Welcome to membership in Mountain Health Network! Building upon the legacy of Colorado Health Neighborhoods in Colorado and the value-based contracts acquired from Steward Health Care Network in Utah, MHN is dedicated to improving outcomes and making care more streamlined and affordable. We intend to do this through the adoption of evidence-based practices, investment in population health infrastructure, and, most importantly, through robust physician engagement. Over the last year our leadership team has assessed partnerships, evaluated infrastructure and analyzed resources so that we can engage in value-based arrangements that help us achieve the mission and vision of MHN.
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Member Selection and Participation Requirements
MHN physicians and advanced practice providers (APPs) are at the core of everything MHN does. By helping participants deliver high quality care, the network is better able to deliver the best care possible to the communities served. Participation in MHN focuses on achieving population health management, where the practices are connected to the infrastructure needed to support attributed patients at every stage of their health care journey. Outlined below is key information about participant criteria, membership selection, and evaluation, benefits and citizenship expectations.
Participation Criteria
Upon request for participation, MHN performs a comprehensive assessment to evaluate interest in joining the network. The following objective criteria will be used in evaluating and recruiting new practices, including but not limited to:
- Network gaps and adequacy
- Past performance in quality, cost and utilization measures
- Patient access
- Experience with value-based programs
- Non-exclusion
- Administrative ease and collaboration (i.e. communicates well with other practices on the care team, easy for patients to obtain appointments, etc)
- Other advantages/disadvantages the practice may bring to Network (i.e. reputation, population health resources, size)
Application Process
- Practice requests membership to MHN. [email protected]
- Practice is sent an intake form to be completed and returned to [email protected]
- Submitted documentation is reviewed against MHN requirements and criteria.
- If the practice is approved, MHN recommends to the MHN Board that the practice be approved for membership. Final MHN Board approval is required.
- Upon final approval, the practice is sent a Provider Participation Agreement (PPA).
Performance Requirements and Expectations
As an MHN participant, you have specific responsibilities to maintain your participation and citizenship in the network. These responsibilities include involvement in key aspects of population health management, quality measures, utilization, and citizenship as outlined below. The participation requirements and expectations that will help ensure all of MHN reach its goals include:
- Work with the population health and performance teams to review performance data and identify opportunities to improve in key quality and utilization metrics.
- Participate in MHN performance improvement programs.
- Dedicate practice resources to help close outstanding clinical and quality gaps.
- Engage with the MHN Continuing Care team to support the highest risk MHN patients.
- Participate in the Risk Adjustment program and ensure accurate documentation is completed.
- Coordinate patient care between MHN primary care physicians, specialists and acute care settings to ensure high-quality, coordinated, efficient services.
- Provide MHN with a complete and accurate practice roster upon enrollment and promptly within 30 days following any practice or staffing changes
- Inform [email protected] of changes in your practitioner roster within 30 days of any change
- Inform [email protected] of changes in your hospital or ACO affiliation within 30 days of any change
- Stay informed of network requirements, news, meetings, and changes by logging into the MHN microsite at least once a month.
- Participate in our quality programs by reviewing the data scorecard we provide you.
- Participate in MHN sponsored CME programs
An ACO is a value-based agreement between a payor and a healthcare network to improve the quality of outcomes and lower the total cost of care. This also means there is a potential for financial rewards that vary by payor (see financial incentives section, below). Learn more about our payor relationships in Colorado and Utah.
| Payors | Value Based Agreement | PMPM | Shared Savings | Downside Risk |
|---|---|---|---|---|
| Anthem | Commercial Enhanced Personal Healthcare (EPHC) | Yes | Yes |
No |
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Anthem |
MA | No | Yes | No |
| Aetna | Commercial CIA | Yes | Yes | No |
| Aetna | MA | Yes | Yes | No |
| United Healthcare | Value Plan* (CommonSpirit Associate Plan) | Yes | Yes | No |
| United Healthcare | Colorado Doctor's Plan | Yes | Yes | No |
| United Healthcare | Individual Exchange Product | Yes | Yes | No |
| Cigna | Commercial | TBD | TBD | TBD |
* Colorado Doctor’s Plan is by invitation only. Please contact Mountain Health Network to learn how to opt-in to this product.
* Cigna Commercial ACO product coming Q1 2025.
*United Value Plan-All practices are required to participate in this product.
| Payors | Value Based Agreement | PMPM | Shared Savings | Downside Risk |
|---|---|---|---|---|
| Aetna | Commercial CIA | No | Yes | No |
| Aetna | MA | No | Yes | No |
| Cigna | Commercial Collaborative Accountable Care | Yes | No | No |
| Humana | MA | No | Yes | Yes |
| Regence | Commercial Total Care | No | Yes | No |
| Regence | MA | No | Yes | No |
| Regence | Savewell Individual Exchange Program | Yes | Yes | Yes |
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Service Level |
Continuing Care |
Quality, Risk, and Population Health |
Data & Analytics |
|---|---|---|---|
| Foundational: Offered to all of our network members |
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| Advanced: Reduced PMPM distribution |
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| Advanced: Reduced PMPM distribution |
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In order to promote outcomes improvement, increased efficiencies and affordability of care for patients, MHN has selected specific quality, utilization and citizenship measures and thresholds that are aligned with all of MHN’s value-based agreements. These will be utilized in the MHN Incentive Award Program methodology. This methodology is subject to change to accommodate contracting changes and MHN will notify practices in advance of any proposed changes.
