Cigna Care Designation and Physician Quality and Cost-Efficiency Displays 2015 Methodologies Whitepaper

Transcription

1 Cigna Care Designation and Physician Quality and Cost-Efficiency Displays 2015 Methodologies Whitepaper For Health Care Professionals February 2015 Introduction... 2 Cigna Physician Quality and Cost-Efficiency Display Principles... 2 Cigna Care Designation and Physician Quality and Cost-Efficiency Displays Overview... 3 Specialty Assessed for Cigna Care Designation and Physician Quality and Cost-Efficiency Displays... 6 Quality Evaluation... 6 Evidence Based Medicine (EBM) Assessment Process... 7 Cost-Efficiency Evaluation Outlier Methodology Assigning the Cigna Care Designation (2015 CCD Inclusion Methodology) Credit for Utilizing Cigna Centers of Excellence Buffer Zone Methodology Collaborative Accountable Care Pathway to Achieving Cigna Care Designation Data Sources Additional Information and Data Limitations Process to Display Strategic Alliances Information Feedback Process Physician Process to Correct Errors, Request Reconsideration, or Appeal How to Register Complaints Physician Evaluation Methodology Changes Appendices Appendix 1: 2015 Cigna Care Designation Market Information Appendix 2: 2015 Quality and Cost-Efficiency Display Markets Appendix 3: EBM Rules Used for the 2015 Physician Evaluation Appendix 4: Appeals Process for Colorado Health Care Professionals Abbreviations List Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 1

2 Introduction We evaluate physician quality and cost-efficiency information by using a methodology consistent with national standards and incorporating physician feedback. Using this information, we are able to provide our customers and clients with relevant consumer-oriented information through the physician quality and cost- efficiency displays and the Cigna Care designation (CCD) program. The purpose of this document is to provide an overview of our Physician Quality and Cost-Efficiency Displays Program, explain the methodology used to measure individual physicians and medical groups for quality and costefficiency results, and provide details regarding the physician quality and cost-efficiency display information used. Cigna Physician Quality and Cost-Efficiency Display Principles We believe that our customers and employers have a right to know information regarding the quality and costeffectiveness of physicians. We follow three key principles when providing our physician quality and costeffectiveness information to customers, clients, and physicians: 1. Standardized performance measures using the most comprehensive data set available We use nationally recognized measures derived from those endorsed by the Forum (NQF), Ambulatory Care Quality Alliance (AQA), Healthcare Effectiveness Data Information Set (HEDIS 1 ), or those developed by national physician organizations such as the American Medical Association (AMA). 2. Responsible use of the information The displays reflect a partial assessment of quality and cost-efficiency based on our claims data, and should not be the sole basis for decision-making (as such measures have a risk of error). Cigna customers are encouraged to consider all relevant factors and to consult with their treating physician when selecting a physician for care. In general, the health care professionals in Cigna's networks are independent practitioners. They are not employees or agents of Cigna. Treatment decisions are made exclusively by the treating physician and the patient. Cigna provides its customers with helpful information to allow them to make more informed decisions. The quality and cost-efficiency markers used in evaluating physicians for Cigna Care designation are intended for that purpose only. Cigna does not guarantee the quality or cost-efficiency of the actual services provided by network physicians - even those physicians that qualify for the Cigna Care designation. 3. Collaboration and Improvement Enablement We are committed to providing information and solutions that can support access to quality health care. A detailed description of our methodology, information about the summary metrics, and ongoing data to help improve performance is available to physicians and physician groups. We also continue to have ongoing discussions with key physician organizations, ranging from national associations to large physician groups, who provide input for future design changes. Frequency of Reviews The methodology for determining the Cigna Care designation and physician quality and cost-efficiency displays is subject to change annually as tools and industry standards evolve and physician feedback is obtained. The assessment review period for Cigna Care designation and quality and cost-effectiveness displays for 2015 is January 1, 2012 through December 31, This review includes claims data from Cigna Managed Care and PPO plans. External Certification Cigna earned Physician and Hospital Quality Certification for the third time in August The NCQA Physician and Hospital Quality (PHQ) certification program evaluates how well health plans measure and report the quality and cost of physicians and hospitals. NCQA Physician Quality Certification Standards meet New York state requirements implemented in November 2007 concerning physician performance measurement, reporting and tiering programs. 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 2

3 Cigna Care Designation and Physician Quality and Cost-Efficiency Displays Overview There are two components of the Cigna Care designation and Physician Quality and Cost-Efficiency Displays programs, each of which is explained in more detail in the following sections of this document: 1. Quality evaluation and display: Physicians are evaluated on a number of criteria that we believe are markers of physician practice quality. The results of this evaluation are displayed in mycigna.com, our online health care professional directory that is available to Cigna customers. Results of selected quality markers (e.g., evidence based medicine (EBM) rule adherence and NCQA Physician Recognition) are used to qualify physicians and physician groups for Cigna Care designation. 2. Cost-efficiency evaluation and display: Individual physicians and physician groups are evaluated for their cost-efficiency using an industry-standard methodology (i.e., Episode Treatment Groups) that determines the average cost of treating an episode of care for a variety of medical conditions and surgical procedures. We then compare those episode costs to those of other physicians and medical groups of the same specialty in the same geographical market. The results of this evaluation are displayed in our online health care professional directory using one, two or three stars, with three stars being the highest rating (i.e., the most cost-efficient). Cigna Care designation: Cigna Care designation is assigned to individual participating physicians and physician groups based on Cigna's cost-efficiency and quality criteria. If an individual physician or physician group does not meet the Cigna Care designation criteria and the physician or physician group participates in a Cigna Collaborative Accountable Care (CAC), they may receive Cigna Care designation if they meet certain cost and quality thresholds (see pages for more details). Cost and quality evaluation provides individual physicians and physician groups that are ranked in the top 40% for quality and the top 40% for cost-efficiency compared to all physicians and physician groups of the same group specialty type in the same geographic market with the Cigna Care designation. In the absence of a sufficient number of cost episodes to evaluate cost-efficiency, physicians and physician groups that rank in the top 34% for quality compared to groups of the same specialty in their market also receive the Cigna Care designation. In the absence of a sufficient number of quality opportunities to evaluate quality, physicians and physician groups that rank in the top 34% for cost compared to groups of the same specialty in their market also receive the Cigna Care designation (see page 11 for more information regarding assigning CCD based on cost and quality). They are identified with a Symbol ( ) and Cigna Care Designation in the online health care professional directory on Cigna.com and mycigna.com. (Please see the sample healthcare professional directory display on page 5.) Cigna Care designation benefit design: The Cigna Care designation is a benefit plan design option offered to organizations sponsoring group health benefit plans. Available in 71 service areas, the designation distinguishes physicians in 21 specialties (three primary care + 18 other specialties) who participate in our network, based on their meeting the above referenced quality and cost-efficiency criteria. The Cigna Care benefit design, which is intended to encourage Cigna customers covered by these plans to consider using a Cigna Care designated physician, affords a lower co-payment or coinsurance for services provided by a designated physician than if the individual were to select a participating, non-designated physician. Overall physician reimbursement is unchanged. Geographical markets that the Cigna Care designation benefit plan is offered in 2015 were defined by our Network Contracting and Market Medical Executive teams. The zip code of a physician s primary office address is used to align a physician with a given market. The physician s specialty and geographic market is then used to determine the physician peer group for comparison of quality and cost-efficiency outcomes. Please see Appendix 1 for a list of markets, the volume of physicians reviewed, and the percent of physicians reviewed in each market that are Cigna Care designated, effective January 1, Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 3

