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MDwise
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 2023 P4V program is outlined below.

1) Physician Pay for Value (P4V)

A) PMPs will be incentivized for reaching specific quality and access The P4V allows PMPs to receive up to $3.25 per member per month (pmpm) for Healthy Indiana Plan (HIP) members and $3.25 pmpm for Hoosier Healthwise members (HHW), 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:

  1. 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 with assigned membership. MDwise will also allow nurse practitioners and physician assistants who carry a panel of MDwise members to participate.
  2. 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.
  3. The PMP must have an annual average of one hundred (100) attributed members per month with those members assigned to the PMP for at least six (6) months of the measurement year.
  4. The PMP must have an open panel to accept new HHW and HIP members at least six (6) months of the measurement year. Please see FAQ #1 below for further detail.
  5. The PMP must participate in both HHW and HIP. Please see FAQ #2 below for further detail.
  6. Ninety percent (90%) of all claims must be submitted electronically during the measurement year.

2) Measures, Performance Goals and Awards

The attached table describes the program’s measures, performance goals and awards.

Measures and awards are reviewed periodically to ensure they bring the expected value to our members. These goals may be adjusted by MDwise annually if warranted.

3) Value Proposition Payment and Distribution

A) The P4V program calculation and payments will be distributed as follows:

  1. MDwise will determine the provider score for each measure based on MDwise specifications.
  2. MDwise will compare the provider score to the set goal for the measurement year.
  3. MDwise will calculate the pmpm membership as of December 31 of the measurement year.
  4. MDwise will pay these annual metrics within six (6) months of the end of the measurement year. Payments will be made directly to the PMP or the PMP group NPI.

Physician Pay for Value (P4V) FAQ

1) The requirement states a PMP must have an open panel to accept new patients at least 6 months of the measurement 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?

A) MDwise will track panel status in the Provider Repository.

2) 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?

 A) 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 because 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 because members are mostly children, that provider will still be able to earn P4V payments.

Download: Physician Pay for Value (P4V) Program.