MN DEPARTMENT OF HEALTH
PROVIDER PEER GROUPING (PPG)
ADVISORY GROUP
‰
DEFINING PARAMETERS
ANN ROBINOW
MEETING 2: JUNE 26, 2009
Introduction
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Comments and changes to meeting summary?
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Review of questions or comments since last meeting
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Public purchasing population
Report Technical Advisory Group responses since
last meeting
Request for roster and agenda
† Meeting summary handout
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Reminder:
What Are We Trying to Achieve?
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Enable comparisons of how provider entities perform
on:
Management of cost and quality for their entire patient
population (aka total cost of care)
† Management of cost and quality of care for specific
conditions
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Uses of information:
Consumer choice of providers
† Provider improvement
† Plan contracting and product development
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TODAY’S TOPIC: DEFINING PARAMETERS
Total Care: What is It?
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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.
Primary Care groups are often held responsible for Total Care.
Hospitals are often also held responsible for the total hospital
portion of Total Care.
Quality Indicators for Total Care are usually related to patient
experience, safety process measures, clinical preventive & chronic
measures.
Condition Specific Care: What is It?
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Similar to Total Care but only includes covered medical services
related specifically to a defined medical condition incurred by an
insured member over a defined period. Can be a time period, eg
12 months of care, or a clinically defined period.
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Examples: Diabetes, Coronary Artery Disease, Maternity, Knee Replacement
Identification of patients and services with defined medical
condition are generally based on diagnosis codes from insurer
claims.
Condition Specific Care is often a way to include specialists in the
peer grouping process.
Clinical Quality Indicators are more developed for some prevalent
conditions such as Diabetes, CHF, CAD Asthma.
Context For Today’s Discussion
High Level Steps in Peer Grouping
Questions for Today’s Meeting
1.
2.
3.
4.
5.
Who will be measured?
How do we define the entity to be measured (unit of
analysis)?
What is a “peer group” (and are these the same or
different for total cost of care v. condition specific
measures)?
What services are included and excluded from this
analysis?
How many and which specific medical conditions will be
measured?
What Provider Entity Will be
Measured for Total Cost of Care?
How Will Hospitals be Measured for
Total Cost of Care of Care?
Provider Unit of Analysis Examples
Provider Unit of Analysis
Provider Unit of Analysis Examples
Provider Unit of Analysis: Hospital
Unit of Analysis—Current Practices
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Who will be Measured? MN plans have used Total Cost to tier Primary Care groups
and Care Systems. Plans have also used the hospital component of Total Cost to tier
hospitals. Some plans tier specialists by practice and analyze specialty practices for cost
and quality for the conditions for which they provide care.
Unit of Analysis- Physician: Most plans compare at the medical group level due to
data validity but see more value to compare at the clinic level. Plans have also
compared physicians at the group level in order to be consistent with available quality
measures. MN Community Measure reports most quality measures at medical group
level but has started to report some conditions at the clinic level. Plans sometimes
internally profile and analyze at the individual physician level but do not share this
publicly.
Unit of Analysis – Hospital: Most plans compare at the individual hospital level.
Publically available quality data is also reported at the individual hospital level.
Provider Peer Groups
Health plans in MN have put geographic parameters around defining provider network peer
groups in order to ensure all tier levels are available across all regions.
Services To Be Included and Excluded:
Current Practices
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Law requires claim data on only MN residents.
Law requires adjustment for catastrophic and outlier cases
(to be discussed in meeting 3 or 4).
Identification of services incurred usually compiled from
retrospective insurer claims data that has been fully
processed and completed.
Usually includes pharmacy services even though these claims
and benefits may be processed and managed by a
separate entity.
Does not include services not covered by the insurer such as
nursing home care, over the counter meds, non-covered
benefits (i.e. cosmetic surgery).
Specific Conditions
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Overview—compare provider performance on cost and quality of
care for specific conditions
Different animal from baskets of care
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Baskets create common “base” definition
Baskets invite voluntary price quote across payers
Providers take “risk” on services included in basket
Current discussion
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Specific conditions measures all applicable providers for all related
services (analyzed by grouper technology)
Requires no provider action
Does not establish financial risk or pricing commitment
Metrics on cost and quality to be included
How Many and Which Specific
Conditions Will Be Measured?
