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PCP 2018
OPA NETWORK GUIDE 2018
Optimum Physician Alliance
Network Guide 1A LETTER FROM THOMAS F. HUGHES III, MD
To Our Valued Network,
Optimum Physician Alliance, LLC (OPA) is the product of a shared
OPA NETWORK GUIDE 2018
vision among local physicians and healthcare leaders to strengthen TABLE OF CONTENTS
partnerships across the Western New York healthcare community, and
improve quality and efficiency in the care delivery system. 03 2018 OPA Trajectory
OPA is patient-focused and physician-led. What makes OPA unique
is our network’s commitment to finding meaningful ways to simplify 05 The OPAdvantage™
the practice of medicine, allowing physicians to do what they do best,
provide quality care to their patients. It is through your voice and
07 2018 OPA Network Program
dedicated engagement, that we will find innovative and impactful ways
to provide the best care for our community.
09 2018 OPA Network Engagement
This handbook is for you, our OPA partner, to navigate and explore the
benefits of being an OPA physician.
11 Network Level Performance Targets
Sincerely,
15 Centers of Excellence
Thomas F. Hughes III, MD 19 Practice Optimization Program
33 Appendix
1 2Where We’re Headed
OPA recognizes the Quadruple Aim as our compass for We exist to empower physicians to create a
1 optimizing the healthcare system. It consists of four (4) main
quadrants, that when combined, provide a holistic view of
healthier community. We do this by creating the
conditions for innovative, patient-centered and
the main areas that drive value in the industry. As you con- value-based care (our vision). We believe in being
tinue through this guide, you will find that each aspect of the physician-centered, action-oriented, progressive,
Supporting 2018 OPA Network Program is inspired by the performance
measures of the Quadruple Aim.
dedicated, and relevant (our values).
Physicians
2
2
Empowering
2018 OPA NETWORK OVERVIEW
Patients 1
2018
OPA TRAJECTORY
3 The OPA
Improving
Outcomes
Quadruple Aim
3
4 4
Affordability
3 4PCMH/PCSP Consultants
The role of Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice
(PCSP) Consultants is to develop and maintain cooperative working relationships with
THE practices to assist with navigating the National Committee for Quality Assurance (NCQA) Patricia Danaher, MD
OPAdvantage™ PCMH and PCSP Recognition and Renewal programs. Consultants align their efforts with
regulatory programs such as HEDIS, MACRA, MIPS, and CPC+, and perform a practice-
I have been very
specific gap analysis to identify areas for quality improvement, streamline workflows and
policies, along with design strategies to ultimately help you achieve practice transformation. impressed by the OPA
OPA Exclusive Resources program and its team
Data Analytics members. The pro-
The industry has continued to increase the demands Data drives decisions. Optimizing the collection, analysis, and availability of healthcare data is gram is transparent,
paramount to achieving the kinds of outcomes and efficiencies required for success. In 2018, which is refreshing in
placed on primary care physicians, but in many cases has
OPA will be investing resources into the development of a multilateral, clinical IT platform that today's PFP and Value
not balanced those demands with the resources needed will allow access to essential patient information across care settings.
Based Payment envi-
to meet established benchmarks. OPA strives to develop
Pharmacy Support Services ronment. The focus
partnerships with our physicians, to not only provide those
is on the success of
Pharmacy support services include high-level practice analysis, as well as patient-specific
resources, but work collaboratively to bridge the gap the physician/practice
education, with a focus on best practice, therapeutic efficacy and cost containment. Practice
between the expectations and the realities of delivering engagement in this area has a significant impact on the reduction of the overall trend and and the support team
2018 OPA NETWORK OVERVIEW
value-based care. improves your ability to optimize cost savings opportunities. exemplifies this goal.
OPA NETWORK GUIDE 2018
I'm thankful to be a
Nutrition Education and Health Coaching
The remaining portion of this section highlights the part of it!
Nutrition Education and Health Coaching are available to improve the health and wellbeing of
many advantages of being an OPA physician! your patients by promoting behavioral and lifestyle changes. Utilizing motivational interview-
ing, in both one-on-one and facilitated group settings, OPA Registered Dietitians will provide
education for disease prevention and the management of chronic conditions. General well-
ness education and coaching are also available to impact long-term habits and health promo-
tion. Please see Appendix I for more details.
Physician Advisors
Integrated Care for Kids (Inc/K)
Your OPA practice is appointed a dedicated Physician Advisor who becomes your Joyce Zmuda, MD
primary liaison for OPA programs, resources, and opportunities. On a quarterly Inc/K offers Behavioral Health (BH) support for children and their families. Services include
basis, advisors will meet with your practice leads to review quality and outcome therapy and psychiatry services conveniently provided at the patient’s PCP office, assistance
At Delaware Pediatrics, we with medication management, and help linking families to other BH support services.
reports, assist with any support services that may benefit your practice, and share
OPA and industry updates. can’t say enough about the
support OPA has provided Variation Analysis
through the years. Whether it The goal of this program is to support physicians in identifying unwarranted variations in
EHR/System Support Specialists
be assistance with population clinical practice among physicians of the same specialty, as well as among physicians within
In the current world of medicine, the role of technology and the impact of digital a particular practice.
management or advice from
disruption can be felt across the industry. OPA’s System Support Specialist will
the pharmacist regarding cost
improve practice efficiency by optimizing the features and functionality available Outreach Associates
through your Electronic Health Record (EHR) system. System Support Specialist effective medication manage-
Outreach Associates will work closely with your practice to streamline workflows and improve
can create templates and alerts to keep your data in-sync and consistent, develop ment, they are always there
quality, efficiency, and communication.
custom reports and dashboards to reduce administrative burdens for staff, and to help us navigate the ever
assist with any technology needs that arise. To see the additional
changing healthcare land- Cortext discounts and bene-
scape. Thank you OPA!
