4515.1 Beginning October 1, 2017, each FQHC that elects the APM rate and meets the standards outlined in Subsection 4515.2 may be eligible to participate in the FQHC performance payment program.
4515.2 To participate in the performance payment program, a FQHC must have elected the APM rate and must submit the following to DHCF by September 1, 2018 and annually thereafter:
(a) Letter of Intent to participate in the performance payment program;(b) Most current HRSA-approved quality improvement plan and any annual updates. In subsequent years, if the FQHC has not updated the HRSA-approved plan, then the FQHC shall provide DHCF with written notification that there have been no changes to the quality improvement plan; and(c) Annual performance data reporting measures described in Subsection 4514.1(a).4515.3 DHCF shall notify the FQHC if all requirements have been met no later than fifteen (15) business days after the receipt of the required materials.
4515.4 The performance payment program's baseline year will be the first year in which FQHC performance is measured to benchmark improvement in future years. The baseline year for FQHCs that elect to participate in the performance payment program shall begin October 1, 2017 and end on September 30, 2018. For FQHCs that elect to participate in the performance payment program after the initial baseline year, their first baseline year will begin on October 1st of the first year that an FQHC elects to participate in the performance program and end on September 30th.
4515.5 The measurement year (MY) is any year following an FQHC meeting the participation requirements described in Subsection 4515.2 and the completion of the baseline year; the first MY under the FQHC performance payment program will begin on October 1, 2018.
4515.6 Assessments and benchmarks will be based on comparing data collected in the baseline year to data collected during the first measurement year. During subsequent years, benchmarks will be based on performance during the prior measurement year.
4515.7 FQHCs shall be assessed based on either the attainment or the improvement of a defined threshold. If a FQHC did not attain its goal, then DHCF shall assess whether the FQHC improved from the previous measurement year. The following guidelines are set forth below:
(a) For measures #3 through 9, as described in Subsection 4514.1(b), a FQHC must achieve above the seventy-fifth (75th) percentile from the previous measurement year;(b) For measures #1 and 2, as described in Subsection 4514.1(b), the improvement benchmark will only be assessed on attainment of the goal. Specifically, whether the FQHC has provided DHCF with documentation demonstrating they have met the specifications outlined in the measures;(c) For measures # 3 through 9 as described in Subsection 4514.1(b), where improvement can be measured, the improvement benchmark will be a statistically significant improvement in the performance of a measure as compared to the prior year's performance. A statistically significant improvement has a probability of 0.05 that the improvement was not due to random error. DHCF shall perform the appropriate statistical analysis (e.g., t-test) to determine that the performance between measurement years is a result that cannot be attributed to chance.4515.8 DHCF shall provide written notification of the attainment and individualized improvement thresholds to each participating FQHC no later than one hundred and eighty (180) calendar days after the conclusion of the previous MY after all performance measures are received and validated.
4515.9 A FQHC may opt to aggregate its beneficiary population with another FQHC's population for the purposes of calculating attainment of a performance measure or improvement on any of the required measures described in Subsection 4514.1(b) subject to the following terms and conditions:
(a) Each FQHC must notify DHCF of their selection of the aggregation option no later than September 1st prior to the baseline or new measurement year;(b) FQHCs opting to aggregate their populations together must do so for calculation of all measures during a given baseline or measurement year;(c) Each FQHC shall report data that is identifiable for the FQHC's individual performance, along with the aggregated data;(d) A FQHC shall elect the option to aggregate annually and may change their selection, including opting against pooling or opting to pool with a different FQHC, on an annual basis; and(e) When a FQHC has opted to aggregate beneficiaries, performance is measured for the aggregated FQHCs throughout the duration of the performance period unless one of the aggregated entities withdraws from the FQHC program during the performance period. If one of the FQHCs that has opted to aggregate beneficiaries withdraws before the performance period is complete, the remaining FQHC's performance will be measured based on the remaining FQHC's beneficiaries.4515.10 For MY2019, beginning on October 1, 2018, the amount of the performance bonus funding pool available for payment shall be the difference between all of the District's FQHCs' uncapped administrative cost and the District's FQHCs' capped administrative cost reflected in 2013 audited cost reports.
4515.11 For MY2020 and future years, the amount of the performance bonus funding pool shall be the amount available in the previous year pool, adjusted annually by the percentage increase in the Medicare Economic Index, established in accordance with Section 1842(i)(3) of the Social Security Act.
4515.12 DHCF shall notify the FQHCs of the performance bonus funding pool amount no later than ninety (90) calendar days prior to October 1, 2018, and annually thereafter ninety (90) calendar days before October 1st.
4515.13 The available funds in the annual performance bonus funding pool will be allocated to each participating FQHC that qualifies for a performance award as described in Subsection 4515.14.
4515.14 A participating FQHC's performance payment shall be the FQHC's maximum annual bonus payment as described in Subsection 4515.15, multiplied by the FQHC's annual performance percentage using the methodology described in Subsection 4515.17.
4515.15 Each participating FQHC's maximum annual bonus payment shall be the FQHC's market share determined in accordance with Subsection 4515.16, multiplied by the annual performance bonus funding pool, plus any additional allocation calculated pursuant to Subsection 4515.16(c).
