings
		FFS-based Shared Risk
		Procedure-based Bundled/Episode Payments
		Population-based Payments not condition-specific
		Population-based Payments condition-specific
		Condition-Specific Bundled/Episode Payments
		Full or Percent of Premium Population-based Payment
For each program identified in the first question, describe its current stage of implementation (Pilot, Expansion, Fully Implemented)*. Please specify the line of business (Comm, MA, MCO).	Indicate Pilot, Expansion, or Fully Implemented* in Column B
		Foundational spending to improve care
		FFS plus Pay for Performance
		FFS-based Shared Savings
		FFS-based Shared Risk
		Procedure-based Bundled/Episode Payments
		Population-based Payments not condition-specific
		Population-based Payments condition-specific
		Condition-Specific Bundled/Episode Payments
		Full or Percent of Premium Population-based Payment
	*	Pilot mode (e.g. only available for a subset of members and/or providers)
		Expansion mode (e.g. passed initial pilot stage)
		Fully implemented (e.g. generally available)

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Sheet 7: Definitions

Definitions
Terms	Definitions
Alternative Payment Model (APM)	Health care payment methods that use financial incentives to promote or leverage greater value - including higher quality care at lower costs - for patients, purchasers, payers and providers. This definition is specific to this exercise. If you are interested in MACRA's definition, please reference MACRA for more details.
	APM Framework White Paper
	MACRA Website
Attribution	A methodology that uses patient attestation and claims/encounter data to assign a patient population to a provider group/delivery system to manage the population's health, with calculated health care costs/savings or quality of care scores for that population. For some products, an individual consumer may select a network of physicians at the point of enrollment in a health plan (e.g. HMO). The Framework is agnostic to the attribution method (e.g. prospective or concurrent).
Category 1	Fee-for-service with no link to quality. These payments utilize traditional FFS payments that are not adjusted to account for infrastructure investments, provider reporting of quality data, for provider performance on cost and quality metrics. Diagnosis-related groups (DRGs) that are not linked to quality are in Category 1.
Category 2	Fee-for-service linked to quality. These payments utilize traditional FFS payments, but are subsequently adjusted based on infrastructure investments to improve care or clinical services, whether providers report quality data, or how well they perform on cost and quality metrics.
Category 3	Alternative payment methods (APMs) built on fee-for-service architecture. These payments are based on FFS architecture, while providing mechanisms for effective management of a set of procedures, an episode of care, or all health services provided for individuals. In addition to taking quality considerations into account, payments are based on cost performance against a target, irrespective of how the financial benchmark is established, updated, or adjusted. Providers that meet their cost and quality targets are eligible for shared savings, and those that do not may be held financially accountable.
Category 4	Population-based payment. These payments are structured in a manner that encourages providers to deliver well-coordinated, high quality person level care within a defined or overall budget. This holds providers accountable for meeting quality and, increasingly, person centered care goals for a population of patients or members. Payments are intended to cover a wide range of preventive health, health maintenance, and health improvement services, among other items. These payments will likely require care delivery systems to establish teams of health professionals to provide enhanced access and coordinated care.
Commercial members/ Medicare Advantage members/ Medicaid beneficiaries	Health plan enrollees or plan participants.
Condition-specific bundled/episode payments	A single payment to providers and/or health care facilities for all services related to a specific condition (e.g. diabetes). The payment considers the quality, costs, and outcomes for a patient-centered course of care over a longer time period and across care settings. Providers assume financial risk for the cost of services for a particular condition, as well as costs associated with preventable complications. [APM Framework Category 4A]
CY 2015 or most recent 12 months	Calendar year 2015 or the most current 12-month period for which the health plan can report payment information. This is the reporting period for which the health plan should report all of its "actual" spend data - a retrospective "look back." This is not an annualized (point-in-time) reporting.
Diagnosis-related groups (DRGs)	A clinical category risk adjustment system that uses information about patient diagnoses and selected procedures to identify patients that are expected to have similar costs during a hospital stay - a form of case rate for a hospitalization. Each DRG is assigned a weight that reflects the relative cost of caring for patients in that category relative to other categories and is then multiplied by a conversion factor to establish payment rates.