4 Physician Cost-Efficiency Displays Information regarding the physician s cost-effectiveness performance is displayed only on mycigna.com, the secure website for Cigna customers. The displays are available in 72 markets for the 21 specialty types assessed for Cigna Care designation, including the 18 specialty types assessed for the Cigna Care designation, and three primary care physician (PCP) specialty types (,, and ). Cost-efficiency stars are used to communicate cost-efficiency performance. Three stars for cost- efficiency represent the top 34% of physicians or physician groups when compared to other physicians and physician groups of the same group specialty type within the geographic market. Two stars represent physicians or physician groups in the middle 33% for cost-efficiency. Physician groups that are in the lower 33% for costefficiency receive one star. Cost-Efficiency Symbols Results in top category for cost-efficiency measures Results in middle category for cost-efficiency Results in the low category for cost-efficiency Please see Appendix 2 for the geographical markets and volume of physicians reviewed for physician quality and cost-efficiency displays, beginning January 1, Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 4

5 Sample: Online health care professional directory displays (mycigna.com) Denotes physician with Cigna Care Designation Quality and cost-efficiency recognitions Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 5

6 Specialty Assessed for Cigna Care Designation and Physician Quality and Cost-Efficiency Displays We assess a total of 21 physician specialty types including primary care, as identified in the following table. A physician may only be assigned one specialty, tax identification number (TIN), and geographical market for Cigna Care designation or physician quality and cost-efficiency displays. The physician s primary specialty, as listed in the Cigna Central Provider File, is used to establish the specialty to evaluate physicians with multiple specialties. Assessed Specialty Allergy and Immunology Cardiology Cardio-Thoracic Surgery Dermatology Ear, Nose and Throat Endocrinology Gastroenterology General Surgery Hematology and Oncology* Nephrology Neurology Neurosurgery Obstetrics and Gynecology Ophthalmology Orthopedics and Surgery Pulmonary Rheumatology Urology *Does not include Radiation Oncology Participating physicians in the 21 specialty types reviewed for the Cigna Care designation account for over 90% of primary and specialty care and 85% of total medical and pharmaceutical spending based on our claims data. Quality Evaluation Information relative to specific quality criteria met by a physician is displayed in the online health care professional directory on both the public and secure websites at Cigna.com and mycigna.com. We use five quality indicators to review participating physicians in the 21 specialty types. Each physician qualifying for a specific quality indicator is identified in our online healthcare professional directory. 1. National Committee for Quality Assurance (NCQA) Physician Recognition The NCQA recognition in our online directory is given to physicians who have received recognition in any of the six NCQA Physician Recognition Programs: back pain, diabetes, heart/stroke, physician practice connections, and patient-centered medical home 2011 (2 versions). Effective January 1, 2015, Cigna began recognizing the additional physician recognition - the NCQA Patient Centered Specialty Practice Program - as a quality indicator for reviewing participating physicians in the 21 specialty types. The verbiage below reflects the display of the quality recognitions in the online directory. NCQA Diabetes Physician Recognition Program (DRP) - identifies primary care physicians, endocrinologists and diabetes specialists who provide care to people with diabetes. This program assesses key measures specific to diabetes care, such as monitoring and management of blood pressure, cholesterol and glucose levels, patient satisfaction, and other important measures. NCQA Heart/Stroke Physician Recognition Program (HSRP) - identifies doctors who provide quality care to people with heart disease or a history of strokes. This program assesses key measures specific to heart disease and stroke care, such as blood pressure and cholesterol level control, smoking status and advice or treatment for quitting, patient satisfaction, and other important measures. NCQA Physician Practice Connections (PPC) - assesses the systematic use of information in doctors' practices to improve the quality of care. This program recognizes physicians who consistently keep their patients well informed about their health, who are actively engaged in improving their patients' health over time, and who successfully use technology and other tools to prevent medical errors. NCQA Back Pain Recognition Program (BPRP) - recognizes physicians and chiropractors who deliver superior care to their patients suffering from low back pain. The program assesses the diagnosis process, treatment and advice focused on helping patients return to normal activities. NCQA Physician Practice Connections - Patient-Centered Medical Home TM (PCMH - 2 versions) - recognizes doctors that effectively manage their patient's care by coordinating with other doctors, specialists and family members to deliver a holistic, or comprehensive, patient treatment. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 6