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How many conditions?
15 conditions drive 56% of costs
† Baskets of Care
7 conditions
† Prometheus pilots
10 conditions
† AHRQ 10 conditions
† AQA
7 conditions
† Medicare
8 conditions
† MN Quality Incentive 6 conditions
† Bridges to Excellence
3 conditions
Selected Conditions by Entity
Condition
Diabetes
Heart Failure
Low back pain
Coronary artery disease
Depression
Heart attack
Pneumonia
Asthma
Hypertension
Total knee Adult preventive
Child preventive
Maternity
Prostate cancer
UTI
Hip fracture
Cholecystitis
COPD
MN QI
X
X
X
X
X
X
AQA
X
X
X
X
X
X
CMS
BTE
X
Baskets of Care
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Selected Condition Criteria
Condition
Diabetes
Heart Failure
Low back pain
Coronary artery disease
Depression
Heart attack
Pneumonia
Asthma
Hypertension
Total knee Adult preventive
Child preventive
Maternity
Prostate cancer
UTI
Hip fracture
Cholecystitis
COPD
Quality
Metrics
X
X*
Choice of Provider
X
X
X
AHRQ Most $$
X
X
X
X
X
X*
X*
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
?
?
X
X
X
X
X
* inpatient measure
X
X
Hi Cost per Commercial Hi Episode
Prevalence Variation
X
X
X
X
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X
X
X
X
X
X
X
X
X
X
X
X
X
X
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X
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X
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X
X
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X
X
X
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X
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X
X
X
X
X
X
X
X
X
X
X
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X
Who Will Be Measured for Specific Conditions?
Questions for Today’s Meeting
1.
2.
3.
4.
5.
Who will be measured?
How do we define the provider entity to be measured
(unit of analysis)?
What is a “peer group” and are these the same or
different for total cost of care v. condition specific
measures?
What services are included and excluded from this
analysis?
How many and which specific medical conditions will be
measured?
Who Will Be Measured?
Entity
Primary Care
Specialists
Care Systems
Hospitals
Total Cost of Care
Specific Conditions
How Do We Define Unit of Analysis?
Unit of Analysis
Individual physician
Clinic site
Care System
Hospital
Total Cost of Care
Specific Conditions
What is a Peer Group?
Peer Group Limitation
Same provider type, e.g.
primary care, specialists
Same provider size, e.g.
less than 3 physicians
Same geographic area,
e.g. rural, urban
Same structure, e.g. single
specialty, multispecialty,
pediatrics only
Total Cost of Care
Specific Conditions
What Services Are Included?
Services
MN residents
Total Cost of Care
Specific Conditions
X
X
Adjust for outliers,
catastrophics
Discuss in Meeting 3 and 4
Discuss in Meeting 3 and 4
Covered services
X
X
Pharmacy
X
X
Exclude non-covered
services
X
X
Which Specific Medical Conditions?
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Diabetes
Heart Failure
Low back pain
Coronary artery
disease
Depression
Heart attack
Pneumonia
Asthma
Hypertension
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Total knee
Adult preventive
Child preventive
Maternity
Prostate cancer
UTI
Hip fracture
Cholecystitis
COPD
Other
Preview of Next Meetings 3 & 4:
Cost Measurement
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Cost comparison
How much does it cost for different provider organizations to
deliver care for similar patient populations/medical conditions?
† What is cost?
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How should resource use be determined?
How should price be determined?
How should these be combined into a cost comparison?
Patient attribution
Why are patients attributed?
† Which providers are really managing which patients?
† Can/should every patient be attributed?
† Can/should patients be attributed to more than one physician?
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Meeting 3 & 4:Cost Measurement
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Risk adjustment
Why is risk adjustment important?
† How can/should methodology account for differences in patient
populations?
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How do illness burdens differ and how does that affect cost?
How do patient demographics differ and how does that affect cost?
How does payer mix differ and what affect does that have on costs?
What tools are available to make adjustments for risk differences?
Outlier Issues
Why should we consider outliers?
† What is and isn’t an outlier?
† How should methodology account for differences in frequency
and cost of outliers?
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