Actual ACO Composite Performance $480.15 $503.69 $594.18 F IBNR Completion Adjustment 1.01 1.01 1.01 G Stop Loss Adjustment 0.98 0.97 0.99 H Final ACO Composite Performance $475.25 $493.46 $594.13 Total Savings/(Losses) $4.80 $25.97 ($118.83) J=E-I Performance vs. Target Percentage 1% 5% -25% K=J/E Outside ±2% MSR Window? No Yes Yes L Outside of Savings/Losses Cap? N/A No Yes M Capped Savings/(Losses) N/A $25.97 ($47.53) N Savings/Losses between 0 3% N/A $15.58 ($14.26) O – Sharing Percentage between 0 3% N/A 50% 40% P – Shared Savings/Losses between 0 – N/A $7.79 ($5.70) Q=O*P 3% Savings/Losses between 3 10% N/A $10.39 ($33.27) R=N-O – Sharing Percentage between 3 10% N/A 25% 20% S – Shared Savings/Losses between 3 – N/A $2.60 ($6.65) T=R*S 10% Shared Savings/Losses Before Quality N/A $10.39 ($12.36) U=Q+T Adjustment Quality Score 0.5 0.95 0.25 V Savings=U*V Final Shared Savings/Losses N/A $9.87 ($11.74) 4.4 Risk adjustment in prospective and retrospective models Risk adjustment will apply within each ACO model to adjust ACO-specific capitation rates/TCOC benchmarks to the risk level for each ACO. For all ACO models, risk scores will be calculated the Massachusetts Social Determinants of Health (SDH) Model, which is the same model that is currently used in the MCO program. This model currently relies on the following predictors: DxCG v4.2 concurrent Medicaid RRS, selected medical conditions,
Actual ACO Composite Performance $480.15 $503.69 $594.18 F IBNR Completion Adjustment 1.01 1.01 1.01 G Stop Loss Adjustment 0.98 0.97 0.99 H Final ACO Composite Performance $475.25 $493.46 $594.13 Total Savings/(Losses) $4.80 $25.97 ($118.83) J=E-I Performance vs. Target Percentage 1% 5% -25% K=J/E Outside ±2% MSR Window? No Yes Yes L Outside of Savings/Losses Cap? N/A No Yes M Capped Savings/(Losses) N/A $25.97 ($47.53) N Savings/Losses between 0 – 3% N/A $15.58 ($14.26) O Sharing Percentage between 0 – 3% N/A 50% 40% P Shared Savings/Losses between 0 – 3% N/A $7.79 ($5.70) Q=O*P Savings/Losses between 3 – 10% N/A $10.39 ($33.27) R=N-O Sharing Percentage between 3 – 10% N/A 25% 20% S Shared Savings/Losses between 3 – 10% N/A $2.60 ($6.65) T=R*S Shared Savings/Losses Before Quality Adjustment N/A $10.39 ($12.36) U=Q+T Quality Score 0.5 0.95 0.25 V Final Shared Savings/Losses N/A $9.87 ($11.74) Savings=U*V 4.4 Risk adjustment in prospective and retrospective models Risk adjustment will apply within each ACO model to adjust ACO-specific capitation rates/TCOC benchmarks to the risk level for each ACO. For all ACO models, risk scores will be calculated the Massachusetts Social Determinants of Health (SDH) Model, which is the same model that is currently used in the MCO program. This model currently relies on the following predictors: DxCG v4.2 concurrent Medicaid RRS, selected medical conditions,
170208-summary-pricing-methodology-aco-and-mco.docx