7 NCQA Patient Centered Specialty Practice (PCSP) recognizes practices that have demonstrated commitment to patient-centered care and clinical quality through: streamlined referral processes and care coordination with referring clinicians, timely patient and caregiver-focused care management and continuous clinical quality improvement. Additional information about these programs is available on the NCQA website ( > Programs > Physician Recognition). 2. Group Board Certification Group board certification criteria, based on American Board of Medical Specialties & American Osteopathic Association certification information, determine if care provided by a group is predominantly provided by board certified physicians. This standard is met if: either 80% of physicians within a group are board certified and provide 50% of the care, or at least 80% of the care is provided by board certified physicians, OR for practices/groups with 4 or fewer physicians, either 65% of physicians within a group are board certified and provide 50% of the care, or at least 65% of the care is provided by board certified physicians 3. Adherence to Evidence-Based Medicine (EBM) Rules The quality of physician care is evaluated using a claims-based assessment based on 99 EBM rules derived from rules endorsed by the Forum (NQF), Ambulatory Care Quality Alliance (AQA), Healthcare Effectiveness Data Information Set (HEDIS), or developed by physician organizations. These rules span 48 diseases and preventive care conditions (see Appendix three), and is potentially applicable to the care provided by physicians in 20 specialty types. For a list of the specialty types that are covered by evidence-based medicine rules, please see the Specialty Covered by Evidence Based Medicine Rules chart below. 4. American Board of Process Improvement Module Completion (ABIM-PIM) We recognize physicians who have completed one or more American Board of Practice Improvement modules (ABIM PIM) as part of the ABIM Maintenance of Certification program. Certification/recertification must be achieved every two years. 5. Evidence-Based Medicine (EBM) Assessment Process Evidence-based medicine rules that we currently use are applicable to 20 primary care and non-primary care specialties. Currently there are no evidence based medicine rules applicable to dermatology. Overall, approximately 15% of physicians in the specialties noted below (including Dermatology) are associated with groups that do not have sufficient volume to assess adherence to the EBM rules however they have sufficient volume to assess cost-efficiency. Similarly, 4,226 or almost 1% of physicians are associated with groups that do not have sufficient volume to assess cost-efficiency and therefore are assessed based on adherence with the EBM rules alone. Evidence Based Medicine (EBM) Assessment Process Specialty Covered by Evidence Based Medicine Rules Allergy and Immunology Cardiology Cardiothoracic Surgery Endocrinology Gastroenterology General Surgery Hematology and Oncology Nephrology Neurology Neurosurgery Obstetrics and Gynecology (OB/GYN) Ophthalmology Orthopedics and Surgery Otolaryngology (ENT) Pulmonary Rheumatology Urology Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 7

8 The EBM assessment component of the Cigna Care Designation program for 2015 involves assessment of compliance with a total of 99 EBM rules (see Appendix 3) for the medical conditions displayed in the following table: Disease and Preventive Care Conditions Covered By Evidence Based Medicine Rules Adenoidectomy Adolescent Well-Care Asthma Atrial Fibrillation Attention Deficit Hyperactivity Disorder (ADHD) Breast Cancer I & II Bronchitis (Acute) Cardiac Surgery Cerebral Vascular Accident Cervical Dysplasia Children and Adolescents' Access to Primary Care Practitioners Children s Access to Primary Care Practitioners Chlamydia Screening Cholesterol Management Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Congestive Heart Failure Colon Cancer -II Depression Medication Management Diabetes COPD Exacerbation, Pharmacotherapy Management Comprehensive Ischemic Vascular Disease Care Coronary Artery Disease Epilepsy Hepatitis C Hypertension Inflammatory Bowel Disease Knee Replacement Low Back Pain Migraine Multiple Sclerosis Obesity and Overweight Osteoporosis Otitis Externa (Acute) Pharyngitis Otitis Media Pneumonia (Community Acquires Bacterial) Persistence of Beta Blocker Treatment After MI Pregnancy Management Prenatal Care Prostate Cancer I & II Rheumatoid Arthritis Rheumatoid Arthritis, Drug Therapy Sickle Cell Anemia Sinusitis Tonsillectomy Tympanostomy Upper Respiratory Infection Definitions used in the following methodology description: 1. Physician specialty type: any one of the 21 specialty types listed in the table of Assessed Specialty found on page 7 of this white paper 2. Group specialty type: any one of the 21specialty types listed in the table of Assessed Specialty found on p. of this white paper if the medical group is comprised of physicians all of the same specialty, or in the case of mixed specialty groups, one of the following mixed specialty group designations: multispecialty medical group (mixture of multiple non-pcp specialists), mixed specialty medical group (mixture of PCPs and non-pcp specialists), primary care medical group (mixture of PCP specialists) 3. Specialty category: primary care specialties (FP, IM, PD) or non-primary care specialties (the 18 other specialties assessed for CCD) Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 8