Cortext offers a HIPAA compliant solution for texting ePHI and provides physicians with a fast, fits available to OPA
convenient, and free way to communicate and collaborate with colleagues. Please contact practices, please see
5 6
OPA to register. Appendix II.2018 OPA NETWORK PROGRAM
Network Engagement
2018 OPA
NETWORK
PROGRAM
The 2018 OPA Network Program consists of three (3) main
components. Practice eligibility will be based on performance
within the OPA Network Engagement Program, which is described
in the following section.
Network Level Performance Targets
Quality Performance Targets (Adult + Pediatric)
Shared Savings Performance Targets
Group-Based Performance Targets
Centers of Excellence – Adult Primary Care
Centers of Excellence – Pediatric Primary Care
OPA Grant Opportunity
7
Practice Optimization Program 82018 OPA BREAKDOWN OF 2018 OPA
NETWORK ENGAGEMENT NETWORK ENGAGEMENT
For the OPA network to be impactful in improving the health Engagement Tier I Tier II Tier III
of our community, we need dedicated engagement from Criteria
each physician and practice. As a result, OPA is excited to
announce the 2018 OPA Engagement Program, which aligns PCMH Recognized 100% Compliance 100% Compliance Non-PCMH
with the third arm of the Quadruple Aim, improving quality Practices
and outcomes. Practices that are engaged in these efforts,
and who dedicate the time and resources will be eligible for Quality Meet Target on Meet Target on 0 -1 Measures Met
2018 OPA NETWORK PROGRAM
enhanced network opportunities, while practices which fail
OPA NETWORK GUIDE 2018
Performance a minimum of a minimum of
to meet established benchmarks, will be disqualified from the Targets 4 Measures 2 Measures
2018 OPA Network Program.
2018 Network Program Eligibility
What You Need to Know
Consistent with last year, OPA practices must maintain PCMH Quality Eligible Eligible Ineligible
recognition to remain eligible for participation within the Performance
Targets
2018 OPA Network Program. New in 2018, practices will
be evaluated based upon achievement of OPA’s Quality Shared Savings Eligible Eligible Ineligible
Performance Targets, which address important public Performance Targets
health issues through the utilization of data and the de-
ployment of population health management strategies. Centers of Eligible Eligible Ineligible
Excellences
Engagement status will be determined at the end of 2018,
based on the full year’s performance. However, your practice Practice Eligible Eligible Ineligible
champions should be meeting with their Physician Advisor Optimization
Program
throughout the measurement period to ensure they have a
clear understanding of your practice’s achievements, as well
as the areas for improvement.
9 10Adult Primary Care Performance Targets
2018 OPA NETWORK
PERFORMANCE TARGETS
Quality Measures Threshold Target Maximum
(95% Payout) (100% Payout) (105% Payout)
Breast Cancer Screening 78% 81% 84%
There are two (2) network level performance targets. Both Colorectal Screening 63% 68% 74%
are calculated at the network level and are paid annually if
established benchmarks are met. Diabetes Care Eye Exam 57% 63% 69%
Diabetes Care-Monitoring for Kidney
91% 93% 94%
Disease
1. Shared Savings Performance Targets Diabetes Care-HBA1C>9
31% 27% 22%
2018 OPA NETWORK PROGRAM
(inverse measure, lower is better)
OPA NETWORK GUIDE 2018
This measure is designed to identify waste and inefficiency in the healthcare system, enhance the quality of services for
patients and improve value across the healthcare continuum. Your physician advisors will be distributing more detailed infor- Influenza Vaccination >65 (new) 63% 68% 73%
mation about this metric in the future.
Medication Reconciliation Post Discharge
5% 16% 30%
2. Quality Performance Targets (new)
The Quality Performance Targets were designed to address several critical public health issues, which are both prevalent in
our community and controllable with proper intervention. Public health can be defined as ‘the science and art of preventing
disease, prolonging life and promoting health through the organized efforts of society.1 OPA strives to do just that through its
Quadruple Aim by engaging physicians, empowering patients, improving outcomes, and affordability. Pediatric Primary Care Performance Targets
OPA measures the network’s ability to manage the health of patient through standards established by the Healthcare Effec-
tiveness Data and Information Set (HEDIS). HEDIS is a tool used by more than 90 percent of America’s health plans to measure
performance on important dimensions of care such as preventive services, chronic disease management and for high-burden
diseases such as diabetes, asthma, and heart disease. BMI Assessment Age 3 - 11 92% 93% 95%
What You Need to Know
BMI Assessment Age 12 - 17 89% 91% 93%
The goal of this measure is to improve the health of our community by leveraging data from electronic medical records, claims
data and other available resources, and then subsequently developing mechanisms for patient outreach and engagement. Counseling for Nutrition Age 3 - 11 12% 25% 37%
In the following sections you will find the 2018 Quality Performance Targets, and a description of each measure.
