Physician Pay For Value

 

Physician Pay for Value (P4V) Program

 
MDwise is committed to providing high quality, cost-effective health care to our members. By establishing our P4V Program, MDwise will maintain a strong partnership with our PMPs and Behavioral Health providers, resulting in improved quality and access to health care services. The goal of the program is to improve access and health outcomes for all members. Effective January 1, 2019 the MDwise Pay for Outcomes (P4O) program was replaced with the MDwise Pay for Value Program (P4V). The 2021 P4V program is outlined below.
 
  1. Physician Pay for Value (P4V)
    • PMPs will be incentivized for reaching specific quality and access metrics. The P4V allows the PMPs to receive up to $3.00 per member per month (pmpm) for HIP members and $3.25 per member per month (pmpm) for HHW members, to be awarded to individual providers based upon their attributed MDwise membership and achievement of the defined metric. The actual award is subject to the following conditions:
      • Per State requirements, providers that may serve as PMPs include internal medicine physicians, general practitioners, family medicine physicians, pediatricians, obstetricians, gynecologists and endocrinologists if primarily engaged in internal medicine. MDwise will also allow nurse practitioners and physician assistants who carry a panel of MDwise members to participate.
      • The PMP must be contracted with MDwise for at least six (6) months of the measurement year and be contracted at the time of the payment.
      • The PMP must have an annual average of 100 attributed members per month and assigned to the PMP for at least six (6) months of the measurement year.
      • The PMP must have an open panel to accept new MDwise HHW and HIP members at least six (6) moths of the measurement year. Please see FAQ #1 below for further detail.
      • The PMP must participate in both HHW and HIP. Please see FAQ #2 below for further detail.
      • Ninety percent (90%) of all claims must be submitted electronically during the measurement year.
      • Behavioral Health providers may receive up to $1.00 pmpm for HHW and HIP members.
  2. Measures, Performance Goals and Awards
    This table describes the program’s measures, performance goals and awards. Measures and awards are reviewed periodically to ensure they are bringing the expected value to our members. These goals may be adjusted by MDwise annually if warranted.
  3. Value Proposition Payment and Distribution
    • The P4V program calculation and payments will be distributed as follows:
      • MDwise will determine the provider score for each measure based on MDwise specifications.
      • MDwise will compare the provider score to the set goal for the measurement year.
      • MDwise will calculate the pmpm for membership as of December 31 of the measurement year.
      • MDwise will pay these annual metrics within six (6) months of the end of the next measurement year. Payments will be made directly to the PMP, inpatient facility or the PMP group NPI.
 

Physician Pay for Value (P4V) FAQ


The requirement states a PMP must have an open panel to accept new patients at least 6 months out of the year. We have panels who have been consistently full and are unable to accept new patients, but they are technically ‘open’ as opposed to being ‘on hold.’ If the restriction is solely regarding providers being on ‘hold’, how will MDwise be able to tell the difference?
 
MDwise will track panel status in the Provider Repository.
 
The requirement states a PMP must participate in both HHW and HIP. Does this apply to pediatric providers as PMPs in the HIP program or internal medicine PMPs in HHW?

The requirement does not apply to all provider types. If a provider practice area is not included in both programs, that fact alone will not disqualify a provider from receiving P4V payments. For example, if a HHW pediatrician does not participate in the HIP program since members are all 19 years old or older, that provider will still be able to earn P4V payments. Likewise, if a HIP internal medicine physician does not participate in HHW since members are mostly children, that provider
will still be able to earn P4V payments.

If a family practice PMP also performs OB services, will that PMP be eligible for the HIP OB Postpartum and Timeliness of Prenatal Care metrics?

Yes, a family practice PMP who also performs OB services for HIP members will be eligible to earn P4V payments for meeting the OB Postpartum and Timeliness of Prenatal Care metrics.
 
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