9 We determine the extent to which an individual physician or physician group complies with evidence-based medicine rules according to the following conventions: Determining peer or market EBM rule adherence for each geographic market: In order for an EBM rule to be included for review at the geographic market level for a physician or physician group, there must be at least 20 opportunities for the rule within the specialty category (primary care or nonprimary care specialties) and market for the most recent two-year data review period. For 2015 displays and Cigna Care designation, that period is January 1, 2012 December 31, 2013 The average adherence rate for each EBM rule is calculated for the specialty category (primary care or nonprimary care specialties) for each geographic market to derive the peer/market average result. Determining individual physician or group practice EBM rule adherence: Opportunities and successes for each eligible EBM rule are aligned to the appropriate individual physician (using the visit requirements outlined below and relevant specialty type category). Visit Requirements: A physician is considered responsible for adherence to the EBM rule if the following conditions are met: o The EBM rule is relevant to the physician s specialty (see Appendix 3). For example, the Cervical Dysplasia EBM rule is relevant to OB/GYN,, and, but it is not relevant to other specialties. o There have been at least two office visit encounters for an individual with Cigna coverage during the claim review period. o At least one of the office visit encounters occurred in the last 12 months of the claim review period. Note: 19 of our EBM measures require only one office visit encounter in the last 12 months of the claim review period. These measures are identified by an asterisk [*] in Appendix 3. Individual physicians are aligned to medical groups (practices), and EBM rule opportunities, successes, and expected successes are then summed to obtain medical group totals. A Quality Index for the medical group is calculated by dividing the physician s or physician group s number of actual EBM rule adherence successes by the physician s or physician group s number of expected EBM rule adherence successes. Expected EBM rule adherence successes are derived by applying the geographic market average EBM rule adherence success rates to that physician medical group s particular rule mix opportunities. A 90% confidence interval around the Quality Index is determined, allowing EBM quality performance to be measured with a strong degree of certainty. The lower bound of the 90% confidence interval for a particular physician or physician group is defined as the Adjusted Quality Index for that physician medical group. Physician medical groups that meet the Cigna group board-certification criteria, have 30 or more total EBM rule adherence opportunities, and have at least 50% of their treatment episodes (used in the physician s or medical group s cost-efficiency (ETG) analysis) attributed to the physician specialty types that are assessed for EBM rule adherence are assessed and ranked using the Adjusted Quality Index score. Physicians or physician groups with an Adjusted Quality Index score in the best 34% of their medical group specialty type and geographic market are placed in the best category for EBM rule adherence. Physicians or physician groups that have results in approximately the lowest 2.5%, for the medical group specialty types in the market where there are at least 20 medical groups of that medical group specialty type in the market, are placed in the bottom category. The remainder is in the middle category. A threshold is set for each market and for each medical group specialty type within a market. These thresholds are determined by specific market considerations such as geography, specialty volume, access to specialty care and contract requirements. Thresholds range from approximately 30% - 70%. The use of threshold adjustments allows for individual market factors to be taken into account; however, it is important to note that when such market-specific threshold adjustments are made, all other physician medical groups in Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 9

10 that market of the same medical group specialty type that also meet the revised market threshold value, will then be deemed to have met the quality requirement for Cigna Care designation. We do not risk-adjust EBM (quality) measures due to the fact that the EBM rules have explicit definitions for both the numerator and the denominator of each measure. The denominator explicitly defines the population that is at risk; thus risk adjustment is incorporated into the definition of the measure. Cost-Efficiency Evaluation We use Episode Treatment Group (ETG) methodology, an industry standard, available through OPTUM to evaluate the cost-efficiency of individual physicians and medical groups. The methodology incorporates case-mix and severity adjustment, and claims are clustered into over 500 different episodes of care. Additional information about the OPTUMInsight Episode Treatment Groups, including a complete listing of the ETGs, is available at Using the ETG methodology, we can determine how a physician medical group s cost-efficiency compares to other physician medical groups of the same group specialty type (primary care physician group, mixed specialty group, multi-specialty group) in the same geographic market. For example, in the case of single-specialty primary care medical groups, the medical group s cost-efficiency performance is compared to the performance of other single-specialty primary care medical groups in the same market, i.e., FP medical groups are compared to other FP medical groups, IM medical groups are compared to other IM medical groups, and PD medical groups are compared to other PD medical groups. A physician or physician group s performance is a result of its fee schedule, utilization patterns and referral patterns (e.g., use of hospitals and other facilities). ETG Assessment Requirements: There must be at least 10 occurrences of a specific ETG (e.g., incorporating episode severity and treatment level, co-morbidity, complications, or the presence of Rx benefits) within the geographic market and specific physician specialty type in order to determine the market average cost for that ETG, and thus include it in the market s analysis. The peer or market average for each specific ETG is established for each market and physician specialty type. To reduce variation within cost-efficiency results, several ETGs are excluded from the assessment process, including routine immunizations and other inoculations, transplants, and ETGs with low volume or wide cost variation. Episodes with a severity level of four (the highest severity level assigned by the OPTUMInsight ETG software), are also excluded from analysis, for most conditions. Example: For the Nashville market during the data analysis period, there are 15 occurrences of ETG XX (with the same severity, treatment level, co-morbidity, complications, and presence of pharmacy benefits) that are attributed to family physicians. The average cost of ETG XX for family physicians in the Nashville market is established by computing the numerical average of the cost of all 15 occurrences of this ETG subject to the application of outlier trimming methodology outlined in the following section. This process is replicated for each ETG with at least 10 occurrences in the Nashville market for a given physician specialty type in order to determine the market cost average for each ETG that is eligible for evaluation in the market. ETG Assessment Process: Individual physician medical groups must have at least 30 total episodes of care during the review period in order to be reviewed for cost-efficiency. In order for an episode to be attributed to a physician (responsible physician), two criteria must be met: (1) the physician must be responsible for more costs for medical or surgical management services than any other physician providing care for the episode, and (2) the medical or surgical management costs for the physician must be at least 30% of the total episode medical or surgical management costs. If these two criteria are not met, the episode is excluded from analysis. While only the costs associated with physicians provision of management services are used to attribute the episode to a particular physician, total costs (physician management costs + all ancillary costs (e.g., lab, X-ray, hospital, ambulatory surgery, physical therapy, etc.) are used to characterize the total cost of the episode. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 10