Counseling for Nutrition Age 12 - 17 13% 26% 38%
Payment for this measure will depend on the network’s performance, a practice’s tiering status, and their total number of
BlueCross BlueShield of Western New York (BCBSWNY) members as of January 1, 2018. Payment will be made following the Medication Age 6 - 12
39% 49% 59%
collection and analysis of 2018 claims data by the end of the second quarter of 2019. (Follow-up ADHD medications, new)
Vaccination (Combo 5) Age 2 yrs. (new) 68% 73% 78%
1
C.E. A. Winslow, “The Untilled Fields of Public Health,” Science, n.s. 51 (1920), p. 2
11 122018 OPA QUALITY Diabetes Care: This measure looks at patients with type 1 or type 2 diabetes between 18 and 75 years of age (as of
12/31/18) who had the appropriate services to monitor for diabetes.
HbA1c >9
(Inverse measure) Documentation must include the lab service date and results.
PERFORMANCE Exclusions:
•
•
Patients with a HbA1c of < 7.
Patients discharged alive for CABG or PCI in 2017 or 2018.
TARGET SUMMARY
• Patients with a diagnosis of ischemic vascular disease (IVD), thoracoabdominal or thoracic aortic
aneurysm, chronic heart failure (CHF), myocardial infarction (MI), chronic renal failure (CRF) or
end-stage renal disease (ESRD), dementia, blindness, or lower extremity amputation on or before
December 31, 2018. Patients who had a diagnosis of gestational diabetes or steroid-induced dia-
betes during 2017 or 2018.
• Patients diagnosed with gestational diabetes or steroid-induced diabetes during 2017 or 2018.
Breast Cancer This measure looks at women 50 - 74 years of age (as of 12/31/2018) who had a mammogram screening
for breast cancer between 10/1/2016-12/31/2018. Influenza
Screening The measure looks at the percentage of patients, 65 years of age and older (as of 12/31/2018), who re-
Target: women who have not had one or more mammogram screenings during the above timeframe.
Vaccination ceived an influenza vaccination between 1/1/2018 – 12/31/2018.
(greater than 65)
Exclusions: Bilateral mastectomy during the patient’s history through 12/31/2018 or two unilateral mas-
tectomies with service dates 14 days or more apart.
Medication This measure looks at the percentage of patients, 18 years of age or older (as of 12/31/2018), for whom
medications were reconciled within 30 days after discharge (31 total days) from an in-patient or long-
Reconciliation term care setting.
Colorectal This measure looks at patients 50 - 75 years of age (as of 12/31/2018) who had one of the five types of
Post Discharge
colorectal cancer screenings within associated timeframes: Review of patients discharges between 1/1/2018 and 12/31/2018
Screening • Fecal occult blood test (FOBT) – look back 2018
• Flexible sigmoidoscopy - look back 2014-2018
• Colonoscopy - look back 2009-2018
• CT Colonography (Virtual colonoscopy) - look back 2014-2018
Pediatric This measure looks at children and adolescents, 3 to 17 years of age (as of 12/31/18), who had an office
visit with a PCP or OB/GYN, and had counseling for nutrition or a referral for nutrition education in 2018.
• FIT-DNA (Cologuard) - look back 2016-2018 Nutrition
Exclusions: Either the diagnosis of colorectal cancer or a total colectomy during the patient’s history Counseling Requirements to meet the metric are below and must be documented in the patient’s medical record:
• Discussion of current nutrition behaviors (e.g. eating habit, diet behaviors), or
through December 31, 2018. • Checklist indicating nutrition was addressed, or
• Counseling or referral for nutrition education, or
• Educational materials received on nutrition during a face-to-face encounter, or
Diabetes Care: This measure looks at patients with type 1 or type 2 diabetes, between 18 and 75 years of age (as of • Anticipatory guidance for nutrition, or
12/31/18), who had the appropriate services to monitor for diabetes. This sub-measure looks at screening • Obesity or weight specific counseling
Eye Exam or monitoring for diabetic retinal disease (retinopathy).
• A retinal or dilated eye exam, by an eye care professional (optometrist or ophthalmologist), in the Exclusion: Patients with a diagnosis of pregnancy during 2018.
measurement year (2018). Retinopathy results can be either positive or negative.
• A negative retinal or dilated exam (negative for retinopathy), by an eye care professional (optom-
etrist or ophthalmologist), in the year prior (2017) to the measurement year.
• A chart or photograph of retinal abnormalities indicating the date of the fundus photography was
Pediatric BMI This measure looks at children and adolescents, 3 to 17 years of age (as of 12/31/18), who had an office
visit with a PCP or OB/GYN, and had a BMI Assessment performed in 2018.
performed.
BMI Percentile: Documentation must include a note indicating the date on which the BMI percentile
Exclusions: Patients who had a diagnosis of gestational diabetes or steroid-induced diabetes, during (including height and weight) was documented in 2018. The appropriate ICD-10 code must be document-
2017 or 2018, or an Eye Enucleation (removal of the eye that leaves the eye muscles and remaining orbital ed and submitted on the claim.
contents intact) anytime during the member's history through 12/31/2018.
Information may be found in either well or sick visits, and can be obtained using multiple visit dates from
the same provider.