4515.16 The market share shall be calculated as follows:
(a) In cases where there are no statistical outliers, the market share for a participating FQHC shall be the number of the FQHC's unique Medicaid beneficiaries that received primary care services from the FQHC during the baseline or previous measurement year, divided by the total number of Medicaid beneficiaries who received primary care services from the participating FQHCs during the baseline or previous measurement year;(b) In cases where there is a statistical outlier, the market share calculation shall be determined as follows: (1) DHCF shall apply a cap for FQHCs whose market share is considered a statistical outlier. A statistical outlier is any FQHC that has a market share less than the lower bound or exceeding the upper bound. The upper-bound and lower-bound outlier shall be determined in the following manner: (i) Calculate the quartiles of the number of unique Medicaid beneficiaries that received primary care services from the FQHC. The quartiles are the three (3) points that divide the data set into four (4) equal groups, each group comprising a quarter (1/4) of the data. The first quartile is defined as the middle number, otherwise known as the median, between the smallest number and the median of the data set. The second quartile is the median of the data. The third quartile is the middle value between the median and the highest value of the data set;(ii) Calculate the interquartile range (IQR) by subtracting the first quartile from the third quartile;(iii) Multiply the IQR by one point five (1.5) to obtain the IQR factor;(iv) Add the third quartile to the IQR factor to calculate the upper bound; and(v) Subtract the IQR factor from first quartile to calculate the lower bound.(2) If an FQHC is a statistical outlier because its total number of beneficiaries exceeds the upper bound, the FQHC's market share will be the median of the upper bound number and the FQHC's actual number of unique Medicaid beneficiaries that received primary care services in the baseline or previous measurement year divided by the total number of Medicaid beneficiaries who received primary care services from the participating FQHCs during the baseline or previous measurement year;(3) If an FQHC is a statistical outlier because its number of beneficiaries is less than the lower bound, the outlier FQHC's market share will be the lower bound number, divided by the total number of Medicaid beneficiaries who received primary care services from the participating FQHCs during the baseline or previous measurement year; and(4) For FQHCs that are not statistical outliers participating during a measurement year when there are statistical outliers, the non-out lier FQHC's market share shall be calculated in same manner as described in subparagraph (a); and(c) If there is an upper bound outlier, and there are remaining performance payment pool after all funds have been disseminated according to market share, the remaining additional funds shall be proportionally allocated to the non-outlier FQHCs based on the number of that FQHCs primary care beneficiaries divided by the total number of non-outlier FQHC beneficiaries.4515.17 To determine the FQHC's annual performance percentage for each year, DHCF shall score each participating FQHC's performance in three measurement domains. This scoring will be determined as follows:
(a) A maximum of one hundred (100) points will be awarded to each FQHC across the three (3) measurement domains (i.e., patient-centered care access (measures 1-3), transitions of care (measures 4-6), and utilization (measures 7-9) as described in Subsection 4514.1(b).(b) Each measure in the domain is assigned points by dividing the total points by the number of measures in each domain. Points for each domain for the first three (3) MYs are described in the table set forth in Subsection 4515.17(c). Future point distribution for measurement attainment or improvement will be provided by DHCF to FQHCs by a transmittal on an annual basis ninety (90) calendar days before October 1.(c)FQHC Performance Measure Point Distribution Methodology |
MY 2019 | MY 2020 | MY 2021 |
Total Patient-Centered Access Domain Points (allowed points per measure) | 20 (10) | 15 (7.5) | 10 (5) |
Total Clinical Process Domain Points | 30 (7.5) | 25 (6.25) | 20 (5) |
Total Utilization Domain Points | 50 (16.67) | 60 (20) | 70 (23.3) |
Total | 100 | 100 | 100 |
(d) Points for each measure shall be awarded in cases where an FQHC meets either the attainment or improvement benchmark based on the prior measurement year's performance as described below:(1) An FQHC shall receive the allowed points per measure as described in Subsection 4515.17(c) if they submit documentation for the Extended Hours and 24/7 Access measures (e.g., ten (10) points in MY2019 for each of these measures);(2) An FQHC shall receive points if they have met or exceeded the seventy- fifth (75th) percentile attainment benchmark.(3) An FQHC performing below the attainment benchmark may be able to receive the allowed points per measure as described in Subsection 4515.17(c) for each measure if it has met its improvement threshold described in Subsection 4515.7(c).(4) If an FQHC neither attains nor improves performance on a given measure, zero points will be awarded for that measure.(e) The annual performance percentage for each qualifying FQHC shall be calculated using the following methodology:(1) Sum points awarded for each measure in the domain to determine the domain totals;(2) Sum domain totals to determine total performance points;(3) Divide total performance points by the maximum allowed points to determine the annual performance percentage.4515.18 If participating FQHCs have aggregated beneficiaries together for determination of performance, the award percentage for the aggregated entities shall be applied to each FQHC's maximum bonus amount to determine the FQHC's performance award individually.
4515.19 Beginning with MY2019, and annually thereafter, performance payments shall be calculated and distributed no later than 180 calendar days after the conclusion of each measurement year once all performance measures are received and have been validated.
D.C. Mun. Regs. tit. 29, r. 29-4515
Final Rulemaking published at 64 DCR 907 (2/2/2018)