Double Count Adjustment (aka discounting or reductions for double counting)	When providing a point-in time January 1, 2016 payment, it is important to adjust for possible double counting of members attributed to multiple APMs. For example, it is possible that a member affiliated with a shared savings ACO is also affiliated with a bundled payment program. The reporting health plan either has to create a hierarchy where the situation for double counting members is eliminated or greatly reduced, or identify the prominent APM and adjust other programs for any overlap in members. For example, if a shared savings ACO is the most prominent model for the health plan, the health plan would discount the percent of total dollars paid through shared savings (numerator/denominator) from the total dollars paid through bundled payment. For example, if the percent of total dollars paid through shared savings is 20% and the total dollars paid through bundled payment is $500 million, one would multiply 500 million x (1-0.20) = $400 million.
Fee-for-service	Providers receive a negotiated or payer-specified payment rate for every unit of service they deliver without regard to quality, outcomes or efficiency. [APM Framework Category 1]
Foundational spending	Includes but is not limited to payments to improve care delivery such as outreach and care coordination/management; after-hour availability; patient communication enhancements; health IT infrastructure use. May come in the form of care/case management fees, medical home payments, infrastructure payments, meaningful use payments and/or per-episode fees for specialists. [APM Framework Category 2A]
Full or percent of premium population-based payments	A fixed dollar payment to providers for all the care that a patient population may receive in a given time period, such as a month or year, (e.g. inpatient, outpatient, specialists, out-of-network, etc.) with payment adjustments based on measured performance and patient risk. [APM Framework Category 4B]
As of January 1, 2016	A point in time in which health plans will report data. The metric will account for the contracts in place on that date and estimate the number of members attributed to those contracts. The contracts referenced for this metric must already be "inked" on 1/1/16. This metric does not reflect potential contracts that might be expected in CY 2016, nor does it adjust for possible growth or attrition of members, contracts, dollars.
Legacy payments	Payments that utilize traditional payments and are not adjusted to account for infrastructure investments, provider reporting of quality data, or for provider performance on cost and quality metrics. This can include fee-for-service, diagnosis-related groups (DRGs) and per diems. [APM Framework Category 1].
Linked to quality	Payments that are set or adjusted based on evidence that providers meet a quality standards or improve care or clinical services, including for providers who report quality data, or providers who meet threshold on cost and quality metrics. The APM Framework does not specify which quality measures qualify for a payment method to be "linked to quality."
Pay for performance	The use of incentives (usually financial) to providers to achieve improved performance by increasing the quality of care and/or reducing costs. Incentives are typically paid on top of a base payment, such as fee-for-service or population-based payment. In some cases, if providers do not meet quality of care targets, their base payment is adjusted downward the subsequent year. [APM Framework Categories 2C & 2D].
Population-based payment for conditions	A per member per month (PMPM) payment to providers for inpatient and outpatient care that a patient population may receive for a particular condition in a given time period, such as a month or year, including inpatient care and facility fees. [APM Framework Category 4A].
Population-based payment not condition-specific	A per member per month (PMPM) payment to providers for outpatient or professional services that a patient population may receive in a given time period, such as a month or year, not including inpatient care or facility fees. The services for which the payment provides coverage is predefined and could be, for example, primary care services or professional services that are not specific to any particular condition. [APM Framework Category 3B].
Procedure-based bundled/episode payment	Setting a single price for all services to providers and/or health care facilities for all services related to a specific procedure (e.g. hip replacement). The payment is designed to improve value and outcomes by using quality metrics for provider accountability. Providers assume financial risk for the cost of services for a particular procedure and related services, as well as costs associated with preventable complications. [APM Framework Categories 3A & 3B].
Provider	For the purposes of this workbook, provider includes all providers for which there is health care spending. For the purposes of reporting APMs, this includes medical, behavioral, pharmacy, and DME spending to the greatest extent possible.
Readmissions for any diagnosis within 30 days	The number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission, for members 18 years of age and older.
Shared risk	A payment arrangement that allows providers to share in a portion of any savings they generate as compared to a set target for spending, but also puts them at financial risk for any overspending. Shared risk provides both an upside and downside financial incentive for providers or provider entities to reduce unnecessary spending for a defined population of patients or an episode of care, and to meet quality targets.
Shared savings	A payment arrangement that allows providers to share in a portion of any savings they generate as compared to a set target for spending. Shared savings provides an upside only financial incentive for providers or provider entities to reduce unnecessary spending for a defined population of patients or an episode of care, and to meet quality targets.
Total Dollars	The total estimated in- and out-of-network health care spend (e.g. annual payment amount) made to providers in calendar year (CY) 2015 or most recent 12 months.