Provider Peer Grouping
Monthly Updates
June 14, 2010
Katie Burns
What is Provider Peer Grouping?
• A system for publicly comparing provider
performance on cost and quality
– …a uniform method of calculating providers'
relative cost of care, defined as a measure of
health care spending including resource use and
unit prices, and relative quality of care…
(M.S.§62U.04, Subd. 2)
– a combined measure that incorporates both
provider risk-adjusted cost of care and quality of
care… (M.S.§62U.04, Subd. 3)
What Types of Provider Peer Grouping
Needs to be Developed?
1. Total Care
2. Care for Specific Conditions
The commissioner shall develop a peer grouping
system for providers based on a combined
measure that incorporates both provider riskadjusted cost of care and quality of care, and for
specific conditions… (M.S.§62U.04, Subd. 3)
How will Provider Peer Grouping
Results be Reported?
• Results distributed confidentially to
providers first
• Providers have opportunity to appeal
results based on accuracy of data
• Results will subsequently be publicly
reported
Uses of Provider Peer Grouping
Information (M.S.§62U.04, Subd. 9)
‘ Commissioner of Finance - to strengthen incentives for
members of the state employee group insurance program to
use high-quality, low-cost providers;
‘ All Political Subdivisions that Offer Health Benefits - must
offer plans that differentiate providers on their cost and quality
performance and create incentives for members to use betterperforming providers;
‘ All Health Plan Companies - to develop products that
encourage consumers to use high-quality, low-cost providers
‘ Health Plan Companies in the Individual Market or the
Small Employer Market - must offer at least one health plan
that establishes financial incentives for consumers to choose
higher-quality, lower-cost providers through enrollee costsharing or selective provider networks.
Uses of Provider Peer Grouping
Information
• DHS now required to use peer
grouping results as basis of a
differential payment system
PPG: New Statutory
Requirements on Timelines
• Total care reports to be released by
October 15, 2010 with public reporting to
occur beginning January 1, 2011
• Condition specific reports to be released
by January 1, 2011 with public reporting to
occur beginning March 30, 2011
PPG: New Statutory Requirements on
Validity and Reliability
• MDH required to ensure validity and
reliability of results
• Best available evidence and research
• Establishment of a minimum reliability
threshold in collaboration with providers
and required users of data
• If more time is needed to ensure these
criteria are met, MDH may delay the
dissemination of results
PPG: New Statutory Requirements on
Provider Review and Appeals
• Providers now have 30 days to review data and
initiate an appeal
• If they appeal, providers must provide reason
why they believe data is inaccurate; provide
supporting evidence and cooperate with MDH in
reaching resolution to issue
• Appeals will be considered withdrawn if these
criteria are not met
• MDH may not publish data that is being appealed
by a specific provider
PPG: New Timelines for Required
Users of Data
• Required users will have 12 months from
when data is published to begin using results
to encourage use of higher quality, lower
cost providers
• DHS no longer required to identify bottom 10
percent; however, still required to use results
for develop differential payment system
based on PPG results
Current Status of Project
• MDH signed a two-year contract with
Mathematica Policy Research to
conduct analysis and share/explain
results to providers
• Many technical decisions remain, and
must be informed by analysis of the
data
PPG: Progress to Date
• Software needed for total care analysis acquired
• Approach clarified for specific condition analysis
• MDH and Mathematica Policy Research working to
understand available data
• Finalizing data collection from major data submitters
• Working through the challenges of large data sets
• Timeline will be delayed somewhat due to these
issues; MDH making progress where possible and
working with test data
Rapid Response Team
• MDH convened this group to provide input
on critical issues
• Approach for specific condition analysis
• Methodology for attributing patients to providers
• Mechanisms to combine information on resource
use and unit prices
• Design and weighting of individual quality
measures into composite quality score
• Treatment of non-users and outlier costs
Approach for Condition-Specific
Analysis
• Diabetes
• Asthma
• Coronary artery disease
• Congestive heart failure
• Total knee replacement
• Pneumonia
Approach for Specific Condition
Analysis
• Use a “total care minus obviously unrelated care”
(e.g. trauma) for people with conditions of interest
– Peer group and publicly report on these results
• Use Episode Treatment Grouper for pneumonia and
Procedural Episode Grouper for total knee
replacement and peer group on those results
• ETG level results for chronic conditions will be
distributed to providers as well
Stakeholder Communications and
Input Additional Opportunities
• Monthly call
• Bi-weekly PPG email beginning in July
• Soliciting feedback from providers about
mock provider reports
• Workgroup on reliability thresholds
Next call
Monday, July 12
7:30-8:30 am