11 The actual cost of an episode of care for each physician group and for the physicians within that group is compared to the market average cost of an episode of care, which is derived using their unique mix of ETGs and the peer averages. The sum of all actual ETG episode costs for a medical group divided by the sum of all corresponding ETG episode market average costs is the medical group s Performance Index. Example: The ABC Physician Group consisting of three family physicians in the Nashville market has five episodes of care belonging to two unique ETGs (ETG1 and ETG2) that are attributable to the group. For the sake of simplicity, disregard for the purpose of this example the requirement that the physician or physician group must have a minimum of 30 attributable episodes in order to be reviewed for cost- efficiency. Average episode costs for ETG1 and ETG2 have been established for all other primary care physicians or groups practicing in the Nashville market. Three episodes of ETG1 are attributable to the ABC Physician Group and two episodes of ETG2 are attributable to the ABC Physician Group. In the table below, the physician group s cost per episode is displayed for each of the three occurrences of ETG1 and for each of the two occurrences of ETG2, along with the market average cost for an episode for ETG1 and ETG2 for all family physicians in the Nashville Market. Actual Episode Cost Market Average Cost ETG ETG ETG ETG 2 15,000 19,000 ETG 2 18,000 19,000 Average 8,000 9,700 Performance Index = 8,000/9,700 = Dividing the average cost of all episodes of care attributable to the physician group by the average of all market average episode costs for the ETGs on which the physician group s cost-efficiency performance is being evaluated yields a Performance Index (PI) of The PI for the medical group can be interpreted as Medical Group ABC is 17.5% more cost-efficient than other family medicine physician medical groups in the Nashville market. A 90% Confidence Interval around the Performance Index is used to determine a range of performance within which the medical group s true performance would fall with a high level of confidence. The upper bound of the confidence interval is defined as the Adjusted Performance Index and is used to compare cost-efficiency performance among physician medical groups. The upper bound of the 90% confidence interval is used in order to ensure that the medical group s performance is at least as good as or better than the upper bound threshold. A threshold is set for each market and for each medical group specialty type within a market. These thresholds are determined by specific market considerations such as geography, specialty volume, access to specialty care and contract requirements. Thresholds range from approximately 30% - 70%. The use of threshold adjustments allows for individual market factors to be taken into account; however, it is important to note that when such market-specific threshold adjustments are made, all other physician medical groups in that market of the same medical group specialty type that also meet the revised market threshold value, will then be deemed to have met the cost-efficiency requirement for Cigna Care designation. Physician groups in the same medical group specialty type that meet Cigna board certification criteria and Cigna minimum volume of 30 episodes of care are ranked using the (cost-efficiency) Adjusted Performance Index score. Those groups with an Adjusted Performance Index score in the top 40% of their respective medical group specialty type and market are placed in the top category for cost-efficiency and consequently meet the cost-efficiency component requirement for Cigna Care designation (provided they also score in the top 40% for quality). To qualify for CCD on the basis of cost alone, medical groups must score in the top 34% of their respective medical group specialty type and market.) Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 11

12 2015 Outlier Methodology In order to portray physicians cost-efficiency performance in the most accurate manner, the cost-efficiency evaluation includes a methodology to account for episodes that are outliers. Outliers are episodes that are substantially different from the market expected amounts. High cost episodes (ETGs) that are greater than 1.5 times the market specialty averages are reduced to 1.5 times the market specialty average. Low cost outlier episodes are determined by the OPTUM software or are episodes of less than $25.00 and are excluded from the evaluation. Level of Evaluation (Unit of Analysis) While we review participating physicians at the individual level, the majority of assessments are performed at the physician group or practice, or group tax identification number level. Individual physicians who are not part of a group are assessed if volume criteria are met. This approach provides robust data for evaluation and is consistent with the assumption that: Patients with Cigna-administered coverage often chose a group rather than a specific physician within the group, and; Patients with Cigna-administered coverage who initially choose a specific physician frequently receive care by another physician within the practice or group. Assigning the Cigna Care Designation (2015 CCD Inclusion Methodology) In order to receive the Cigna Care designation, a physician must qualify on the basis of both medical group specialty quality and cost-efficiency OR be ranked in the top 34% for quality or cost-efficiency of an eligible medical group specialty within his/her geographic market for cost-efficiency. The details of the Cigna Care Designation assignment logic are outlined below and are displayed in the diagram on page 14. To be considered for Cigna Care Designation, physicians must be MDs and/or DOs in one of 18 non- primary care specialties or one of three primary care specialties. Note: Cigna performs its evaluations at the group level. Some groups include geriatric physicians, nurse practitioners, and physician assistants who deliver primary care services as part of the group. In such cases, geriatric physicians, nurse practitioners, and physician assistants will be considered for Cigna Care designation as part of the group. Physicians must meet a board certification requirement. For medical groups, this standard is met if: o either 80% of physicians within a group are board certified and provide 50% of the care, or at least 80% of the care is provided by board certified physicians, OR o for practices/groups with 4 or less physicians, either 65% of physicians within a group are board certified and provide 50% of the care, or at least 65% of the care is provided by board certified physicians The physician practice must have at least 30 evidence-based medicine (EBM) opportunities during the data collection period and at least 50% of the total care provided by the practice must be provided by physicians for whom there are applicable EBM rules. A Quality Index and Adjusted Quality Index are calculated for each practice. Physician practices are assigned to one of three quality categories based on the Adjusted Quality Index: top 34% of practices in the market for the practice s group specialty type; bottom 2.5% of practices in the market for the practice group specialty type; middle 2.5% to 66% of practices in the market for the practice s group specialty type. Practices in the Top 34% of Practices for Quality Based on EBM Assessment: If the Adjusted Quality Index for the practice is in the top 34% of all physician practices in the geographic market of the same physician group specialty type OR if the group has 50% or more of their physicians recognized in one of the six NCQA recognition programs, the practice meets the CCD quality requirement and is then evaluated on its cost-efficiency. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 12

13 The practice must have at least 30 episodes available for ETG assessment during the data collection period. A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice Adjusted Performance Index shows the practice is in the top 40% of all practices of the same group specialty type in the geographic market, the practice is awarded Cigna Care designation. Practices in the Middle Category (2.5% - 66%) for Quality Based on EBM Assessment: If the Adjusted Quality Index for the practice is in the middle category (2.5% - 66%) of all physician practices in the geographic market of the same specialty physician group specialty type, the practice is evaluated to determine if it is in the top 34% of all practices for cost-efficiency. The practice must have at least 30 episodes available for ETG assessment during the data collection period. A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice Adjusted Performance Index shows the practice is in the top 34% of all practices of the same group specialty type in the geographic market, the practice is awarded Cigna Care designation. Practices in the Bottom 2.5% for Quality Based on EBM Assessment: If the Adjusted Quality Index for the practice is in the bottom 2.5% of all physician practices in the geographic market of the same physician group specialty type, the practice, if it is a medical group, is excluded from Cigna Care designation. Note: Practices are only assigned to the bottom 2.5% in quality performance if there are at least 20 or more quality ranked groups in a specific geographic market. Practices Having Insufficient Volume to Assess Quality Based on EBM Assessment: If the practice has an insufficient volume of EBM opportunities (less than 30) in order to be assessed for quality based on EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes eligible for ETG assessment. If it meets the 30 episode criterion and the calculated practice Adjusted Performance Index is in the top 34% of all practices of the same physician group specialty type in the geographic market, the practice is awarded Cigna Care designation. If the practice has an insufficient volume of EBM opportunities in order to be assessed for quality based on EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes eligible for ETG assessment. If it meets the 30 episode criterion and the calculated Practice Adjusted Performance Index is NOT in the top 34% of all practices of the same group specialty type in the geographic market, the practice is excluded from Cigna Care designation. Practices Having Insufficient Volume to Assess Cost Based on ETG Assessment: If the practice has an insufficient volume of ETG opportunities (< 30) for cost profiling but has a sufficient number of EBM opportunities (>= 30) for quality profiling or meets the NCQA recognition criterion, the practice is eligible for CCD designation through a quality-only pathway. If the Adjusted Quality Index of the practice places it within the top 34% of practices of the same group specialty type in the same geographic market, the practice is awarded Cigna Care designation. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 13

