MN DEPARTMENT OF HEALTH
PROVIDER PEER GROUPING (PPG)
ADVISORY GROUP
PROVIDER ATTRIBUTION: CONDITION SPECIFIC
QUALITY MEASUREMENT: CONDITION SPECIFIC
COST MEASUREMENT: TOTAL CARE
ANN ROBINOW
MEETING 4: JULY 17, 2009
Introduction
Comments and changes to meeting summary?
Review of questions or comments since last meeting
Report Technical Panel responses since last meeting
Data does not support peer grouping at individual clinician level.
Outcome of surgery also dependent on hospital so individual
clinician reporting may not be appropriate.
An episode with a hospital component is included when the
physician clinic or group is the unit of analysis.
Attribute with greater credibility more preferable than attribute
a greater number.
Questions for Today’s Meeting: Condition
Specific Attribution
Provider Attribution Questions:
1. Who will be measured for condition specific?
2. How do we define the entity to be measured (unit of
analysis) for condition specific?
3. What is a “peer group” for condition specific
measures?
4. What recommendations/principles should be used to
determine patient attribution to providers?
5. How many providers should patients be attributed to
for condition specific peer grouping?
Specific Condition Measurement
Condition
Who to Measure
Unit of Analysis
Peer Group
Diabetes
Primary Care
Endocrinologist
Clinic site (when possible)
May include a Hospital component
All measured
providers
Pneumonia
Hospital
Individual Hospital
All measured
hospitals
Heart
Failure
Primary Care
Cardiology
Clinic site (when possible)
May include a Hospital component
All measured
providers
Total Knee
Replace
Orthopedic
Clinic site (when possible)
Will always include a Hospital component
All measured
providers
Coronary
Artery
Primary Care
Cardiology
Clinic site (when possible)
May include a Hospital component
All measured
providers
Asthma
Primary Care
Pediatrician
Pulmonologist
Allergist
Clinic site (when possible)
May include a Hospital component
All measured
providers
ETG Examples
Condition
ETG
Description
Diabetes
Type I diabetes, with
comorbidity
Type I diabetes, w/o
28
comorbidity
Type II diabetes, with
29
comorbidity
Type II diabetes, w/o
30
comorbidity
Diabetic retinopathy, w/o
223
surgery, with comorbidity
27
Diabetic retinopathy, w/o
surgery, w/o comorbidity
Viral pneumonia, with
371
comorbidity
Viral pneumonia, w/o
372
comorbidity
224
Pneumonia
ETG Examples
Condition
ETG
Asthma
386
387
388
389
Description
Asthma, with
comorbidity, age less
than 18
Asthma, with
comorbidity, age 18+
Asthma, w/o
comorbidity, age less
than 18
Asthma, w/o
comorbidity, age 18+
Episode Grouper: Output Example
Episode #251: Coronary artery disease, with AMI, with coronary artery bypass graft
Attributed
MD Group A
Attributed
MD Group B
Attributed
MD Group C
Episode Count
Patient Count
Total Actual Allowed $
Actual Allowed $ / Episode
Facility – IP: Allowed $ / Episode
Facility - OP : Allowed $ / Episode
Professional: Allowed $ / Episode
Rx : Allowed $ / Episode
Radiology: Allowed $ / Episode
Lab: Allowed $ / Episode
Anesthesia: Allowed $ / Episode
Physician Attribution Options for Condition
Specific Cost Measurement
Specific Condition Attribution
Condition
Who to Measure
Unit of Analysis
Single or Multiple
Attribution?
Diabetes
Primary Care
Endocrinologist
Clinic site (when possible)
Technical Panel
recommendation:
Pneumonia
Hospital
Individual Hospital
Heart Failure
Primary Care
Cardiology
Clinic site (when possible)
Total Knee
Replacement
Orthopedic
Clinic site (when possible)
Err on the side of
credible attribution
versus attributing a
higher percentage of
patients with greater
potential for
questionable attribution.
Coronary
Artery
Primary Care
Cardiology
Clinic site (when possible)
Asthma
Primary Care
Pediatrician
Pulmonologist
Allergist
Clinic site (when possible)
This recommendation
would tend to support
Single Attribution.
Analyze episodes not
clearly attributed and
potentially attribute
based on a secondary
rule.
Episode Summary Recommendations
Options
Issue
Episode Software
Recommendation
ETG
Cost
Actual
Reprice
Actual & Reprice
Calculate Actual & Reprice methodologies but not
necessarily report both for varied audiences.