Diabetes Care: This measure looks at patients with type 1 or type 2 diabetes, between 18 and 75 years of age (as of
12/31/18), who had the appropriate services to monitor for diabetes. This sub-measure looks at monitor- Exclusion: Patients with a diagnosis of pregnancy during 2018.
Monitoring for ing or screening for diabetic nephropathy or evidence that the patient already has nephropathy.
Kidney Disease Nephropathy screening test: Documentation must include a note indicating the date on which the
urine test was performed and the result. Any of the following meet laboratory criteria:
Medication This measure looks at the percentage of children, 6 to 12 years of age (as of 12/31/2018), who were newly
prescribed attention-deficit/hyperactivity disorder (ADHD) medication and had one follow-up visit with a
• 24-hour urine for albumin or protein (follow-up ADHD practitioner with prescribing authority, during the 30-day initiation phase.
• Timed urine for albumin or protein
• Spot urine for albumin or protein
prescriptions)
Review of patients 1/1/2018 and 12/31/2018
• Urine for albumin/creatinine ratio
• 4-hour urine for total protein
• Random urine for protein/creatinine ratio Vaccination This measure looks at the percentage of patients 2 years of age (as of 12/31/2018) who received the Com-
bo 5 vaccinations consistent with HEDIS guidelines.
Exclusions: Patients who had a diagnosis of gestational diabetes or steroid-induced diabetes during (Combo 5)
2017 or 2018, as well as patients with ESRD. Combination 5: DTaP, IPV, MMR, HiB, Hep B, VZV, PCV, and RV
13 14CENTERS OF EXCELLENCE
Codified Self-Reporting
ADULT + PEDIATRIC CARE
This measure encourages practices to develop self-reporting mechanisms to identify patients due, or overdue for services. It
is the responsibility of practices to generate quarterly reports, with a twelve (12) month a look back period. Reports are due by
the fifteenth (15) of the month following the close of the quarter. Physician advisors will be meeting with practice champions
The Centers of Excellence (COE) are group-based performance measures designed to during 1Q18 to review file formats and required data elements. Reports must be sent electronically to OPAinfo@opawny.com.
promote teamwork within each practice, as well as collaboration across the network. Adult Care Reporting Measure: Diabetic foot exams (type 1 or 2, for patients 18-75 years of age).
During 2018, physicians will be asked to attend quarterly meetings, develop self-reporting
Pediatric Care Reporting Measure: Chlamydia screenings (16-26 years of age)
mechanisms and strategies, and improve network efficiency by recognizing prescribing
patterns and identifying saving opportunities.
Certain COE measures are paid quarterly, while others are paid annually. Quarterly
payments will be calculated using the total number of patients at the beginning of each 2018 Reporting Submission Schedule
2018 OPA NETWORK PROGRAM
OPA NETWORK GUIDE 2018
quarter, and are paid within sixty (60) days after the close of the quarter. Annual measures
Quarter Quarter End Date Due Date
will be based on the total number of BCBSWNY members as of December 31, 2018. 1 3/31/2018 4/15/2018
Payment will be made following the collection and analysis of 2018 claims data by the end 2 6/30/2018 7/15/2018
of the second quarter of 2019. Below is a brief description of each metric. 3 9/30/2018 10/15/2018
4 12/31/2018 1/15/2019
OPA Primary Care Workgroups & Events Pharmacy Metrics (Adult + Ped)
(Adult + Ped)
At its core, OPA is an alliance of physicians working to achieve In years past, the OPA pharmacy trend was measured solely
the Quadruple Aim, which cannot happen without the collec- at a network level. New in 2018, OPA is releasing group-level
tive engagement of the network. Despite busy schedules, it measures, giving practices more autonomy to control costs
is essential that we connect on a regular basis to discuss the and maximize on shared cost savings opportunities. The COE Patient Experience Project
opportunities ahead of us, the obstacles we face as a net- pharmacy measure is broken into three (3) components:
Pediatric Only
work, and our collective ability to create positive change.
I. Achieve a generic dispensing rate ≥ 87%.
Part I
To that end, the format of the workgroups and OPA events
Practices are asked to review their Patient Experience Survey from 2017, and develop a patient experience project for 2018 based
will be designed to encourage a more collaborative and inter- II. Eliminate the use of DAW medications (Target = Zero).
on the prior year’s feedback. A project summary must be submitted to OPA by March 31, 2018 describing the initiative (see opawny.
active environment, where physicians can network with col- Partial credit will be given to physicians who prescribe
com for a sample form). The project should be implemented at that time and run for approximately six (6) months.
leagues, troubleshoot challenges, and discuss best practice. six (6) or fewer DAW per quarter.*
Part II
New in 2018, physicians will have more flexibility over when, III. Eliminate the use of certain High Cost/Low Impact med-
To measure the success of their patient experience initiative, practices should complete their 2018 Patient Experience Survey and
and how they participate, giving physicians more ownership ications (see appendix III for the 2018 High Cost/Low Im-
provide a summary of the results to OPA by December 31, 2018 (see opawny.com for a sample form).
over the initiatives and issues that matter most. We ask that pact Drug list).
each physician, within each practice, attend four (4) OPA
events throughout 2018. Participation credits can be earned
annually, but will be paid quarterly, if all physicians, in a prac-
tice, attend during that quarter. Multiple opportunities will be * Narrow Therapeutic Index (NTI) medications, medications to treat seizures, and
15
available throughout 2018. those to prevent transplant rejections, are excluded from this metric.
