Anthem Blue Cross and Blue Shield

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1 Anthem Blue Cross and Blue Shield 2008 Quality Incentive Program for Cardiology and Obstetrics/Gynecology Part of the Anthem Quality Insights suite of innovative, quality recognition and health improvement programs 7543EST Rev. 2/08

2 Anthem Blue Cross and Blue Shield 2008 Quality Incentive Program for Cardiology and Obstetrics/Gynecology Anthem Blue Cross and Blue Shield is pleased to introduce the AQI Quality Incentive Program for eligible Cardiology and Obstetrics/Gynecology physicians throughout Connecticut, Maine and New Hampshire. This program rewards performance for specialty care services based on industry standard measures of quality, including process measures, technology measures and pharmacy measures that enhance patient care. The AQI Quality Incentive Program is just one component of the Anthem Quality Insights suite of innovative, quality recognition and health improvement programs that are designed to help address some of the most pervasive and costly health concerns. Anthem Quality Insights is redefining the relationship that health care physicians traditionally have had with insurers by creating a mutually beneficial, patient-focused collaboration that is right for today s health care environment. The 2008 Quality Incentive Program will reward eligible physicians who render cardiology and obstetric/gynecology services to our members. It is just one more example of how we are working to fulfill our mission of improving the lives of the people we serve and the health of our communites. We are committed to applying the resources of our company to help prevent disease and disability; to helping our members achieve their personal health goals; and to leading the way in improving the quality and affordability of health care delivery. What are the goals of the Quality Incentive Program? This Program was developed to foster positive, collaborative relationships with our participating physicians that will enable us to promote improved health outcomes through an emphasis on quality care services. Who is eligible for the Program? Participating physicians who specialize in and have designated their primary specialty as Cardiology or Obstetrics/Gynecology are eligible. Eligible physicians providing services to members with Anthem Blue Cross and Blue Shield commercial plans and products (HMO, POS, PPO, and Traditional/ Indemnity) as their primary coverage in Connecticut, Maine or New Hampshire. For physicians who are part of a multi-specialty group, participation in this program is limited to those physicians in the group who are in the specialties listed above. A physician group is defined as an organization at the Tax ID level. A group may include one or more practitioners. A group is eligible for the program if at least one physician in the group is eligible as of December 31, Physician groups that are part of individually negotiated contracts, such as PHOs and other entities, may not be eligible for the program at this time. Scoring and any compensation increases will be limited to those physicians who are eligible to participate in the program. A physician group must have a minimum number of Anthem Blue Cross and Blue Shield members for each component, as outlined in the chart below, to be eligible for points related to that component of the program. This helps to ensure that we will be able to effectively and fairly assess the group. Component Cardiology Coronary Artery Disease OB/GYN Primary and Preventative Care/Postpartum Care Pharmacy Generic Utilization Technology EMR/EHR, e-rx, Electronic Disease/ Patient Registry Use of AQI Web Portal Minimum Number of Unique Anthem Members Required for Eligibility 25 members, in total, in each program for all Process Measures Combined (members are counted only once) 1 member with prescription drug coverage administered by Wellpoint NextRx 1 member 1

3 What period of time does the Program cover? The measurement period for the program is January 1, 2008 through December 31, What do practices need to know about the AQI Web Portal? The AQI Web Portal, which is an online tool, is available at anthem.com through Anthem Online Provider Services (AOPS). Physicians must enroll free of charge with AOPS for access to the portal. The portal allows physician offices to receive information about the program. In addition, it offers Web-based tools to help practices provide quality care to their patients and to optimize their incentive opportunity. We encourage you to sign up for the portal. We anticipate implementation of the Web portal for Cardiology and Obstetrics/Gynecology practices in summer If you have any questions please contact your Network/Provider Relations Consultant or us at: When will my performance results be available? Final performance results will be available on the Web Portal to physicians in June You will have until June 15, 2009 to review and comment on your final results. If you have any questions please contact your Network/Provider Relations Consultant or us at: What are the measures used in the Program? The program includes a combination of Chronic Disease, Primary, Preventive and Postpartum Process Measures, as well as measures focused on technology and pharmacy utilization. Process measures and pharmacy measures are based on administrative paid claims only. Additional information about the measures follows. How were the measures developed? We used a variety of resources, including focus groups, research, and data analysis in the development of these measures. The Process Measures are similar to the National Quality Forum (NQF) Endorsed TM National Voluntary Consensus Standards and HEDIS. Professional NQF members include the American College of Cardiology, American College of Obstetricians and Gynecologists, American Heart Association, American Medical Association, and Physician Consortium for Performance Improvement, Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). The Health Plan Employer Data and Information Set reporting, HEDIS reporting is the standard for data collection and performance measurement of managed care. NQF Endorsed TM is a registered trademark of the National Quality Forum. HEDIS is a registered trademark of the National Committee for Quality Assurance. CARDIOLOGY PROCESS MEASURES Coronary Artery Disease (CAD) The American Heart Association estimates that chronic stable coronary artery disease (CAD) is the leading cause of mortality in the United States, accounting for one in five deaths in The incidence of CAD events and reoccurrence can be reduced with appropriate care. The estimated direct and indirect cost of CAD is $142.5 billion a year. Measures Lipid Profile Members age 18 with CAD who had at least one lipid profile during the measurement year. ACE Inhibitor or ARB Therapy Members age 18 with CAD who also have diabetes and who were prescribed ACE inhibitor or ARB therapy during the measurement year. Lipid Lowering Therapy Members age 18 with CAD who were prescribed lipid-lowering therapy during the measurement year. 2