Additionally, the MHN incentive awards program was designed with the following principles in mind:
- Simplicity
- Distribute funds based on measurable performance
- Reduce complexity of distribution model
- Ensure funds flow transparency across the Network
- Ensure that funds held by MHN are enough to cover operating expenses for Foundational and Advanced levels of support services and hold reserves where necessary
Eligibility
- Must be a PCP or a primary care specialist who payers deem eligible to receive attribution. Primary Care includes:
- Family Medicine
- Pediatrics
- Internal Medicine
- Geriatric Medicine
- OB/GYN
- Compliance with PPA requirements
- Practice must be active with the network at time of distribution in order to receive PMPM payments.
Payor PMPM payments are designed to provide funds for care coordination and care management infrastructure. Depending on the level of service that our participating practices desire (as described in section D), PMPM percentage payments will differ for Foundational, Advanced and Maximum level support. Distributions are quarterly and based on PMPM paid by payer contract for attributed patients.
- For Foundational level support services offered by MHN, MHN will distribute 70% of gross PMPMs received from value-based agreements (VBAs) to independent practices.
- For Advanced support, including reviewing additional clinical documentation for open care gaps via EMR access and then closing those gaps with the payors, MHN will distribute 50% of gross PMPMs received from value-based agreements.
- For Maximum support services offered to practices by MHN, including Chronic Care Management and patient scheduling, MHN will distribute 30% of gross PMPMs received from VBAs
- Practices must fulfill the citizenship requirements to be eligible for PMPM payments (see scorecard table below)
Distribution of shared savings will be determined by performance in a specific set of Quality Measures, Utilization Measures, and Citizenship Requirements as outlined below. Practice must be active with the network at time of distribution in order to receive payment.
- Quality:
- Diabetes: Glycemic Status Assessment for Patients with Diabetes <8.0% (Commercial), <9.0% MA (10 points)
- Colorectal cancer and Breast cancer screenings (7.5 points each metric, 15 points total)
- Kidney health for patients with diabetics - KED (5 points)
- Child and Adolescent well child visits age 3-21yo (10 points)
- Well Child visits from birth to 15mos (10 points)
- Utilization:
- ED visits/1,000 (10 points)
- Readmissions (10 points)
- Citizenship:
- Provide MHN with physician and APP emails (not just practice managers) (5 points)
- Engage with the Quality and Provider Relations team to review patient care gap rosters and participate in quarterly (minimum) performance reviews (20 points)
- Timely updates to MHN of new or terminated providers and overall roster management (5 points)
- Minimum points out of 100 threshold to be eligible for shared savings distribution: 65 points (*this is achieving all citizenship metrics and hitting half of the quality and utilization thresholds)
- Share in 50% of shared savings
- 75 points achieved: 65% of shared savings
- 85 points achieved or higher: 80% of shared savings
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- No distributions will be made if MHN does not receive PMPM payments or does not earn shared savings.
- All payments are paid to the Tax ID, not individual providers.
- No payments will be made if the aggregate payment amount to the Tax ID is less than $100
- Payments will be made according to the following schedule:
- PMPM amounts - quarterly upon receipt of funds from the payer
- Shared savings: within 6 months reconciliation with payer
Although MHN has selected a limited number of metrics for quality measurement, payers still measure MHN according to numerous metrics. MHN will share all payer metrics with practices and any measurement reports received from payer. To achieve optimal results for each payer’s program, practices need to be aware of all metrics and strive to achieve key payer metrics.
Our financial incentives, as a member, include:
- Our ACO arrangements have two potential financial incentives:
- Per member per month (PMPM) payments
- Shared savings
- These are hand delivered or mailed every quarter and checks are ~9 month arrears.
- Allocate these incentives to support practice transformation.
Per Member Per Month Payments:
Payments are based on the number of patients enrolled in a plan with a value-based agreement. In most cases, the payors provide either an at-risk or non-risk PMPM payment. MHN passes a percentage of PMPM to groups/practices and MHN holds on to at-risk PMPM until reconciled to minimize individual group/practice risk.
Shared Savings Payments:
These are payments that can be achieved on some agreements when the total cost of patient care is less than expected for a given contract year. In addition to generating a surplus, the MHN network must also achieve specific quality measures to receive shared savings.
Have a question about your membership? An idea for a future training or educational opportunity?
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