16Centers of
Excellence Grids
Adult Primary Care Pediatric Primary Care
Measure Description Maximum Payment Measure Description Maximum Payment
Value Frequency Value Frequency
OPA Primary Care Every OPA PCP must attend 4 per year $1 Paid quarterly OPA Primary Care Every OPA PCP must attend 4 per year $1 Paid quarterly
Workgroups & Events Workgroups & Events
2018 OPA NETWORK PROGRAM
OPA NETWORK GUIDE 2018
Pharmacy 1. Achieve a generic dispensing rate $3.05 Paid quarterly Pharmacy 1. Achieve a generic dispensing rate $3.05 Paid quarterly
greater than or equal to 87% - $1/ greater than or equal to 87% - $1.00/
PMPM PMPM
2. Eliminate the use of DAW medications 2. Eliminate the use of DAW medications
(partial credit will be given to physi- (partial credit will be given to physi-
cians who prescribe 6 or fewer DAW cians who prescribe 6 or fewer DAW
per quarter).* per quarter).*
A. 0 DAW medications = $1.05/PMPM
A. 0 DAW medications = $1.05/PMPM
B. Less than or equal to 3 DAW medications
= $0.85/PMPM B. Less than or equal to 3 DAW medications
= $0.85/PMPM
C. Less than or equal to 6 DAW medications
= $0.50/PMPM C. Less than or equal to 6 DAW medications
= $0.50/PMPM
3. Eliminate the use of certain High Cost/
Low Impact medications - $1/PMPM
(see appendix III) 3. Eliminate the use of certain High
Cost/Low Impact medications - $1/
PMPM (see appendix III)
Bonus
Practices who achieve each pharmacy
Codified Self Reporting: Develop and generate quarterly reports $1 Paid quarterly
measure, and who prescribe zero DAW $1
Chlamydia Screenings with a 12 month look back period that
medications, in a given quarter, will receive
contain the correct data elements and CPT
an additional $1 PMPM for that quarter.
codes - $1 PMPM
Codified Self Reporting: Develop and generate quarterly reports
Diabetic Foot Exams with a 12 month look back period that Pediatric Patient Identifying opportunities to improve the
$1 Paid quarterly patient experience - $1 PMPM $1 Paid annually
contain the correct data elements and CPT Experience Project
codes - $1 PMPM
17 1819
2018 OPA PRACTICE OPTIMIZATION PROGRAM
PRACTICE
PROGRAM
OPTIMIZATION
20Submission Dates and Times
2018 PRACTICE OPTIMIZATION PCMH practices are eligible to submit only one (1) POP application, per calendar year. Once approved, the application will
remain in effect for the remainder of the year.
PROGRAM GUIDELINES
Applications are due no later than 11:59 PM on January 31, 2018, for a retroactive effective date of January 1st, 2018. It is
recommended that practices submit their application in advance. Late and/or incomplete submissions will be held until the
next submission period. If the application is approved in a subsequent submission period, practices will be eligible for fund-
ing based on the number of months remaining in the year as indicated in the chart below:
When OPA was established in 2012, one of the charges
given to its leadership was to listen to the voice of the POP Application Submission Program # of Months Eligible
Submission Due Date Effective Dates for POP Payments
physicians and support them in providing the best care to
Opportunities
the patients of Western New York. We have listened and a
1 Qtr February 14 January 1 12
reoccurring theme has emerged; the practice of medicine is
2 Qtr March 1 April 1 9
simply, getting harder. In pursuit of clinical excellence, new
2018 OPA PRACTICE OPTIMIZATION PROGRAM
3 Qtr June 1 July 1 6
burdens are being placed on physicians, and fueling greater
4 Qtr September 1 October 1 3
and greater levels of physician burnout.
In years past, OPA PCP practices have had an opportunity
to apply for Practice Optimization Program (POP) grants Submission Methodology
to help transform their practices, which have been used
Applications must be submitted electronically. Electronic copies of the application can be found at https://opawny.com and
to make exciting changes such as EMR implementations, emailed to your physician advisor.
PCMH Recognition, and infrastructure improvements.
New for 2018 Program Criteria and Eligibility
In 2018, the focus of the POP will be to develop programs that help improve the phy- It is important to note that all • The practice must be PCMH Recognized.
sician experience, and by doing so, bringing back the joy of practicing medicine. OPA programs, including the
POP, are subject to change • The applicant must be a participating OPA PCP practice and be compliant with all OPA Standards for Participation.
Your application must identify factors that contribute to physician dissatisfaction,
year after year. Practices
and clearly demonstrate how the implementation of such a plan can decrease phy- should not rely solely on OPA • Eligible primary care physicians within the group must be participating in OPA.
sician stress, improve job fulfillment, and/or work-life balance. funds to support necessary
business functions. • Eligible primary care physicians are defined as participating OPA physicians who conduct patient care a minimum
Practices will be accountable for ensuring the awarded funds are allocated and
applied to achieve the objectives stated in their POP application. In an effort to of twelve (12) hours per week, at sites directly associated with the applicant’s group.
understand the impact of this grant, OPA will be conducting physician surveys
• OPA practices must have eleven (11) or more BCBSWNY patients. Practices with ten (10) or less BCBSWNY patients are
to measure the success of the program. The results of these surveys will help us
determine if programs such as POP are a good use of resources moving forward. not eligible.