Outlier Adjustment
Remove
Truncate
Trim
(specific to population size)
•
•
•
•
Set thresholds specific to population size;
Remove low outliers;
Truncate high outliers with any necessary
actuarial corrections for small clinics/groups;
Continued analysis of outliers
Severity of Illness
Demographic
Risk Adjustment
One level
Two levels
•
•
Apply two levels of risk adjustment
Consider some adjustment for income via zip
code
Payer Mix
Adjustment
No adjustments or
Compare by payer
Normalize payer mix
Compare by payer categories
AND
Normalize to standard payer mix
Attribution to one or
many providers?
Single
Multiple
Single with attribution method that supports
credibility over greater numbers.
Continuous improvement for attribution rules.
PPG Advisory Meeting Schedule
MEETING
DATE
TIME
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues
Meeting 9
Wednesday, September 30
Final Review
Context For Today’s Discussion
High Level Steps in Peer Grouping
Questions for Today’s Meeting:
Quality Measures Condition Specific
What quality measures should be included in physician peer grouping
for Condition Specific?
What quality measures should be included in hospital peer grouping for
Condition Specific? (Pneumonia is only condition selected to be peer grouped at
hospital level only)
For groups that have a hospital component attributed as part of an
episode, should hospital quality measures be attributed to group as
well?
Should analysis of Condition Specific include more than one measure? If,
yes, how should multiple measures be combined into a composite quality
measure?
What types of risk adjustment should be performed for Condition
Specific quality measures?
Technical Panel Recommendations:
Condition Specific Quality Measures
1.
Very few sources of quality data where all providers are submitting same
measures in the same way.
2.
Clinical care measures and Patient Experience should both be incorporated
(applies more to Total Care).
3.
Totaling quality results for each condition (eg: summing on a weighted point
based system) is feasible but individual measures & results must be made
available.
4.
Acknowledgment that selection and weighting of quality measures is a
subjective process requiring value judgments.
5.
If weighting measures for a total quality score, should consider:
Short term v. long term impact of measure, not just frequency
Physician control & influence over patient for measure
Prevalence to population
Combining Types of Measures
Quality Clinical care
Structural
Do you have EMR?
Process
Was eye exam given?
Outcome
Was BP below 130/80?
Readmission rate for CHF?
Types of Responses
Yes/No response
Examples: Yes, patient’s blood pressure was below
130/80; No, clinic does not have an EMR
Less value judgment to interpret response
Easiest to apply points
Quantitative response
Example: Hospital readmission rate for long term
complications of diabetes
Only meaningful when compared to others or a
standard
Patient Experience
Subjective
Ease of seeing doctor of
your choice?
Objective
Does clinic offer after
hours appt?
Scaled response
Examples: Were you satisfied with your visit? very,
somewhat, not at all
Condition Specific: Composite Quality
Measure
Is it meaningful to have a composite quality measure for each condition?
How to combine responses measured on different scales?
Pneumonia Quality Measures
Measure
Pneumonia - Appropriate care
measure (composite measure)
Hospital admissions for bacterial
pneumonia
Hospital readmissions for bacterial
pneumonia
Hospital ER visit rate for
pneumonia
Pneumococcal vaccination
Blood cultures performed in ED
prior to initial antibiotic received in
hospital
Adult smoking cessation advice
Initial antibiotic received w/in 6 hrs
of hospital arrival
Initial antibiotic selection for
community-acquired pneumonia in
immunocompetent patients
Influenza vaccination
NQF
endorsed
Source
Unit of
Measurement
MN Hospital
Association/Stratis
Hospital
AHRQ Prevention
Quality Indicators
Hospital**
Availability
Hospital
now
can be calculated using
available data
can be calculated using
available data
can be calculated using
available data
yes
CMS Hospital Compare
Hospital
now
yes
yes
CMS Hospital Compare
CMS Hospital Compare
Hospital
Hospital
now
now
yes
CMS Hospital Compare
Hospital
now
yes
CMS Hospital Compare
Hospital
now
yes
CMS Hospital Compare
Hospital
now
yes
Hospital
30 day mortality after discharge
Yes
CMS
Hospital
now (Medicare only)
Pneumonia vaccination status, age
Physician or
65+
yes
NCQA
clinic
would need to collect
** Hospital measures that are not intended to measure hospital quality but are more a reflection of the quality of
ambulatory care (rates of preventable hospital admissions).
