Scenario 4
In this capitation scenario a payment arrangement for calendar year 2018 is made between the healthcare payer and an Accountable Care Organization (ACO) for payment of care coordination fees (monthly rate amounts per member). This rate amount is calculated based on a percentage of the member payment amount provided in the member data. However the fees will not be paid for members of Administrative Services Only (ASO) groups. At the end of the year, the scores from a performance metric (Patient All Cause Readmissions) are uploaded. If the ACO’s score does not meet a specific threshold, the ACO will only receive 85% of the care coordination fee. Since payments were already made in prior months, if the ACO does not meet the score, a portion of the already paid fees needs to be clawed back.
Configuration
In the sections below the default time periods, rates, adjustments and capitation contract that are configured for the above specified scenario are described.
Default Time Periods
The payment arrangement is made for calendar year 2018, so a default time period is configured for calendar year 2018. The rates and adjustments that are specified in the sections below are in the context of this default time period.
Default Time Periods
| Display Name | Start Date | End Date |
|---|---|---|
Calendar Year 2018 |
01-01-2018 |
12-31-2018 |
Rates
The base rate amount that is paid per member is based on a payment percentage, so a schedule definition with a payment percentage dimension is configured.
Schedule Definition
| Code | Description | Type |
|---|---|---|
PERCENTAGE BASED RATES |
Payment percentage based rates |
Rate |
Schedule Dimensions
| Display Name | Field Name | Type | Usage |
|---|---|---|---|
Payment Percentage |
paymentPercentage |
Generic (nr) |
Value |
To fetch the payment amount from the member information and calculate a percentage of it, a dynamic logic function with signature Rate is configured.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
MEMBER PAYMENT AMOUNT |
Rate |
def contractAlignments = attribution.person.contractAllignmentList.asOf(referenceDate) for contractAlignment in contractAlignments( if (contractAlignment.capitationContract.code == attribution.contractCalculationPeriod.capitationContract.code) return Money.create(contractAlignment.paymentAmount).percentage(rateScheduleLine.paymentPercentage) ) |
A rate schedule is configured with rate schedule lines for the default time period "Calendar Year 2018", based on the above specified schedule definition.
Rate Schedule
| Code | Schedule Definition | Amount Interpretation | Currency |
|---|---|---|---|
MEMBER PAYMENT AMOUNTS |
PERCENTAGE BASED RATES |
Contract Calculation Period |
$ |
Rate Schedule Lines
| Payment Percentage | Rate |
|---|---|
100 |
MEMBER PAYMENT AMOUNT |
Adjustments
A Patient All Cause Readmissions (PCR) threshold adjustment applies to the base rate amount, meaning that the ACO is paid less if the threshold is not met, so a schedule definition with a dimension for PCR Threshold Not Met is configured.
Schedule Definition
| Code | Description | Type |
|---|---|---|
PCR THRESHOLD BASED |
PCR threshold based adjustments |
Adjustment |
Schedule Dimensions
| Display Name | Field Name | Type | Usage |
|---|---|---|---|
PCR Threshold Not Met |
pcrThresholdNotMet |
Dynamic Field (contract.pcrThresholdNotMet) |
Value |
An adjustment schedule is configured with adjustment schedule lines for default time period "Calendar Year 2018", based on the above specified schedule definition. This adjustment only applies to specific contracts so the adjustment type is set to Contract.
Adjustment Schedule
| Code | Schedule Definition | Adjust. Type |
|---|---|---|
PCR THRESHOLD ADJUSTMENT |
PCR THRESHOLD BASED |
Contract |
Adjustment Schedule Lines
| PCR Threshold Not Met | Adjustment |
|---|---|
Y |
-15 % |
Capitation Contract
A capitation contract is configured that uses the MEMBER PAYMENT AMOUNTS rate schedule. Payment is made to the ACO (specified as the contracting organization), so the attribution type of the contract is set to Member. The PCP Threshold Not Met is a time valid dynamic field configured on the contract; initially this field is not set.
Capitation Contracts
| Code | Description | Attribution Type | Rate Schedule | Contracting Organization | Contract Alignment Filter Condition | PCP Threshold Not Met (2018) |
|---|---|---|---|---|---|---|
ACO CONTRACT |
Accountable Care Organization Contract |
Member |
MEMBER PAYMENT AMOUNTS |
ACO |
CAF ASO GROUP |
In the sections below the contract calculation periods, contract provider filter rules, contract adjustments, contract rate splits and dynamic logic that are part of this contract are described.
