Achieving Platinum status means meeting five key performance indicators within one or more condition-specific categories.
Four Condition-specific Categories
ACE now breaks out facility evaluations into four condition-specific categories, with additional condition-specific categories possibly added in the future. This will allow for a truer “apples-to-apples” comparison of performance. To qualify for evaluation, a facility must be in-network and have a minimum number of qualified admissions to one of several levels of care at the facility. In addition to Acute Inpatient, ACE 2.0 now evaluates data from PHP and Residential levels of care. This was a change made to align with the feedback we’ve received from providers regarding ACE as well as closely examining overall facility performance from the last the years..
In order to qualify under a specific condition category, the facility must meet the following minimum admissions:
- 25 admissions for Mental Health (excluding eating disorder and autism admissions)
- 25 admissions for ETOH substance use
- 25 admissions for opioid and other substance use
- 10 admissions for eating disorder
Five performance indicators a Platinum facility must meet
- Rate of unplanned readmissions to any level of behavioral health care within 30 days of discharge from that same level of care
- Developed using the CMS methodology for hospital-wide readmissions
- Consumers must have continuous eligibility with Optum for 12 months prior to the initial admission
- Risk adjustment accounts for age, prior year and current admission behavioral health diagnoses, product type (Commercial, Medicaid, Medicare), Level of Care (LOC), and disability status
Follow-up After Hospitalization
- Rate of follow-up appointments kept within 7 days of discharge
- Optum’s standards are built upon NCQA’s HEDIS® methodology
- Follow-up must be with a mental health practitioner for outpatient, intensive outpatient or partial hospitalization treatment
- Consumers with a primary Substance Use Disorder diagnosis are excluded
- The percentage of acute inpatients admissions that step down to a lower LOC, such as RES, PHP, or IOP, at the same facility, and then step back up to a higher LOC during the treatment episode
Residual Length of Stay
- Difference between the raw Average Length of Stay (ALOS) and the case-mix adjusted ALOS
- Risk adjustment accounts for consumer age, gender, behavioral health diagnosis, product type, Level of Care (LOC) and community type (Rural, Suburban, Urban) among others considerations
Behavioral Health Spend Per Inpatient Episode
- Developed using the CMS methodology for Medicare Spending per Beneficiary (MSPB)
- Includes behavioral health costs from 3 days prior to admission at any level of care through 30 days after discharge from that level of care
- Consumers must have continuous eligibility with Optum for 93 days prior to admission
- Risk adjustment accounts for consumer age, gender, behavioral health diagnosis, Level of Care (LOC) and product type
ACE reviews several administrative measures that do not impact a facility’s overall score and rank. The purpose of these measures is to see if there are any ancillary functions outside of direct patient care that affect ACE scores.
- The rate at which a facility is using the ReviewOnline portal to submit Initial Reviews, Concurrent Reviews and Discharges.
Compliance with precertifcation
- This measures the number of admissions where a precertification occurred within 48 hours of the admission
Peer Review Rate
- This measures the percent of admissions in which one or more peer reviews occurs. This measure was previously used to evaluate a facility’s effectiveness but has been moved to the administrative category in response to provider feedback