The BlueCompare SM Physician Designation Program

Transcription

1 The BlueCompare SM Physician Designation Program Continuing escalation of health care costs has driven premiums and medical expenses to higher and higher levels each year, motivating employers and consumers to search for information about the value (quality and cost) they receive for their health care dollars. These stakeholders are asking Blue Cross and Blue Shield of Texas (BCBSTX) to support their purchasing decisions by identifying the providers who offer the best quality and cost. BCBSTX must pay attention to the needs of its employers and members. The BlueCompare program measures performance using state and national guidelines. BCBSTX understands the complexities of measuring provider quality and cost performance. Fortunately, state and nationally published guidelines and requirements for provider transparency methodologies and programs are now available. BCBSTX has taken care to incorporate these guidelines and requirements into the BlueCompare Physician Designation program to meet the demand for provider performance information. See Appendix A for more information on national guidelines. BCBSTX s BlueCompare Physician Designation program measures physicians on both quality-related performance and cost-efficiency: o The quality-related assessment utilizes Evidence-Based Measures (EBMs) from nationally recognized entities such as the National Quality Forum (NQF), the Ambulatory Care Quality Alliance (AQA), and the National Committee for Quality Assurance (NCQA). o The cost-efficiency assessment is based on an Episodes of Care methodology. o Both the quality-related and cost-efficiency performance measurement utilize two years of BCBSTX PPO incurred claims data. bcbstx.com 1

2 o The BlueCompare program adheres to nationally recognized transparency methodology and program standards and guidelines (NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality) and complies with Texas Insurance Code Chapter Measured Specialties and Eligibility BCBSTX only measures cost-efficiency on those Working Specialties where it can also measure quality-related performance. The BlueCompare Physician Designation Program applies to the Working Specialties for which both quality-related performance and cost-efficiency can be measured. Physicians must practice in one of the measurable Working Specialties and be a contracted physician in good standing with the BCBSTX BlueChoice provider network to be eligible for participation in the BlueCompare Physician Designation Program. There are a select number of available EBMs for quality-related measurement that meet nationally recognized standards (e.g. NQF, AQA and NCQA) and methodology adherence for quality measurement. BCBSTX only measures cost-efficiency on those Working Specialties where it can also measure quality-related performance. BCBSTX applies quality-related measurement and the cost-efficiency assessment to the following 13 Working Specialties: Allergy-Immunology Cardiovascular Disease-Non-Interventional Cardiovascular Disease-Interventional Endocrinology Family Practice Geriatric Medicine Internal Medicine Nephrology Obstetrics-Gynecology Pediatric Allergy-Immunology Pediatric Pulmonary Disease Pediatrics Pulmonary Disease bcbstx.com 2

3 BlueCompare Evidence-Based Measures (EBMs) Assessment BCBSTX uses claims and enrollment data to assess a physician s adherence to nationally recognized EBMs when treating his/her qualifying patients. These measures cover significant areas of preventive care such as diabetes, cardiovascular disease and other health care services. A complete list of the EBMs used in the evaluation, along with the clinical intent and sponsoring organizations, is contained in Appendix B. BCBSTX uses claims and enrollment data to assess a physician s adherence to nationally recognized EBMs when treating his/her qualifying patients. Physicians are evaluated using only the EBMs that are considered relevant to their Working Specialty and relative to their specialty peers in Texas. All physicians within a common Practice Evaluation ID (typically the Tax Identification Number) and Working Specialty are evaluated together, regardless of the level of individual physician contribution, and are given the same BlueCompare EBM designation. For example, a group of physicians practicing under a common Tax Identification Number that is comprised of Internal Medicine, Family Practice, and Obstetrics-Gynecology specialties would receive three distinct evaluations and BlueCompare designations. A physician who practices under multiple Tax Identification Numbers can achieve different EBM evaluation results for each group and Working Specialty in which the physician is evaluated. EBM performance is attributed to physicians based upon their involvement in treating the BCBSTX PPO members who qualify for the measures, according to Health Care Effectiveness Data and Information Set (HEDIS) standards. The number of members who qualify for the EBMs (denominator) is compared to the number of members who were provided services satisfying the EBM criteria (numerator). A minimum of 30 denominator events must be attributed to the physician or specialty group to qualify for an evaluation. Although two calendar years of PPO claims data is used, some EBMs use five years of claims data. The methods for determining the specific denominators and numerators differ by measure. These details are available at EBM Performance Scoring Details A physician group s performance score is derived from the following factors: o A count of qualifying events, which defines a denominator. An example is the continuously enrolled diabetic patients for whom a specified test or other service is expected. bcbstx.com 3