Diabetes Quality Measures
NQF
endorsed
Source
Unit of
Measurement
Yes
MNCM
MNCM
MNCM/NCQA
Clinic site
Clinic site
Clinic site
now
now
now
Modified
MNCM
MNCM
MNCM
Clinic site
Clinic site
Clinic site
now
now
now
Eye exam
Hemoglobin A1c testing
Blood pressure measurement
Yes
Yes
Yes
NCQA
NCQA
NCQA
Physician or clinic available from claims data
Physician or clinic available from claims data
Physician or clinic available from claims data
Urine protein screening
Yes
NCQA
Physician or clinic available from claims data
Lipid profile
Rate of hospital admissions for short-term
complications
Rate of hospital admissions for long-term
complications
Rate of hospital admissions for
uncontrolled diabetes
Yes
NCQA
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
Measure
Optimal diabetes care (composite
measure of below 5 measures)
Blood pressure below 130/80 mm/Hg
LDL cholesterol below 100 mm/dL
HbA1c level*
Daily aspirin use (age 40 & older)
Documented non-tobacco use
Availability
Physician or clinic available from claims data
can be calculated using
Yes
Hospital**
available data
can be calculated using
Yes
Hospital**
available data
can be calculated using
Yes
Hospital**
available data
can be calculated using
Rate of lower-extremity amputation
Yes
Hospital**
available data
can be calculated using
Rate of hospital ER visits for
available data
diabetes
Hospital
** Hospital measures that are not intended to measure hospital quality but are more a reflection of the quality of ambulatory
care (rates of preventable hospital admissions).
Coronary Artery Disease Quality Measures
NQF
endorsed
Measure
Unit of
Measurement
Source
Availability
Optimal vascular care (composite
measure)
Modified? MNCM
Blood pressure below 130/80 mm/Hg
MNCM/NCQA
Clinic site
Clinic site
now
now
LDL cholesterol below 100 mm/dL
Yes
Daily aspirin use (age 40 & older)
Documented non-tobacco use
Coronary artery disease symptom and
activity assessment
Yes
Clinic site
Clinic site
Clinic site
Physician or
clinic
now
now
now
available from claims
data?
AMA
Physician or
clinic
Physician or
clinic
Physician or
clinic
available from claims
data?
available from claims
data?
available from claims
data?
NCQA
Physician or
clinic
available from claims
data?
available from claims
data
available from claims
data
available from claims
data
ACE inhibitor/angiotensin receptor
blocker therapy (CAD patients who
also have diabetes or LVSD)
MNCM/NCQA
MNCM
MNCM
AMA
Yes
AMA
Antiplatelet therapy
Yes
Beta blocker therapy (for patients with
prior heart attack)
Yes
Beta blocker prescription within 7 days
after hospital discharge for heart
attack
Yes
AMA
Hospital admission rate for CAD
Hospital re-admission rate for CAD
Hospital ER visit rate for CAD
Asthma Quality Measures
Measure
Unit of
Measurement
Yes
Source
MNCM
NCQA
(HEDIS)
Yes
AMA
Physician or
clinic
now
Physician or
clinic
would need to collect
Management plan for people with asthma
Yes
IPRO
Physician or
clinic
would need to collect
% of patients prescribed either the
preferred long-term control medication or
an acceptable alternative treatment
Yes
AMA
Physician or available from claims
clinic
data?
Pediatric inpatient asthma patients who
received relievers for inpatient asthma
Yes
Joint
Commission
Hospital
would need to collect
Yes
Joint
Commission
Hospital
Yes
AHRQ
Hospital**
would need to collect
can be calculated
using available data
Rate of hospital re-admission for asthma
Hospital
can be calculated
using available data
Rate of hospital ER visit for asthma
Hospital
can be calculated
using available data
Use of appropriate medications for
people with asthma
Asthma assessment (% of patients
assessed for frequency of symptoms
Pediatric inpatient asthma patients who
received systemic corticosteroids
Rate of inpatient admissions for adult
asthma
NQF endorsed
Availability
Heart Failure Quality Measures
Measure
Assessment of activity level
Assessment of clinical symptoms of volume
overload (excess)
NQF
endorsed
Yes
Source
AMA
Unit of
Measurement
Availability
Physician /clinic available from claims data?
Yes
AMA
Physician /clinic available from claims data?
Left ventricular function assessment
Yes
AMA
Physician /clinic available from claims data?
ACEI/ARB therapy (HF patients w/LVSD)
Patient education
Yes
Yes
AMA
AMA
Physician /clinic available from claims data?
Physician /clinic available from claims data?
Beta blocker therapy (HF patients w/LVSD)
Warfarin therapy for patients with atrail
fibrillation
Yes
AMA
Physician /clinic available from claims data?
Yes
AMA
Physician /clinic available from claims data?
Weight measurement
Yes
Physician /clinic available from claims data?