• POP applications must be used to address the issue of physician burnout.
• Eligibility is determined at the group level, not per location.
21 22Funding and Allowable Expenses Distribution Timeframe
POP grants can be used for hiring new staff (e.g. clinical coders and scribes) to Funds will be distributed on a quarterly basis, sixty (60) days following the close
support the physicians in the practice. However, funds may not be used for main- of the quarter. Payment amounts will be determined using the annual maximum
taining positions that are traditionally part of an office team (e.g. administrative value formula.
staff, advanced practice providers, etc.). Grant money can be used for infrastructure
or technology improvements (e.g. ergonomic office equipment for the physicians),
but not for routine office purchases (e.g. replacing old computers). Other programs Application Review Process
can be considered as long as they are appropriate to a practice’s needs and are
consistent with the spirit of the metric. Ultimately, the litmus test for whether a pro- Each application will be reviewed for the following:
gram is appropriate will be based on the answer to this question: Will this project
improve the life of the physician? 1. Thoroughness and completeness
2. Supporting documentation
3. Alignment with the 2018 POP goals
4. Clearly defined time-frames
Funding Restrictions 5. Physician eligibility
Exclusions include, but are not limited to, the following:
If clarification is needed, additional information may be requested. The requested
2018 OPA PRACTICE OPTIMIZATION PROGRAM
Bonuses information must be submitted within three (3) days of the request. Applications
Indirect costs + deemed incomplete, ineligible or non-compliant will not be accepted, and the
Capital campaigns other standard expenses practice will be notified within fifteen (15) days of submission.
OPA NETWORK GUIDE 2018
Debt reduction Investments
Employee gifts Land acquisition Award Notification
Endowments Political campaigns
The final determination and the awarded amount will be communicated in writing
Event sponsorship Projects completed prior to to the applicant within fifteen (15) days of submission, unless additional information
the initiation of this program is needed.
Fundraising
Salaries
General construction or
facility renovations Scholarships Appeal Process
If an application is denied, the applicant may appeal the decision within three (3)
Allowable Amounts business days. Appeals must be made in writing and should be accompanied by
the denial letter. All documentation can be emailed to your physician advisor.
Eligible groups may request up to the maximum annual value,
which is determined using the following methodology: Each applicant is allowed one (1) cycle of revisions. If more than one (1) cycle is
needed, the application may be rejected, but can be resubmitted at the next sub-
(# of eligible primary care physicians at the time of submission) x ($2,500) x (# of months) mission cycle.
Example: program timeline 01/01/18 – 12/31/18:
(10 eligible PCP’s) x ($2,500) x (12 months) = $300,000 Audit Requirements
Number of months is based on the effective date of the program, OPA physician advisors will monitor the POP initiatives at each practice. Groups
and the number of months remaining in the calendar year. may be asked to provide physician feedback, transaction reports identifying expen-
ditures year-to-date, process workflows, program descriptions and/or to complete
a self-audit form.
23 24POP Eligibility Worksheet
2018 PRACTICE OPTIMIZATION Eligible primary care physicians are defined as contracted OPA physicians who conduct patient care a minimum of twelve
(12) hours per week at sites directly associated with the applicant’s group and are compliant with all OPA Standards for
PROGRAM APPLICATION Participation.
E
Thank you for your interest in participating in the 2018 # Clinical
# Physician Name Primary Location Cell Phone Email
hrs/wk
Optimum Physician Alliance (OPA) Practice Optimization
Program (POP). For additional information on this program, 1 ☐ > 12 hrs
PL
including application instructions, program rules, reimburse-
ment methodology and the review process, please see the 2 ☐ > 12 hrs
Practice Optimization Program Guidelines. It is important to
2018 OPA PRACTICE OPTIMIZATION PROGRAM
3 ☐ > 12 hrs
remember while completing this application that submis-
sions must be aligned with the focus of the 2018 POP, which
4 ☐ > 12 hrs
OPA NETWORK GUIDE 2018
is to improve the physician experience.
5 ☐ > 12 hrs
Applications must be submitted electronically. Electronic
copies of the application can be found at opawny.com and 6 ☐ > 12 hrs
emailed to your physician advisor.
Complete Group Name:
AM 7
8
9
10
☐ > 12 hrs
☐ > 12 hrs
☐ > 12 hrs
☐ > 12 hrs
Tax Identification Number:
11 ☐ > 12 hrs
Address: (primary address only):
12 ☐ > 12 hrs
Name of Physician Champion: Telephone:
13 ☐ > 12 hrs
Email address:
14 ☐ > 12 hrs
Assigned POP Project Administrator & Title: Telephone:
15 ☐ > 12 hrs
Email address:
25 26Maximum Annual Value Formula
(# of eligible primary care physicians at the time of submission) x ($2,500) x (# of months)
APPLICATION
Example: program timeline 01/01/18 – 12/31/18: QUESTIONS
E
(10 eligible PCP’s) x ($2,500) x (12 months) = $300,000
Number of months is based on the effective date of the program,
and the number of months remaining in the calendar year.
Please complete each question below. If additional space is need-
ed, please be sure to limit the length of your answers to no more
PL
than 6 pages total (for the entire application).
