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.

Table 1. Default Time Periods
Display Name Start Date End Date

Calendar Year 2018

2018-01-01

2018-12-31

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.

Table 2. Schedule Definition
Code Description Type

PERCENTAGE BASED RATES

Payment percentage based rates

Rate
Table 3. 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.

Table 4. 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.

Table 5. Rate Schedule
Code Schedule Definition Amount Interpretation Currency

MEMBER PAYMENT AMOUNTS

PERCENTAGE BASED RATES

Contract Calculation Period

$
Table 6. 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.

Table 7. Schedule Definition
Code Description Type

PCR THRESHOLD BASED

PCR threshold based adjustments

Adjustment
Table 8. 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.

Table 9. Adjustment Schedule
Code Schedule Definition Adjust. Type

PCR THRESHOLD ADJUSTMENT

PCR THRESHOLD BASED

Contract
Table 10. 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.

Table 11. 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.

Table 12. Contract Calculation Periods
Start Date End Date

2018-01-01

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

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.

Table 13. 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.

Table 14. Contract Time Periods
Display Name Start Date End Date

Contract Year 2018

2018-01-01

2018-12-31

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.

Table 15. 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.

Table 16. 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.

Table 17. Contract Alignments
Member Payment Amount Start Date End Date

John Smith

10.00

2018-01-01

2018-12-31

Alice Jones

8.00

2018-01-01

2018-12-31

Members

The members that are aligned to the contract have specific characteristics which are important in the context of this contract.

Table 18. Members
Name Code Date of Birth ASO Group Assigned Providers

John Smith

M631893

1984-08-08

Rodrigo Martinez (PCP from 2015-01-01)

Alice Jones

M259012

1951-10-06

ASO GROUP 1

Michael Lawrence (PCP from 2014-01-01)

Providers

The providers that are assigned to the above specified members have specific characteristics which are important in the context of this contract.

Table 19. Providers
Name Code Provider Group

Rodrigo Martinez

P10654

PCP PROVIDERS (from 2015-01-01)

Michael Lawrence

P33421

PCP PROVIDERS (from 2013-01-01)

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.

Table 20. Attributions
Member Calc. Period Start Date End Date

John Smith

January 2018

2018-01-01

2018-01-31

Calculation Results

For every attribution a calculation result with calculation result lines is created, based on the configured rate and adjustment schedules.

Table 21. Calculation Results
Member Calc. Period Attr. Start Date Rate Adj. Result Vers. Rev.

John Smith

January 2018

2018-01-01

10.00 $

0.00 $

10.00 $

1

N

The calculation result lines are created per rate/adjustment component.

Table 22. Calculation Result Lines
Calculation Result Seq. Schedule Am. Inter. Retr. Value Input Am. Result

John Smith - January 2018 (2018-01-01) - V1

1

MEMBER PAYMENT AMOUNTS

CCP

10.00 $

10.00 $

Financial Results

For every calculation result a base financial object is created.

Table 23. Base Financial Objects
Member Code Contract Code Calc. Period Start Date Attr. Start Date

M631893

ACO CONTRACT

2018-01-01

2018-01-01

For every base financial object a financial transaction is created.

Table 24. Financial Transactions
Base Financial Object Total Am. Rev. Vers.

M631893 - ACO CONTRACT - January 2018 (2018-01-01)

10.00 $

N

1

The financial transaction details are created per rate/adjustment component.

Table 25. Financial Transaction Details
Financial Transaction Seq. Component Code Counterparty Code[1] Amount

M631893 - ACO CONTRACT - January 2018 (2018-01-01) - 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 2018-01-01) 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 2018-01-01) 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.

Table 26. Calculation Results
Member Calc. Period Attr. Start Date Rate Adj. Result Vers. Rev.

John Smith

January 2018

2018-01-01

10.00 $

0.00 $

10.00 $

1

Y

John Smith

January 2018

2018-01-01

10.00 $

-1.50 $

8.50 $

2

N

New calculation result lines are created for the new calculation results.

Table 27. Calculation Result Lines
Calculation Result Seq. Schedule Am. Inter. Retr. Value Input Am. Result

John Smith - January 2018 (2018-01-01) - V2

1

MEMBER PAYMENT AMOUNTS

CCP

10.00 $

10.00 $

John Smith - January 2018 (2018-01-01) - 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.

Table 28. Financial Transactions
Base Financial Object Total Am. Rev. Vers.

M631893 - ACO CONTRACT - January 2018 (2018-01-01)

-10.00 $

Y

1

M631893 - ACO CONTRACT - January 2018 (2018-01-01)

8.50 $

N

2

New and reversal financial transaction details are created for the above specified financial transactions.

Table 29. Financial Transaction Details
Financial Transaction Seq. Component Code Counterparty Code[1] Amount

M631893 - ACO CONTRACT - January 2018 (2018-01-01) - V1 - Reversed Y

1

MEMBER PAYMENT AMOUNTS

ACO

-10.00 $

M631893 - ACO CONTRACT - January 2018 (2018-01-01) - V2 - Reversed N

1

MEMBER PAYMENT AMOUNTS

ACO

10.00 $

M631893 - ACO CONTRACT - January 2018 (2018-01-01) - V2 - Reversed N

2

PCR THRESHOLD ADJUSTMENT

ACO

-1.50 $
1. The counterparty code is stored on the related financial transaction detail process data records