Evaluation of left ventricular systolic function
Yes
Hospital discharge instructions
Yes
Adult smoking cessation advice/counseling
Yes
AMA
CMS, Joint
Commission
CMS, Joint
Commission
CMS, Joint
Commission
Hospital mortality rate
Yes
AHRQ
Hospital
30-day mortality after hospital discharge
Rate of hospital admissions for congestive
heart failure
Rate of hospital re-admission
Yes
CMS
Hospital
Yes
AHRQ
Hospital**
Hospital
Hospital
now
Hospital
now
Hospital
now
can be calculated using
available data
now (Medicare only)
can be calculated using
available data
Rate of hospital ER visits heart failure
Hospital
** Hospital measures that are not intended to measure hospital quality but are more a reflection of the quality of
ambulatory care (rates of preventable hospital admissions).
Total Knee Quality Measures
Measure
General surgical measures: surgical
site infection, antibiotic prophylaxis,
VTE prophylaxis
NQF
endorsed
Source
Unit of
Measurement
Hospital
Rate of hospital re-admission
Hospital
Rate of hospital ER visit after surgery
Hospital
Availability
would need to collect
can be calculated using
available data
can be calculated using
available data
Condition Specific Quality Measurement:
Risk Adjustment
Condition Specific Risk Adjustment methods are limited and not yet
well developed.
Structural measures are provider-level measures and do not need
adjustments for patient characteristics
Process measures may have some simple risk adjustments. Generally,
measures only include like patients with like services performed.
Outcome measures risk adjustment limited to a few hospital
measures.
Patient experience measures difficult to risk adjust due to aggregate
response reporting, not at patient level.
Payer Mix adjustment could be applied similar to cost.
Context For Today’s Discussion
High Level Steps in Peer Grouping
TOTAL CARE
Questions for Today’s Meeting: Total Care
Cost Measurement
1.
2.
3.
4.
What is Total Cost?
How will costs be risk adjusted for Total Care?
How should outliers be defined for Total Care peer
grouping and how will they be accounted for?
Should peer grouping be analyzed by payer type to risk
adjust for payer mix?
Review Total Care: What is It?
Representation of all covered medical services (physician, hospital,
ancillary, and Rx) for all medical conditions incurred by an insured
member over a defined time period, usually one year.
Members who received no care during the defined time period are also
included.
Primary Care groups are often held responsible for Total Care.
Total Cost for Total Care is often represented as cost per member per
month (PMPM) or cost per member per year (PMPY).
Total Care for Hospitals only evaluates all admissions to the hospital
incurred by insured members over a defined time period. Members who
were not admitted are not included.
Review Total Care Units of Measure Recommendations
Condition
Who to Measure
Unit of Analysis
Peer Grouping
Total Care -Physician
All providers functioning
as Primary Care,
regardless of specialty
type
Clinic site (when
possible)
All measured
providers
Total Care -Hospital
Hospital
Individual Hospital
All measured
hospitals
Recommendations: Condition v Total Care
Issue
Options
Risk
Adjustment
Software
Cost
Outlier
Adjustment
Condition Recommendation
Commercial software
Total Care Recommendation
Commercial software
(eg: ERGs by Ingenix & Adjusted Clinical
Grouper (ACG) by Johns Hopkins)
Actual
Reprice
Actual &
Reprice
Calculate Actual & Reprice
methodologies but not necessarily
report both for varied audiences.
Remove
Truncate
Trim
•
•
•
•
Set thresholds specific to
population size;
Remove low outliers;
Truncate high outliers with any
necessary actuarial corrections
for small clinics/groups;
Continued analysis of outliers
Same as Condition
Include low outliers,
otherwise same as Condition
Recommendations: Condition v Total Care
Issue
Options
Condition Recommendation
Severity of
Illness
Demographic
Risk Adjustment
One level
Two levels
Payer Mix
Adjustment
No adjustments
Compare by
payer
Normalize payer
mix
Compare by payer categories
AND
Normalize to standard payer mix
Single
Multiple
Single with attribution method that
supports greater confidence over
greater numbers.
Attribution to
one or many
providers?
•
•
Apply two levels of risk
adjustment
Consider some adjustment for
income via zip code
Total Care
Recommendation
•
•
Apply one level of risk
adjustment
Consider some
adjustment for income
via zip code
Same as Condition
Single
By definition, Total Care is
assignment of all costs to
one entity.
PPG Advisory Meeting Schedule
MEETING
DATE
TIME
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
f/u Quality Measures for Conditions
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues
Meeting 9
Wednesday, September 30
Final Review