Project Budget
Please be sure to include only eligible expenses. For a listing of ineligible expenses, Statement of Need
2018 OPA PRACTICE OPTIMIZATION PROGRAM
please see the Practice Optimization Program Guidelines.
Why is this program important and how will it improve the physician experience? It’s very important to
present a clear, compelling case about why this program is needed.
OPA NETWORK GUIDE 2018
Practice OPA
Item Total
Contribution Contribution
Budget Rationale
Total
AM Program Information
A) Goals: What goals do you hope to achieve by implementing this program?
Goals are overarching principles that guide decision making. They reflect the big picture and clearly
serve the interests of the program.
Explain each line item above.
27 28Ex: Improve physician satisfaction
B) Milestones: Describe the milestones you plan to achieve as a result of the goal set in your application.
Milestones act as landmarks along the path to achieving your goal. They should describe the anticipated out-
Objective
comes and can be either qualitative or quantitative. Baseline data should be presented as a point of reference.
E
PL
Hire scribe
Activity
C) Activities: What activities are necessary to achieve your goal and address the need(s) identified in the need statement?
If applicable, cite research which verifies that the activities you want to adopt will be effective in addressing the need.
2018 OPA PRACTICE OPTIMIZATION PROGRAM
OPA NETWORK GUIDE 2018
Method of Measure
Physician survey
AM
D) Key Personnel: The key personnel section should include anyone who is going to work on the project and
their role in your organization.
Source of Data
Physicians
Start Date
1/1/2018
F) Evaluation Plan: In the following grid, please include the objective(s) you have developed and the cor-
Completion
responding activities needed to meet each objective. Include the method of measurement (how data will be
12/31/2018
measured) and the source of that data. Don’t forget to include your projected start and completion date and the
Date
individual(s) ultimately responsible for each action item.
Responsible
Individual
Jane Doe
29 30E) Additional Information: Please include any additional information about your organization or project that
you think is relevant to this submission. Also, please list any supporting documentation that is being submitted
FOR INTERNAL USE ONLY
with this application.
Practice name:
E
Name of OPA physician advisor:
No. of eligible primary care physicians:
Application submission date:
PL
Effective date:
2018 OPA PRACTICE OPTIMIZATION PROGRAM
No. of months remaining in calendar year
(following the effective date of program):
Quarterly payment approved: Total amount approved:
OPA NETWORK GUIDE 2018
Approved by: Date:
AM
31 32APPENDIX
APPENDIX
33 34APPENDIX I: OPA HEALTH PROMOTION EDUCATION
Keeping the community healthy.
High Blood Pressure Pre-Diabetes Healthy Choices
This class will cover ways to For patients that have pre-diabetes, it’s For Your Family
help lower blood pressure. not too late to take action and reduce
We will review strategies the risk of Type 2 Diabetes. Topics Attend these two classes to help you and your family make healthier
to decrease sodium intake, include, understanding risk factors, nutrition and wellness choices (two 60 minute classes).
increase physical activity, blood work associated with pre-
incorporate balance into meal diabetes, healthy eating, portion control, CLASS 1
planning and much more (one weight management, and physical Nutrition Basics and Healthy Meal Planning: This class will review
60 minute class). activity (one 60 minute class). the current Nutrition Guidelines, meal planning, snacking sugges-
tions, and appropriate portion sizes. It emphasizes the positive per-
High Cholesterol Diabetes spectives needed to promote change, while practicing accountabili-
ty, mindful eating behaviors and tips on tackling the “Picky Eater.”
In this class, participants This class will address ways
will learn what cholesterol to balance carbohydrate CLASS 2
numbers mean, lifestyle intake to help participants Applying your Nutrition Knowledge: Participants learn how to read
OPA NETWORK GUIDE 2018
changes that can be made manage diabetes and prevent labels, healthy grocery shopping tips, food preparation, healthier
in order to help manage associated risk factors. We’ll choices when eating out and on the go, the importance of activity
cholesterol, and tips on how also review label reading, for optimum health and proper hydration.
APPENDIX I
to reduce unhealthy fats. In benefits of physical activity,
addition, we’ll cover label and common struggles such
reading and grocery shopping as holidays and traveling (one
tips (one 60 minute class). 90 minute class).
Healthy Living Congestive
Longer + Stronger Heart Failure (CHF) Healthy Lifestyles
This class will review nutrition In this class, we will discuss (Adult Weight Management)
and wellness for the aging what heart failure means and
adult. It will review the how patients can take action to
importance of managing your Attend these four classes and create a healthier lifestyle (four 60
manage their CHF. Topics also
health with regular medical minute classes).
include ways to help reduce
visits, attention to personal sodium intake, while still adding
safety, physical activity, proper CLASS 1
flavor to foods (without the extra
hydration and nutrition. Talking A Positive Perspective for Making Healthy Changes: Covers motiva-
salt), label reading, and tips to
points will include the changes tions for change, health benefits of change, establishing attainable
eating healthy while dining out
in nutritional needs as we age, goals, and barriers to success.