4 OBSTETRICS/GYNECOLOGY PROCESS MEASURES Primary and Preventive Care (OB/GYN) The American College of Obstetricians and Gynecologists states prevention and early detection are the keys to reducing deaths from cervical and breast cancers and incidence of Chlamydia infection. Chlamydia is a major cause of infertility, pelvic inflammatory disease (PID), and ectopic pregnancy in women, and the direct and indirect costs of these illnesses exceed $2 billion as reported by the Centers for Disease Control and Prevention; Measure Cervical Cancer Screening Women ages who had one or more Pap tests during the measurement year or the 2 years prior to the measurement year. Mammography Screening Women ages who had one or more mammograms during the measurement year or the year prior to the measurement year. Chlamydia Screening Women ages who are sexually active and had at least one Chlamydia test during the measurement year. Postpartum Care According to the American College of Obstetricians and Gynecologists maternal medical risk factors can contribute to serious pregnancy complications and infant deaths, particularly if risk factors are not assessed or are not treated properly. Measures Postpartum Care Women age 18 who had a postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery. TECHNOLOGY MEASURES Technology services can reduce errors, improve clinical quality and promote administrative and cost efficiencies in physician offices. Measure A physician/group can earn points if at least one of the physicians under the group s Tax ID is utilizing any of the following technologies to the extent described. Electronic Medical Record (EMR) or Electronic Health Record (EHR): Implemented and in us prior to January 1, 2009, that is used to manage patient documentation for at least some of your patients on a regular basis. Electronic Prescription (e-rx): Implemented and in use prior to January 1, The practice must be using this tool to generate prescriptions in place of handwritten prescriptions. It is not required that the product electronically submits prescriptions directly to the pharmacy. Electronic Disease/Patient Registry: Implemented and in use prior to January 1, The system must be able to produce lists of patients with chronic diseases/conditions and must be able to produce patient lists that can be used for patient recalls, follow ups, and other purposes. Use of the AQI Web Portal: The practice has registered for access to the AQI Web Portal. We recommend the use of the portal to review member rosters and monitor your performance in the program. What information is required from practices for the Technology Component? The Technology Component will be scored based on a survey. Information about the availability of the survey will be posted on the web portal in July Completed surveys must be submitted by February 15, 2009 to be considered for technology related points. 3