4 o A count of the clinical responses to the qualifying events, which defines the numerator. An example is the number of diabetic patients in the denominator who receive the expected test or service. o The weighting associated with the applicable indicator. This is determined by the statistical reliability of a measure, as determined by its variance. The composite performance score for a physician group is derived by applying and aggregating the above factors. This score is used to assess the group s performance relative to its peers. The composite score is considered valid only if a physician group has a minimum of 30 denominator events across all indicators. Practices with scores that are at or above the performance threshold are recognized. Performance is aggregated across all relevant EBMs. Each EBM is weighted by the inverse of the variance of the measure, resulting in a weighted average that reflects both the total number of denominator events and the variability of performance by peers. This methodology decreases the impact of differences in the number of denominators that occur from practice to practice, and summarizes performance on individual measures into a single EBM score. The practice EBM scores are distributed for a specialty-wide comparison of performance. A system based on statistical methods is used to identify a performance threshold within this distribution. Practices with scores that are at or above the performance threshold are recognized. Practices with a score more than two standard deviations from the mean, compared to the peer average, are considered outliers. An external statistician, with extensive experience in biostatistics, reviewed and validated the EBM scoring methodology for appropriateness. A more detailed explanation of the scoring methodology can be found in Appendix C. Where there are no measures present for a specialty, insufficient data is available, or threshold performance on the EBMs is not met, an appropriate designation will be assigned to the physician. For more information on designations, see BlueCompare Designation section contained later in this document. This EBM measurement is the quality-related component of the BlueCompare Physician Designation Program. It must be satisfied for a physician to be eligible for the cost-efficiency evaluation. bcbstx.com 4

5 BlueCompare Physician Cost Assessment (PCA) Consistent with national guidelines (NCQA PHQ), BCBSTX first assesses a physician for performance on quality-related measures. Pending that outcome, BCBSTX reviews the physician for cost-efficiency. A cost-efficiency assessment is only performed if the specialty-specific quality-related criteria are met. BCBSTX engaged physicians currently in clinical practice to assist in developing the new PCA methodology described below. To assess a physician s cost-efficiency, BCBSTX analyzes Episodes of Care that are attributable to the physician. To assess a physician s cost-efficiency, BCBSTX analyzes Episodes of Care that are attributable to the physician. Truven Health Analytics Medical Episode Group (MEG) software is used for the Episode of Care analysis. PCAs are created using two incurred years of outlier-trimmed claims data. Similar to the BlueCompare quality-related assessment, the PCA is calculated at the Practice Evaluation ID/Working Specialty level. PCA Peer Comparisons takes into account the disparate costs in the geographic area in which the physician practices. BCBSTX has 22 Peer Comparison areas for which physician cost-efficiency can be assessed as depicted below. 790 AMARILLO Digit ZIP Code Groupings 799 EL PASO ODESSA- MIDLAND 792 LUBBOCK WHICHITA FALLS S.A LAREDO FORT WORTH- ARLINGTON 762 DALLAS TYLER 766 WACO ABILENE KILLEEN TEMPLE BRYAN - SAN AUSTIN COLLEGE STA. ANGELO HOUSTON SAN ANTONIO 774 VICTORIA TEXARKANA BEAUMONT- PORT ARTHUR CORPUS CHRISTI 3-Digit ZIP Boundaries Rating Areas by 3-Digit ZIP 785 MCALLEN-EDINBURG-MISSION bcbstx.com 5