Contract Calculation Periods
Payments are made monthly so for each month in 2018 a contract calculation period is configured.
Contract Calculation Periods
| Start Date | End Date |
|---|---|
01-01-2018 |
01-31-2018 |
02-01-2018 |
02-28-2018 |
03-01-2018 |
03-31-2018 |
04-01-2018 |
04-30-2018 |
05-01-2018 |
05-31-2018 |
06-01-2018 |
06-30-2018 |
07-01-2018 |
07-31-2018 |
08-01-2018 |
08-31-2018 |
09-01-2018 |
09-30-2018 |
10-01-2018 |
10-31-2018 |
11-01-2018 |
11-30-2018 |
12-01-2018 |
12-31-2018 |
Contract Provider Filter Rules
The contract only applies to primary care providers that are in the PCP PROVIDERS network, so a contract provider filter rule is configured with a PCP provider assignment type and a PCP PROVIDERS provider group.
Contract Provider Filter Rules
| Sequence | Provider Assignment Type | Provider Group |
|---|---|---|
1 |
PCP |
PCP PROVIDERS |
Contract Adjustments
The adjustment schedules of adjustment type Contract are added to contracts in the context of contract time periods, so a contract time period for calendar year 2018 is configured.
Contract Time Periods
| Display Name | Start Date | End Date |
|---|---|---|
Contract Year 2018 |
01-01-2018 |
12-31-2018 |
The PCR threshold adjustment is added to the contract in the context of the above configured contract time period. It applies to the base rate amount, so the sequence is set to 1.
Contract Adjustments
| Contract Time Period | Adjustment Schedule | Sequence |
|---|---|---|
Contract Year 2018 |
PCR THRESHOLD ADJUSTMENT |
1 |
Contract Rate Splits
The entire result amount is paid to the ACO, so no rate spits are needed. Setting the ACO as the counterparty on the financial transaction details is done in the financial transaction dynamic logic.
Dynamic Logic
The dynamic logic condition and function that are used within the contract is configured as specified below.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
CAF ASO GROUP |
Contract Alignment Filter |
return contractAlignment.person.asoGroup == null |
FT |
Financial Transaction |
for financialTransactionDetail in financialTransaction.financialTransactionDetailList( financialTransactionDetail.financialTransactionDetailProcessData.counterpartyCode = calculationResult.contractCalculationPeriod.capitationContract.organization.code ) financialTransaction.financialTransactionProcessData.finTransactionSetGrouping = calculationResult.contractCalculationPeriod.capitationContract.code return financialTransaction |
Contract Alignments
A subset of the contract alignments, members and providers that are in the context of this contract are specified in the sections below.
Alignments
In the table below a number of contract alignments that apply to the contract are specified.
Contract Alignments
| Member | Payment Amount | Start Date | End Date |
|---|---|---|---|
John Smith |
10.00 |
01-01-2018 |
12-31-2018 |
Alice Jones |
8.00 |
01-01-2018 |
12-31-2018 |
Members
The members that are aligned to the contract have specific characteristics which are important in the context of this contract.
Members
| Name | Code | Date of Birth | ASO Group | Assigned Providers |
|---|---|---|---|---|
John Smith |
M631893 |
08-08-1984 |
Rodrigo Martinez (PCP from 01-01-2015) |
|
Alice Jones |
M259012 |
10-06-1951 |
ASO GROUP 1 |
Michael Lawrence (PCP from 01-01-2014) |
Providers
The providers that are assigned to the above specified members have specific characteristics which are important in the context of this contract.
Providers
| Name | Code | Provider Group |
|---|---|---|
Rodrigo Martinez |
P10654 |
PCP PROVIDERS (from 01-01-2015) |
Michael Lawrence |
P33421 |
PCP PROVIDERS (from 01-01-2013) |
Calculation
When the Capitation Calculation activity is run for the contract with a calculation input date in January 2018, a number of attributions, calculation results and financial results are created based on the contract alignments and the configuration of the contract.
Attributions
One attribution is created in the context of the contract alignments that are specified above. Alice Jones is part of the ASO group, so no attribution is created for her.
Attributions
| Member | Calc. Period | Start Date | End Date |
|---|---|---|---|
John Smith |
January 2018 |
01-01-2018 |
01-31-2018 |
Calculation Results
For every attribution a calculation result with calculation result lines is created, based on the configured rate and adjustment schedules.