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15 Credit for Utilizing Cigna Centers of Excellence Cigna evaluates hospital patient outcomes and cost-efficiency information through the Cigna Centers of Excellence (COE) program for all practices. Utilization of COEs by a reviewable physician practice provides credit towards Cigna Care designation. If at least 50% of the physicians in the practice each had at least three COE admissions during the data analysis period, then a one percentage-point increase in the Performance Index (for cost-efficiency) and a one percentage-point increase in the Quality Index will be granted. The increased Performance Index and Quality Index are then used to determine eligibility for Cigna Care designation. COE admissions must be consistent with the specialty of the physician providing the COE-related care in order to qualify. Buffer Zone Methodology Variation in physician group or physician group performance (e.g., positive or negative, substantial, or minimal) is inevitable and expected in an annual review process due to various factors (e.g., changes to physician group makeup, external market factors, and practice pattern modifications). A buffer zone methodology addresses small-scale variation for physician groups or physician groups whose Cigna Care designation changes from the previous year. A practice may maintain its Cigna Care designation status if the group was designated during the prior cycle, is within 3% of the current year's quality AND cost criteria, OR is within 3% of the cost index when the group does not meet cost and quality criteria. The selected physician group must meet certain standard Cigna Care designation criteria to achieve the 2014 buffer zone designation. The standard criteria applied includes meeting the physician group Board Certification criteria, the Board Certified physicians must be responsible for at least 50% of the group episodes, the group must have at least 30 episodes, and the group must not be in the bottom 2.5 market percentile for EBM quality performance in a market with greater than 20 groups within the specialty category in the market. Collaborative Accountable Care Pathway to Achieving Cigna Care Designation CAC to CCD Pathway Cigna has teamed up with selected physician groups in order to help them achieve the triple aim of improving quality, improving cost-effectiveness and improving the patient experience of care. This is called the Cigna Collaborative Accountable Care (CAC) model. Cigna's approach builds upon the foundation of Accountable Care Organizations (ACOs) and Patient Centered Medical Home (PCMH) models by recognizing physicians affiliated with the CACs that demonstrate improvement in medical delivery and clinical outcomes plus achieve improvement in reducing the cost of care. Cigna's approach is to work with physicians to provide them with resource support and data that can help them deliver optimal care. This support can include data about ER visits, hospitalizations, potential gaps in care, medication compliance, etc., which the physician might not otherwise have access to, and which can support the physician in optimal management of care delivery across multiple settings. This support can also focus on chronically ill patients by working with nurses who are part of the group practice, to provide them with information and tools to help them manage these patients and coordinate case management and educational support when needed. Cigna's CAC model is designed for collaboration with large physician groups that may or may not include specialists. These groups must meet volume thresholds for physicians and Cigna customers, as well as other minimum criteria. The groups enter into a contract with Cigna in which they agree to be evaluated based on quality and cost criteria that are unique to the CAC model. For 2015, physicians and physician groups will go through the CCD assessment through the standard CCD pathway to determine inclusion. If the physicians and physician groups were unable to achieve designation through the standard CCD pathway described previously in this white paper but they are affiliated with the CAC, then the CAC pathway inclusion criteria may be applied next to determine if they can be designated. The CAC achieving a Total Medical Cost Performance Index of less than or equal to 1.03 AND a CAC Quality Index of greater than or equal to 0.99 will be assigned the Cigna Care designation. Specialists that are affiliated with a CAC that meets the CCD criteria for inclusion and the Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 15