6 Episodes of Care An Episode of Care is built by linking sets of health care services provided to a patient over time to treat a specific disease or health status, and can be comprised of one or more encounters or visits, procedures or inpatient admissions. The episode continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status. Episode Grouping Logic example: The responsible physician is determined without regard to the physician s contract status with BCBSTX. The example above demonstrates how a complete episode ranges in time between the lab test and the final office visit. A lab or X-ray cannot initiate an episode; however, the look-back period can incorporate such services. Physician Episode of Care Attribution Only one physician per episode is considered to be the responsible physician. The responsible physician is assigned as follows: o Physician who performs procedures with the highest total Relative Value Units (RVUs) billed; if none, then o Physician with the greatest number of Evaluation and Management (E&M) services billed; if none; then o Physician with the highest allowed dollars This logic helps to ensure that primary care physicians are not inappropriately attributed high cost cases for which they are not primarily responsible. The responsible physician is determined without regard to the physician s contract status with BCBSTX. bcbstx.com 6

7 Episode of Care Data Trims A trim is an exclusion to the data set done prior to calculation of the PCA. BCBSTX makes several data trims to the base episode of care data to help ensure that the results are not influenced by patient severity, case mix or burden of illness. BCBSTX uses only complete Episodes of Care that are risk and severity adjusted. Listed below is a summary of the trims that are made to the data before the PCA calculation is performed. BCBSTX makes several data trims to the base Episode of Care data to help ensure that the results are not influenced by patient severity, case mix or burden of illness. Episodes will be removed if they: o are incomplete o are high or low cost outliers o are attributed to members with fewer than nine member months for the time period of the episode o belong to a MEG/Sub stage with low volume o represent an episode where the responsible physician has less than 80 percent of the RVUs driving utilization o contain emergency room revenue codes or place of service o are for preventive care o are in MEG categories not typically provided by a particular Working Specialty After these data trims are complete, the result is a set of qualified episodes, which are used in calculating the PCA. Physician Cost Assessment Calculation The PCA is calculated based on the average cost of qualified episodes partitioned by: o episode group o severity of illness for the episode o relative risk of the patient o time period of the episode o Working Specialty of the physician o geographic area of the physician bcbstx.com 7

8 The PCA is calculated by comparing the actual allowed cost of the physician s Episodes of Care to an expected allowed cost for the physician s episodes of care in their Working Specialty. PCA = Sum across episodes: Actual Allowed Cost Sum across episodes: Expected Allowed Cost Consistent with national guidelines, BCBSTX uses a Confidence Interval methodology to determine if physicians meet cost-efficiency performance thresholds for a Working Specialty within a geographic area. Determination of Physician Cost-Efficiency Performance Level Consistent with national guidelines, BCBSTX uses a Confidence Interval methodology to determine if physicians meet cost-efficiency performance thresholds for a Working Specialty within a geographic area. Specifically: o PCA results are cited at the physician/practice, Working Specialty level in conjunction with a 90 percent Confidence Interval relative to o If the lower bound of the Confidence Interval is higher than 1.00, then the physician/practice is determined to have costs that are higher than their peers and therefore, do not meet the costefficiency designation performance threshold. o If a physician/practice s Confidence Interval contains 1.00, then the physician/practice is not determined to have costs that are either higher or lower than their peers. Therefore, costs are similar to their peers and the physician meets the cost-efficiency designation performance threshold. bcbstx.com 8

9 In the example below, the PCA is 1.16 with a confidence interval from.92 to Because the lower bound of the Confidence Interval is below 1.00, the physician in this example meets the cost-efficiency performance threshold. bcbstx.com 9