Calculation Results
| Member | Calc. Period | Attr. Start Date | Rate | Adj. | Result | Vers. | Rev. |
|---|---|---|---|---|---|---|---|
John Smith |
January 2018 |
01-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
1 |
N |
The calculation result lines are created per rate/adjustment component.
Calculation Result Lines
| Calculation Result | Seq. | Schedule | Am. Inter. | Retr. Value | Input Am. | Result |
|---|---|---|---|---|---|---|
John Smith - January 2018 (01-01-2018) - V1 |
1 |
MEMBER PAYMENT AMOUNTS |
CCP |
10.00 $ |
10.00 $ |
Financial Results
For every calculation result a base financial object is created.
Base Financial Objects
| Member Code | Contract Code | Calc. Period Start Date | Attr. Start Date |
|---|---|---|---|
M631893 |
ACO CONTRACT |
01-01-2018 |
01-01-2018 |
For every base financial object a financial transaction is created.
Financial Transactions
| Base Financial Object | Total Am. | Rev. | Vers. |
|---|---|---|---|
M631893 - ACO CONTRACT - January 2018 (01-01-2018) |
10.00 $ |
N |
1 |
The financial transaction details are created per rate/adjustment component.
Financial Transaction Details
| Financial Transaction | Seq. | Component Code | Counterparty Code[1] | Amount |
|---|---|---|---|---|
M631893 - ACO CONTRACT - January 2018 (01-01-2018) - V1 - Reversed N |
1 |
MEMBER PAYMENT AMOUNTS |
ACO |
10.00 $ |
Recalculation
Let’s consider that the PCP Threshold Not Met (time valid dynamic field) value for 2018 on the contract is retroactively (effective from 01-01-2018) changed from null to Y. This change is monitored by a configured change event rule of type Recalculation, which results in the creation of a contract mutation. When the Capitation Calculation activity is run for the contract with a calculation input date in January 2019 (and look back date 01-01-2018) new results are of course created for January 2019, but because a contract mutation exists the existing results are reversed and new results are created.
The existing calculation results are reversed and new calculation results are created.
Calculation Results
| Member | Calc. Period | Attr. Start Date | Rate | Adj. | Result | Vers. | Rev. |
|---|---|---|---|---|---|---|---|
John Smith |
January 2018 |
01-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
1 |
Y |
John Smith |
January 2018 |
01-01-2018 |
10.00 $ |
-1.50 $ |
8.50 $ |
2 |
N |
New calculation result lines are created for the new calculation results.
Calculation Result Lines
| Calculation Result | Seq. | Schedule | Am. Inter. | Retr. Value | Input Am. | Result |
|---|---|---|---|---|---|---|
John Smith - January 2018 (01-01-2018) - V2 |
1 |
MEMBER PAYMENT AMOUNTS |
CCP |
10.00 $ |
10.00 $ |
|
John Smith - January 2018 (01-01-2018) - V2 |
2 |
PCR THRESHOLD ADJUSTMENT |
-15 % |
10.00 $ |
-1.50 $ |
Reversal financial transactions for the reversed calculation results and new financial transactions for the new calculation results are created.
Financial Transactions
| Base Financial Object | Total Am. | Rev. | Vers. |
|---|---|---|---|
M631893 - ACO CONTRACT - January 2018 (01-01-2018) |
-10.00 $ |
Y |
1 |
M631893 - ACO CONTRACT - January 2018 (01-01-2018) |
8.50 $ |
N |
2 |
New and reversal financial transaction details are created for the above specified financial transactions.
Financial Transaction Details
| Financial Transaction | Seq. | Component Code | Counterparty Code[1] | Amount |
|---|---|---|---|---|
M631893 - ACO CONTRACT - January 2018 (01-01-2018) - V1 - Reversed Y |
1 |
MEMBER PAYMENT AMOUNTS |
ACO |
-10.00 $ |
M631893 - ACO CONTRACT - January 2018 (01-01-2018) - V2 - Reversed N |
1 |
MEMBER PAYMENT AMOUNTS |
ACO |
10.00 $ |
M631893 - ACO CONTRACT - January 2018 (01-01-2018) - V2 - Reversed N |
2 |
PCR THRESHOLD ADJUSTMENT |
ACO |
-1.50 $ |