16 markets determine the specialists are to be included with the CAC; the specialists will be assigned designation. To be considered for Cigna Care designation, CAC physicians must be MDs and/or DOs in one of three primary care specialties or one of 18 non-primary care specialties. Note: Cigna performs its evaluations at the group level. Some groups include geriatric physicians, nurse practitioners, and physician assistants who deliver primary care services as part of the group. In such cases, geriatric physicians, nurse practitioners, and physician assistants will be considered for Cigna Care designation as part of the group. Quality Assessment The CAC must have at least 30 evidence-based medicine (EBM) opportunities during the data collection period. A Quality Index is calculated for each CAC based on adherence to Evidence Based Medicine (EBM) measures. If the CAC s Quality Index is 0.99 or better, the quality requirement is met. Cost-Efficiency Assessment To contract with Cigna as a CAC, a minimum volume of Cigna customers is required so there is sufficient volume for cost evaluation. Based on 2014 data, this results in episode counts ranging from 8,600 to 131,000 episodes per group, per year. Total Medical Cost (TMC) is used to evaluate cost-efficiency for CAC arrangements. A Total Medical Cost Performance Index (PI) is calculated. If the group's TMC Performance Index is 1.03 or less, the practice meets the CCD cost requirement for CCD. The Quality Index and Total Medical Cost Index are calculated as follows: Quality Index The Quality Index is calculated based on adherence to Evidence Based Medicine (EBM) standards, and EBM rules for CACs are the same as those described for primary care specialties in the section titled "Evidence-Based Medicine (EBM) Assessment Process" which appears on pages 7-10 of this paper. Determining CAC EBM rule adherence: Opportunities and successes for each eligible EBM rule are aligned to the appropriate individual physician (using the visit requirements outlined below and relevant specialty type category). Visit Requirements - A physician is considered responsible for adherence to the EBM rule if the following conditions are met: The EBM rule is relevant to the physician s primary care specialty (see Appendix 3). For example, the Cervical Dysplasia EBM rule is relevant to OB/GYN,, and, but it is not relevant to other specialties. There have been at least two office visit encounters for a Cigna customer At least one of the office visit encounters occurred in the last 12 months of the claim review period. Note: Nineteen of our EBM measures require only one office visit encounter in the last 12 months of the claim review period. These measures are identified by an asterisk [*] in Appendix 3. Individual physicians are aligned to the CAC, and EBM rule opportunities, successes, and expected successes are then summed to obtain CAC totals. A Quality Index for the CAC is calculated by dividing the number of actual EBM rule adherence successes for the CAC by number of expected EBM rule adherence successes. Expected EBM rule adherence successes are derived by applying the geographic market average EBM rule adherence success rates from primary care groups in the market. Total Medical Cost Index The Total Medical Cost index reflects all medical costs for Cigna customers who are aligned to PCPs in the CAC, excluding pharmacy and non-pcp behavioral health costs. For the CAC model, Cigna maintains a roster of all Cigna customers who are patients of the CAC. Patients get aligned to a specific PCP if they've had at least 1 visit in the prior 12 months. If no visit is found, the look back period is 24 months and the patient is aligned to the PCP with the most recent visits. When there are no visits to PCPs in 24 months, then the same search is conducted for Nurse Practitioners, Physicians Assistants and OB/GYN physicians in the group. If a patient was seen by more Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 16

17 than one primary care practitioner in the CAC, the patient is aligned to the practitioner with the most visits. Once the aligned patients and practitioners are identified, the Total Medical Cost is calculated as follows: Capture all claims expenses (excluding pharmacy expense) for patients who are aligned to the CAC PCPs for the 12 month reporting period. Pharmacy costs and non- PCP Behavioral Health costs are not included in TMC calculation. Calculate member months for all aligned patients of the CAC and the market. Calculate an Episode Risk score using Episode Risk Grouper (ERG) software for both the market and the CAC. Additional information about the OPTUMInsight Episode Risk Grouper software is available at Calculate total medical cost for all aligned patients of the CAC. Outliers are identified and outlier claim expense is capped at $100,000. Calculate per Patient per Month (PPPM) expenses for both the market and the CAC practice. (PPPM is calculated by dividing the total medical cost by member months). Adjust the CAC PPPM to consider to ERG risk score for patients of the CAC. Divide the final risk adjusted CAC PPPM score by the market PPPM score to create the TMC performance index. When the CAC adjusted expense is the same as the market, the result will be 1.0. A TMC Performance Index of less than 1.0 reflects that claim expenses are lower than the market average and a TMC performance index of greater than 1.0 reflects that claim expenses are higher than the market average. Buffer Zone Methodology Variation in CAC performance (e.g., positive or negative, substantial, or minimal) is inevitable and expected in an annual review process due to various factors (e.g., changes to physician group makeup, external market factors, and practice pattern modifications). A buffer zone or grandfathering methodology addresses variation for physician groups or physician groups whose Cigna Care designation changes from the previous year. A CAC may maintain its Cigna Care designation status if the CAC was in during the prior cycle. NOTE: Individual markets may adjust the grandfathering criteria for CACs at the market level, in order to exclude from grandfathering those CACs with large scale variation in results from the prior year. Adjustments are made at the market level and are applied to all CACs in the market. Collaborative Accountable Care (CAC) Review Process The evaluation methodology is applied annually (and quarterly as needed) to all existing CAC arrangements and to new CACs that become effective. CACs that do not meet criteria can be re-evaluated using quarterly data, through our reconsideration process. If the quality and performance indexes improve and are meeting the market criteria for inclusion during two consecutive quarters, the CAC will be given Cigna Care Designation status. Since CACs can earn CCD status on a quarterly basis, Cigna reserves the right to remove the CCD status if the CAC demonstrates significant decline in performance below the required criteria in 4 consecutive quarters, or if the CAC discontinues it collaborative agreement with Cigna and does not meet the standard CCD criteria. A re-evaluation occurs annually where grandfathering may be applied. As noted above, individual markets may adjust the grandfathering criteria at the market level. When adjustments are made at the market level they are applied to all CACs in the market. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 17

18 Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 18

19 Data Sources The evaluation data sources and how the information from each source is used are outlined below. Data Source How Information is Used Cigna Physician Metrics (January 2012 December 2013 Use combined Managed Care and PPO product data with episodes of care or EBM rules attributed to the responsible physician. Cigna Central Physician File (CPF) (as of April 2014 Physician Recognition Program File obtained from National Committee for Quality Assurance (NCQA) (as of April 2014 and at least six times per year) Physician Recognition Program obtained from the American Board of at least semiannually The data is used to produce ETG efficiency and EBM summary reports. Note: Data for Medicare-eligible individuals is removed. File extracts to identify contracted physicians, TIN, groups, specialty, board certification status, network, and products contracted. The status of physicians recognized for the diabetes, heart/stroke, back pain, physician practice connections, patient-centered medical home 2012 or patient centered specialty practice recognition programs is updated based on information received from NCQA. Percent of physicians recognized in an NCQA program for a group is calculated based on the recognition and group alignment To display the ABIM-PIM quality recognition in Cigna directory Cigna Utilization and Centers of Excellence (COE) Data Specialty groups that admit to Center of Excellence facilities (based on utilization data) will receive credit towards Cigna Care Designation inclusion Additional Information and Data Limitations The Cigna Care designation and physician quality and cost-efficiency displays are a partial assessment of physician quality and cost-efficiency, and are intended to provide information that can assist Cigna customers in health care decision-making. It should not be used as the sole basis for decision-making (as such measures have a risk of error). Cigna customers are encouraged to consider all relevant information and to consult with their treating physician in selecting a physician for care. While we use what we believe to be the best available information to create an objective assessment methodology, there are some limitations: The EBM and cost-efficiency information are based on our claim data only. Aggregated claim data from multiple payers (e.g. insurance companies, self-insured, and government plans) may provide a more complete picture of physician performance. We support data aggregation initiatives, and will consider using it in evaluations when credible data are available. We can only use received claim data in evaluations. There may be health care services performed for which no information is provided to us. Specific service line item detail may not always be available due to the way claims may be submitted by physicians or processed by us. Pharmacy data inclusion is limited to only those customers that we administer pharmacy benefits to. We use Episode Treatment Groups (ETGs), an industry standard grouper, to risk-adjust for patient severity. Although ETG software is recognized as a leading risk adjustment model, perfect patient severity risk adjustment does not exist. Many physicians or physician groups are unable to be displayed for quality and cost-efficiency due to small patient populations. We will not display results for those physicians or physician groups whose episodes or opportunities sample do not meet certain volume thresholds. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 19