10 BlueCompare Designations Results of the BlueCompare Physician Designation Program are displayed by using the online Provider Finder tool at bcbstx.com. When members search for providers in the PPO network, search results include one of the following symbols/designations next to the physician s name: When members search for providers in the PPO network, search results include a symbol/ designation next to the physician s name. Specialty Not Measured Not Enough Data Not Enough Cost Data Voluntarily Declined Meets or exceeds expected qualityrelated performance compared to other doctors. Meets or exceeds expected qualityrelated and cost - efficiency performance compared to other doctors. Performance measures are not available for this specialty. There is not enough data to measure performance or this doctor is new to the network. Re-evaluations are conducted periodically. Meets or exceeds expected quality-related performance compared to other doctors, but there is not enough BCBSTX claims data to measure costefficiency performance. This doctor requested to not participate in the BlueCompare program. Physicians who are in a measured Working Specialty but do not meet the required quality-related and cost-efficiency recognition threshold do not have a symbol in Provider Finder. The BlueCompare tool is provided for informational purposes only. Physician selection is a personal choice, and consumers are informed that they should not base decisions solely on information displayed in BlueCompare. BlueCompare designations are based on claims from BCBSTX PPO membership records and may not be indicative of the physician s overall practice. bcbstx.com 10

11 The Review Process Affected physicians who are dissatisfied with their BlueCompare results have the right to request a review in writing. Affected physicians who are dissatisfied with their BlueCompare results have the right to request a review in writing. In addition to the written fair review reconsideration process, BCBSTX also provides a fair reconsideration proceeding as described below: o When a physician requests a review, BCBSTX will provide a fair reconsideration proceeding. This proceeding will be conducted by teleconference or in person, whichever the physician prefers. o A physician requesting a review has the right to provide information, to have a representative participate and to submit a written statement at the conclusion of the reconsideration proceeding. o BCBSTX will communicate the outcome of the reconsideration proceeding in writing, including the specific reason(s) for the final determination. bcbstx.com 11

12 Appendix A National Guidelines 1. NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality: 2. Ambulatory Care Quality Alliance 3. National Quality Forum 4. Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review bcbstx.com 12

13 Appendix B Evidence -Based Measures The following Evidence-Based Measures are used in the BlueCompare quality -related assessment. Evidence Based Measure Cervical Cancer Screening Colorectal Cancer Screening Diabetic Retinal Exam (Annual) Glycosylated Hemoglobin (HbA1c) Test for Diabetics (Annual) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Clinical Intent Involved Organization(s) Specialty Attribution To ensure that all women ages receive a cervical cancer screening test during the measurement year or the 2 years prior. To ensure that members years of age received appropriate screening for colorectal cancer. To ensure that all diabetic members ages receive at least 1 retinal or dilated eye exam during the measurement year. To ensure that all diabetic members ages receive at least 1 glycosylated hemoglobin test during the measurement year. To ensure that children, ages 3 months to 18 years of age as of the end of the measurement year, diagnosed with nonspecific upper respiratory infections are not being inappropriately treated with antibiotics. United States Preventive Services Task Force (USPSTF), American Cancer Society, American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Preventive Medicine, American Medical Assn. (AMA), Canadian Task Force on Preventive Health Care, American Academy of Pediatrics, NCQA (HEDIS 2009 Technical Specification), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed NCQA (HEDIS 2009 Technical Specification), United States Preventive Services Task Force (USPSTF), American Cancer Society, American College of Obstetricians and Gynecologists (ACOG), American Academy of Family Physicians (AAFP), American Gastroenterological Association, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed NCQA (HEDIS 2009 Technical Specifications), American Diabetes Association, American Academy of Ophthalmology, American College of Physicians, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed American Diabetes Association, American Association of Clinical Endocrinologists, American College of Endocrinology, Centers for Disease Control and Prevention, Veterans Affairs Administration, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Centers for Disease Control and Prevention, American College of Physicians, American Society of Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, Infectious Diseases Society of America, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Family Practice, Internal Medicine, Obstetrics- Gynecology Family Practice, Geriatric Medicine, Internal Medicine, Obstetrics-Gynecology Endocrinology, Family Practice, Geriatric Medicine, Internal Medicine, Nephrology Endocrinology, Family Practice, Geriatric Medicine, Internal Medicine, Nephrology Allergy-Immunology, Family Practice, Pediatrics, Pediatric Allergy and Immunology Educational: Otolaryngology, Pediatric Otolaryngology, Pediatric Pulmonary Disease LDL Monitoring for Diabetes (Annual) To ensure that all members age years old with diabetes receive LDL monitoring during the measurement year. American Diabetes Association, NCEP-ATP-III Guidelines, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Cardiovascular Disease Interventional, Cardiovascular Disease - Non-Interventional, Endocrinology, Family Practice, Geriatric Medicine, Internal Medicine, Nephrology bcbstx.com 13