(one 60 minute class).
shopping tips, label reading
and healthy choices when CLASS 2
Supermarket Tours Knowing Your Numbers to Promote Healthy Outcomes: Includes
eating out or when challenged
with limited food preparation The first step in building learning more about Body Mass Index (BMI), determining Basal
abilities (one 60 minute class). a healthy eating plan is Metabolic Rate (BMR), and the importance of activity.
learning what to buy. During
Smoking Cessation CLASS 3
this class participants will
Stress Management be shown how to navigate In this class, participants learn Nutrition Basics and Healthy Meal Planning: Reviews Macro/Micro
Learn what stress is, its the supermarket aisles how to quit smoking for good by nutrients, meal planning ideas, healthy snacking, and portion sizes.
symptoms, and causes. We’ll and choose the healthiest developing a personal quit plan,
also review tips and strategies options. We will also review managing cravings and triggers, CLASS 4
for managing stress and food labels, ingredients, meal and finding other outlets for stress Apply Your Nutrition Knowledge: Addresses how to read food labels,
relaxation techniques(one 60 planning ideas and more management (two 60 minute healthy grocery shopping tips, food preparation, and healthier choic-
35 minute class). (one 60 minute class). classes). es when dining out.
36Talk Soft
Talksoft offers a variety of automated practice support services,
now at a reduced discount to new OPA physician customers.
Talksoft’s integrated phone, text and email messaging platform
will allow your practices the ability to reach a higher volume of
patients, with minimal effort from your office staff. For more in-
formation, visit their website at https://www.talksoftonline.com/
and please be sure to mention that you are an OPA partner to
receive the special discount.
APPENDIX II
OPA BENEFITS
Circuit Clinical
Circuit Clinical™ is a Buffalo-based company bringing the ben-
OPA NETWORK GUIDE 2018
efits of human drug studies within reach for busy, communi-
APPENDIX II
ty-based physicians and their patients. Circuit Clinical™ will pro-
vide your practice with a dedicated team to guide you through
the clinical research process. Clinical trials are performed at no
cost to practices and create an opportunity to generate reve-
nue. For more information, please visit their website at http://
www.circuitclinical.com/.
Health Wear
of WNY
Health Wear of WNY is a locally owned and operated, full
service, medical linen, and garment supplier. They provide both
rental and purchase option for gowns, scrubs, blankets, sheets,
towels and more. As an OPA practice, you can take advantage
of a special discount on rental services and on the purchase of
scrubs and lab coats. For more information, visit their website at
www.healthwearwny.com, and please be sure to mention that
37
you are an OPA partner to receive the special discount. 38APPENDIX III Prescription Drug Name Cost* Alternative Drug Cost*
High Cost/Low Impact medications per 30 day Rx per 30 day Rx or 1
or 1 unit unit or OTC price
Auvi-Q $4,566.25 E pinephrine pen $307.75
OTC Abreva or oral acyclovir/ $17.64 or
Denavir/Zovirax $715.32
valacyclovir $4.87/$8.25
ibuprofen 800mg + famotidine
Duexis $2,290.43 $1.70 + $7.56
20mg
diclofenac 1% gel or diclofenac
diclofenac 3% gel $1,624.39 $83.93 - $272.61
1.5% solution
Narcan or generic naloxone
Evzio $3,792.05 $122.18 - $35.17
injection
OTC lidocaine patches or
Flector patch $648.99 $26.27 - $9.99
cream (4%)
metformin ER (generic for
Glumetza $1,562.19 $3.87
Glucophage XL)
ciclopirox 8% topical sol or
Jublia $1,129.80 OTC Fungicure, Vicks VapoRub $27.72 - $19.99
OPA NETWORK GUIDE 2018
(56% cure rate) Tea Tree oil
ciclopirox 8% topical sol or
APPENDIX III
OTC Fungicure, Vicks VapoRub
Kerydin $720.90 $27.72 - $19.99
(56% cure rate), Tea Tree oil or
apple cider vinegar
generic metformin extended
metformin ER osm or MOD $863.27 release (generic for $3.87
Glucophage XR)
Zegerid OTC or omeprazole,
omeprazole/sod bicarb capsule $2,375.71 pantoprazole or lansoprazole $24.99 -$178.54
or esomeprazole
diclofenac 1% gel or diclofenac
Pennsaid 2% (diclofenac solution) $2,269.86 $44.09 - $291.66
1.5% solution
Sumavel (sumatriptan needleless sumatriptan or Zomig nasal
$1,303.52 $289.00 -$372.52
injector) spray
Take a look at Synera patch
Treximet
$922.26
$771.99
OTC lidocaine patch or OTC
4% lidocaine topicals
naproxen 500mg +
$26.27 - $9.99
$7.14 + $16.07
the High Cost
sumatriptan 100mg
naproxen 500mg + Nexium
Vimovo $2,275.43 $7.14 + $18.90
24hr OTC (covered on Rx)
and Low Impact
Wellbutrin XL/SR $1,574.18 bupropion XL/SR $23.42
OTC Abreva + OTC 1%
Xerese $1,136.13 $17.64 + $2.28
hydrocortisone cream
medications.
Zileuton ER $1,602.82 montelukast $7.56
39 40
* Prescription Drug cost taken from MRM database; OTC prices from local pharmacies (Walmart, Target, etc.) (prices subject to change)Notes
OPA NETWORK GUIDE 2018
APPENDIX
Created by OPA
© 2018 Optimum Physician Alliance (OPA). All rights reserved.
Printed in the U.S.A. This document contains proprietary information
of OPA; it is provided only for the reference of the individual
provided with this document and is protected by copyright law. This
document is not for distribution externally. The information in this
document is subject to change.
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