5 PHARMACY MEASURE Generic Drug Utilization In addition to cost savings, studies have shown that patient compliance is greater with generic prescriptions. Measure Generic drugs prescribed, during the measurement period, better (higher) than the network rate. This measure is calculated on a point system by first looking at the specialty of the physician/group and then comparing that physician/group s generic utilization to the state-wide network rate for that same specialty. We anticipate the generic reports will be available on the AQI Web Portal in July These reports will allow you to review your performance. If you wish to obtain an up to date generic drug report, please contact our Clinical Account Pharmacists: CT Lisa Meland at (203) ME Helen Pervanas at (603) NH Helen Pervanas at (603) How are the measurements scored? Each provider/group will be scored on their aggregate points*. The maximum achievable points is 100. The chart below depicts the maximum achievable points for each component. Program Component: Chronic Disease and Preventive (Process) 50 Pharmacy: Generic Drug Utilization 25 Technology (Structure): EMR/EHR, 20 e-rx, Electronic Disease Registry Use of the AQI Web Portal 5 Points Physician s Group Total 100 * For physicians who are part of a multi-specialty group, please note that only those physicians in the group who have designated their primary specialty as cardiology and obstetrics/gynecology will be included in the program. Scoring and any compensation increases will be limited to those physicians who are eligible to participate in the program. When and how is the quality incentive paid? The 2008 Quality Incentive Program will reward qualifying physicians through an adjustment to fee schedule-based payments over the period July 1, 2009 through June 30, Services to members with Anthem s commercial products (HMO, POS, PPO, traditional/indemnity), FEP, national accounts and BlueCard as their primary coverage in Connecticut, Maine and New Hampshire are eligible for fee schedule based adjustments. Physician groups that meet or exceed the Plan threshold goal, but do not meet the Plan target goal, will be eligible to receive a 2% fee schedule-based increase (provided they satisfy the threshold number of members required). Physician groups that meet or exceed the Plan target goal, but do not meet the Plan maximum goal, will be eligible to receive a 4% fee schedule-based increase (provided they satisfy the threshold number of members required). Physician groups that meet or exceed the Plan maximum goal will be eligible to receive a 6% fee schedule-based increase (provided they satisfy the threshold number of members required). Physician groups who do not meet the Plan threshold goal will not be eligible for the incentive reward. For eligible specialists in a group practice, the eligibility criteria and performance results of all the eligible specialists in the group will be aggregated at the Tax ID level. Total Points Achieved % % % Adjustment to Fee Schedule The above rewards are non-cumulative. In other words, a physician group cannot qualify for more than one fee schedule increase. In a multi-specialty group, any fee schedule increase will apply only to the eligible specialists in the group. How can I find out more about the Quality Improvement Program targets and scoring? Additional information and updates will be available on the AQI Web Portal. The Web Portal is available at anthem.com. We encourage you to sign up for the portal. We anticipate implementation of the Web Portal for Cardiology and Obstetrics/Gynecology in the summer of

6 Who do I contact with questions? If you have any questions about the Anthem Blue Cross and Blue Shield 2007 AQI Quality Incentive Program for Cardiology and OB/GYN physicians, please contact your Network/Provider Relations Consultant or contact us at ppmne@anthem.com. Anthem Quality Insights 2008 Cardiology Quality Incentive Measures and Scoring Component Goals and Scoring Maximum Possible Points Process Measures Requires a minimum of 25 unique members eligible for all Process Measures combined. Lipid Profile Drug Therapy for lowering LDL cholesterol (LDL-C) ACE Inhibitor Therapy for members who also have diabetes Threshold Goal 30 Total Process Measures score from 50% to 55% Target Goal 40 Total Process Measures score from 56% to 69% Maximum Goal 50 Total Process Measures score greater than or equal to 70% 50 Pharmacy Measure Applies only to members with pharmacy coverage through NextRx. Generic Utilization Percentage difference between Group and Network Rates Threshold Goal 15 Generic rate equal to the Comparison Network Rate and up to 1.99% above the Comparison Network Rate. Target Goal 20 Generic rate between 2% and 2.99% above Comparison Network Rate Maximum Goal 25 Generic rate greater than or equal to 3% above Comparison Network Rate 25 Technology Measures Applies only to technology in use for at least one unique member under the group s tax ID. Technologies Applies only to technology in use by at least one provider under the group s tax ID. Electronic Patient/Disease Registry 10 Electronic Rx 15 EMR/EHR Use of AQI Web Portal Registered User of AQI Web Portal 5 5 Total Points 100 5

7 Anthem Quality Insights 2008 OB/GYN Quality Incentive Measures and Scoring Component Goals and Scoring Maximum Possible Points Process Measures Requires a minimum of 25 unique members eligible for all Process Measures combined. Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening Post-Partum Follow Up Threshold Goal 30 Total Process Measures score from 50% to 55% Target Goal 40 Total Process Measures score from 56% to 69% Maximum Goal 50 Total Process Measures score greater than or equal to 70% 50 Pharmacy Measure Applies only to members with pharmacy coverage through NextRx. Generic Utilization Percentage difference between Group and Network Rates Threshold Goal 15 Generic rate equal to the Comparison Network Rate and up to 1.99% above the Comparison Network Rate. Target Goal 20 Generic rate between 2% and 2.99% above Comparison Network Rate Maximum Goal 25 Generic rate greater than or equal to 3% above Comparison Network Rate 25 Technology Measures Applies only to technology in use for at least one unique member under the group s tax ID. Technologies Applies only to technology in use by at least one provider under the group s tax ID. Electronic Patient/Disease Registry 10 Electronic Rx 15 EMR/EHR Use of AQI Web Portal Registered user of the AQI Web Portal 5 5 Total Points 100 6

8 Anthem Blue Cross and Blue Shield is the trade name of: In Connecticut: Anthem Health Plans, Inc. In Maine: Anthem Health Plans of Maine, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Virginia: Anthem Health Plans of Virginia, Inc. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association.