14 Appendix B Evidence-Based Measures continued Evidence- Based Measure Mammography Screening Appropriate Use of Imaging in Low Back Pain Assessment Use of Long- Term Control Drugs for Persistent Asthma CAD Event or IVD Diagnosis Cholesterol Test Acute Bronchitis: Treatment in Adults without antibiotics Pharyngitis Treatment for Children Clinical Intent Involved Organization(s) Specialty Attribution To ensure that all eligible women age receive a mammography screening test during the measurement year or year prior. To ensure that all members diagnosed with lower back pain did not receive a clinically inappropriate imaging study. To ensure that members age 5 50 with persistent asthma receive medication appropriate for long term control of asthma. To ensure that members age discharged for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA) or who had a diagnosis of ischemic vascular disease (IVD) receive lipid level monitoring at a clinically appropriate frequency. To ensure that members without comorbidity diagnosed with bronchitis are not being inappropriately treated with antibiotics. To ensure that members 2-18 years of age diagnosed with pharyngitis and treated with antibiotics receive appropriate testing for streptococcus pharyngitis United States Preventive Services Task Force (USPSTF), Canadian Task Force on Preventive Health Care, American Academy of Family Physicians (AAFP), American College of Preventive Medicine, American Medical Assn. (AMA), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology, American Cancer Society, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Agency for Healthcare Research and Quality, Institute for Clinical Systems Improvement, American Academy of Family Physicians, American College of Physicians, American College of Radiology, American Pain Society, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed The National Asthma Education and Prevention Program, The Joint Council of Allergy, Asthma and Immunology, National Heart, Lung and Blood Institute, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed American College of Cardiology, American Heart Association, National Cholesterol Education Profram, National Quality Forum (NQF) endorsed American Academy of Family Practice, American College of Physicians, Centers for Disease Control and Prevention, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed NCQA (HEDIS 2007 Technical Specification), American Academy of Family Physicians, Infectious Disease Society of America, American College of Physicians, American Society of Internal Medicine, The American Heart Association Family Practice, Geriatric Medicine, Internal Medicine, Obstetrics-Gynecology Family Practice, Geriatric Medicine, Internal Medicine, Educational: Neurology Allergy Immunology, Family Practice, Internal Medicine, Pediatrics, Pediatric Allergy and Immunology, Pediatric Pulmonary Disease, Pulmonary Disease Cardiovascular Disease Interventional, Cardiovascular Disease Non -Interventional, Family Practice, Geriatric Medicine, Internal Medicine Educational: Endocrinology Educational: Allergy-Immunology, Family Practice, Internal Medicine, Otolaryngology,Pulmonary Disease Educational: Allergy-Immunology, Family Practice, Otolaryngology, Pediatrics, Pediatric Allergy and Immunology, Pediatric Otolaryngology, Pediatric Pulmonary Disease bcbstx.com 14

15 Appendix B Evidence-Based Measures continued Evidence Based Measure Chlamydia Screening for Women Monitoring for Diabetic Nephropathy Monitoring for Patients on Persistent Medications: Anticonvulsants Monitoring for Patients on Persistent Medications: Digoxin Monitoring for Patients on Persistent Medications: ACE/ARB Monitoring for Patients on Persistent Medications: Diuretics Disease modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Hepatitis C Viral Load Test Clinical Intent Involved Organization(s) Specialty Attribution To ensure that sexually active women years of age had at least one screening test for chlamydia during the measurement year. To ensure diabetic members ages receive a diabetic nephropathy screening test during the measurement year or evidence of nephropathy during the measurement year. To ensure that all members age 18 years and older who receive Anticonvulsants receive appropriate laboratory monitoring drug serum concentration test at least annually. To ensure that all members age 18 years and older who receive Dioxin receive appropriate laboratory monitoring for renal function and serum potassium at least annually. To ensure that all members age 18 years and older who receive angiotensin converting enzyme (ACE) inhibitors, and/or angiotensin receptor blockers (ARB) receive appropriate laboratory monitoring at least annually. To ensure that all members age 18 years and older who receive Diuretics receive appropriate laboratory monitoring for renal function and serum potassium at least annually. To ensure that patients 18 years and older who were diagnosed with rheumatoid arthritis were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD) during the measurement year. To ensure that patients with Hepatitis C (HCV) who began HCV antiviral therapy during the measurement year, had HCV Viral Load testing within 6 months (180days) prior to initiation of antiviral therapy. American Academy of Family Physicians, Centers for Disease Control and Prevention and U.S. Preventive Services Task Force (USPSTF), NCQA (HEDIS 2009 Technical Specification), National Quality Forum (NQF) endorsed measure American Diabetes Association, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed NCQA (HEDIS Technical Specifications), National Quality Forum (NQF) endorsed NCQA (HEDIS Technical Specifications), National Quality Forum (NQF) endorsed Joint National Committee on Prevention, Detection, Evaluation and treatment of High Blood Pressure, Seventh Report, National Quality Forum (NQF) endorsed, NCQA (HEDIS Technical Specifications) Joint National Committee on Prevention, Detection, Evaluation and treatment of High Blood Pressure, Seventh Report, National Quality Forum (NQF) endorsed, NCQA (HEDIS Technical Specifications) NCQA (HEDIS Technical Specifications), National Quality Forum (NQF) endorsed Resolution Health, Inc., National Quality Forum (NQF) endorsed Educational: Family Practice, Internal Medicine, Obstetrics- Gynecology Educational: Endocrinology, Family Practice, Geriatric Medicine, Internal Medicine Educational: Family Practice, Geriatric Medicine, Internal Medicine, Neurology Educational: Cardiovascular Disease Interventional, Cardiovascular Disease - Non- Interventional, Family Practice, Geriatric Medicine, Internal Medicine Educational: Cardiovascular Disease Interventional, Cardiovascular Disease - Non- Interventional, Family Practice, Geriatric Medicine, Internal Medicine, Nephrology Educational: Cardiovascular Disease Interventional, Cardiovascular Disease - Non- Interventional, Family Practice, Geriatric Medicine, Internal Medicine, Nephrology Educational: Family Practice, Internal Medicine, Rheumatology Educational: Family Practice, Gastroenterology, Internal Medicine bcbstx.com 15

16 Appendix B Evidence-Based Measures continued Evidence Based Measure Follow-up after Initial Diagnosis & Treatment of Colorectal Cancer Colonoscopy. Well child Visits 3 6 yrs Prostate Cancer Cancer Surveillance Prostate Cancer Three Dimensional Radiotherapy Clinical Intent Involved Organization(s) Specialty Attribution To ensure that all eligible members who have been newly diagnosed with colorectal cancer receive a follow-up colonoscopy within 15 months of resection. To ensure that patients 3-6 years of age receive one or more well child visits with a PCP during the measurement year. To ensure that males with prostate cancer have had their PSA monitored in the past 12 months. To ensure that all males older than 18 years, with a diagnosis of clinically localized prostate cancer who receive external beam radiotherapy as primary treatment, with or without metastatic disease, receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT). American Cancer Society, American Society of Clinical Oncology, American Society of Colon and Rectal Surgeons, American Society for Gastrointestinal Endoscopy, National Comprehensive Cancer Network, National Quality Forum (NQF) endorsed, NCQA (HEDIS Technical Specifications) NCQA (HEDIS Technical Specifications), National Quality Forum (NQF) endorsed Active Health Management, National Quality Forum (NQF) endorsed American Medical Association-Physician Consortium for Performance Improvement, National Quality Forum (NQF) endorsed Educational: Colon-Rectal Surgeon, Family Practice, Gastroenterology, Geriatric Medicine, Internal Medicine, Oncology Educational: Family Practice, Pediatrics Educational: Family Practice, Internal Medicine, Oncology, Urology Educational: Family Practice, Internal Medicine, Urology bcbstx.com 16

17 Appendix C Details on Calculating EBM Scores For each relevant EBM indicator category, a physician p-score is calculated as the ratio of the number of occasions on which the indicated service was provided by the physician to the number of eligible patient encounters. The aggregate p-score for a physician is the weighted average over all relevant indicators of the physician s p-scores. Before summing, each p-score is multiplied by the inverse of its approximate variance. This weighting factor explicitly takes into account the number of eligible patient encounters within each indicator for the physician so that p-scores based on a large number of encounters are more influential in determining the aggregate score than p-scores based on a smaller number of encounters. The statewide p-score for the indicator is the ratio of the total number of occasions in the state on which the indicated service was provided to the total number of eligible patient encounters, all within the indicator category. The same inverse-variance weighting factors are used, so the numbers of eligible patient encounters within each indicator category are again taken into account. The expected p-score for the physician is the weighted sum over all relevant indicators of the statewide p-scores. The physician EBM score is the ratio of the physician s aggregate p-score to the corresponding statewide p-score, divided by the approximate standard deviation of the ratio. The EBM score may be positive or negative, indicating that the physician s overall rate of performance of indicated services falls above or below statewide rate. To determine the practice group EBM score, each member physician s EBM score is weighted by the inverse of its variance and then aggregated across the relevant indicators. This results in a weighted average that reflects both the total number of patient encounters for each physician and the variability of the EBM score. EBM scores based on many patient encounters are weighted more heavily than those based on fewer encounters. This methodology takes into account differences in the numbers of patient encounters for both individual physicians and for practice groups. The specialty ratio for a practice group is the ratio of the number of occasions on which the indicated service was provided to the number of eligible patient encounters, aggregated over all physicians in the group. A physician group is evaluated using only those indicators which are considered relevant to the specialty. Thirty or more patient encounters across all indicators must be attributed to the physician group to be included in the assessment. A group s performance is assessed relative to other physicians in the same specialty within the BCBSTX network. bcbstx.com 17

18 Definitions Actual Allowed Cost: This is the allowed cost (physician payment and patient liability) for all services provided by all physicians, ancillary providers and facilities related to the episodes of care attributed to the physician. Confidence Interval: The probability at a 90 percent level of confidence that a PCA lies within a specified range. Expected Allowed Cost: This is based on the average allowed cost of qualified episodes partitioned by MEG, severity, comorbidity group, and time period for a specialty in a geographic region. Episode of Care: An episode of care is composed of one or more encounters or visits, procedures or inpatient admissions. It is built by linking sets of health care services provided to a patient over time to treat a specific disease or health status. It continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status. MEG (Medical Episode Group): The Truven Health Analytics Medical Episode Group numeric code identifying a clinically homogenous episode of care. PCA: Total cost of all qualified episodes attributed to the Practice Evaluation ID (for a Working Specialty) divided by the total expected cost for those episodes. Peer Comparison: All comparisons are made to specialty peers in the same geographic area on episodes in the same Medical Episode Group (MEG) at the same level of severity, in the same comorbidity group and during the same time period. Practice Evaluation ID: The Tax Identification Number for group providers or other unique identifier for solo providers. Severity: Indicates the level of severity observed in episodes of a specific clinical condition (Medical Episode Group). Subdivisions (x.xx) indicate more precise classification. For some Medical Episode Groups, severity is further classified using age, gender and type of episode. 0 History of a significant predisposing factor for the disease, but no current pathology, e.g., history of carcinoma or neonate born to mother suspected of infection at time of delivery 1 Conditions with no complications or problems with minimal severity 2 Problems limited to a single organ or system; significantly increased risk of complications than Stage 1 3 Multiple site involvement; generalized systemic involvement; poor prognosis Working Specialty: A specialty designation derived by utilizing the physician s primary, secondary and tertiary specialties on record, practice limitations, physician type, and in certain cases, primary place of service. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association bcbstx.com 18