20 Process to Display Strategic Alliances Information Health Alliance Plan (HAP) Physicians or physician groups in the Eastern Michigan area (Genesee, Oakland, Lapeer, St. Clair, Livingston, Washtenaw, Macomb, Wayne, and Monroe counties) are evaluated using the claim data from Health Alliance Plan. HAP data reflects the contracted rates and physician utilization statistics associated with HAP membership in the Michigan area. Consistent with our methodology, HAP's 2014 physician profiling process includes NQF EBM rules, NCQA recognition, ABIM's Practice Improvement Modules, and board certification to evaluate physicians. The Cigna Care designation icon displays when physicians or physician groups in Eastern Michigan have met the quality and cost-efficiency inclusion criteria, but tiered benefits are not available in the HAP service area. Specific Market Activities California IHA P4P Cigna HealthCare of California participates in a statewide initiative coordinated by Integrated Health Assessment (IHA) to measure and improve clinical quality, patient experience, use of information technology, and public reporting of physician performance results. Incentive payments are paid annually by Cigna to physician organizations based upon performance against standard quality measures. The common set of key measures used for assessment relies on national standards or evidence based medicine practices. The measure set, audit manual, and data submission file layouts are released each year by IHA. More information about the program and the assessment results can be found by visiting the website. Feedback Process Cigna customers, clients, and participating physicians are encouraged to provide feedback and suggestions for the improvement of reports or other suggested improvements. Clients and patients with Cigna administered plans should call the telephone number listed on the back of their Cigna ID card. Participating physicians may provide feedback by calling our Customer Service Center at Cigna ( ). Feedback and suggestions are reviewed, and changes to the physician evaluation methodology, reporting formats, and processes are implemented as appropriate. Methodology changes are generally reviewed and implemented on an annual basis. Physician Process to Correct Errors, Request Reconsideration, or Appeal Participating physicians or physician groups have a right to seek correction of errors and request data review for both the Cigna Care designation and physician quality and cost-efficiency displays. us at [email protected] or fax us at to request additional information, for detail reports, to request reconsideration, to correct inaccuracies, or to submit additional information. The request for reconsideration must include the reason for the reconsideration and any documentation you wish to provide in support of the request. The National Selection Review Committee process is initiated within five business days of Cigna's receipt of a reconsideration or appeal request. A Cigna Network Clinical Manager (NCM) will contact the physician practice or physician group to clarify information received for reconsideration and generate detail reports. The NCM may change the physician group designation if the obtained information meets committee guidelines. These may include, but are not limited to: a verification of board certification; a revision to the Evidence Based Medicine (EBM) adherence score; or a verification of completion of one or more NCQA physician recognition programs. The National Selection Review Committee will review the request if the obtained information does not meet committee guidelines. The National Selection Review committee participants include Cigna physicians and Cigna network clinical performance staff. Voting committee participants include the National Medical Director and physician representatives from the three Cigna regions, their alternates and ad hoc physicians. Non-voting participants include the Assistant Vice President of Provider Measurement and Performance, National Network Business Project Sr. Analyst, Health Data Senior Specialist, Marketing Product Sr. Specialist, Network Product Integration Leads, and Network Clinical Managers. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 20

21 The National Selection Review Committee determination may include changing the designation, upholding the original designation, or pending the determination for additional information. The decision notification is mailed to the physician group after the committee determination is made. The National Selection Review Committee process and final decision is complete within 45 days of receipt of a reconsideration or appeal request. Colorado health care professionals should refer to Appendix 4 on page 37 of this document for Colorado specific appeals. How to Register Complaints At any time, Cigna customers may register a complaint with us about the Cigna Care designation or the physician quality and cost-efficiency displays by calling the telephone number located on the back of the Cigna ID card. Registering a Complaint for Cigna Customers in New York The National Committee for Quality Assurance (NCQA) is an independent not-for-profit organization that uses standards, clinical performance measures and member satisfaction to evaluate the quality of health plans. NCQA serves as an independent ratings examiner for Connecticut General Life Insurance Company and Cigna HealthCare of New York, Inc., reviewing how Cigna Care designations and physician quality and cost-efficiency displays meet criteria required by the State of New York. Complaints about Cigna Care designations or physician quality and cost-efficiency displays in New York may be registered to NCQA, in addition to registering with Cigna as above, by submitting them in writing to customer support at or to NCQA Customer Support, th Street, NW, Suite 1000, Washington, DC Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 21

22 2015 Physician Evaluation Methodology Changes Changes to the Cigna 2015 physician evaluation methodology are outlined below: Methodology Item 2015 Change/Enhancement Details/Rationale General Methodology Physicians and physician groups will go through the CCD assessment through the normal CCD pathway for CCD inclusion. Collaborative Accountable Care Pathway Physician practices that contract with Cigna as a Collaborative Accountable Care (CAC) partner have a separate process for achieving CCD If physicians and physician groups affiliated with the CAC did not meet CCD inclusion criteria, then the CAC pathway inclusion criteria will be applied to determine if a physician can be designated. The physicians and physician groups can be designated if the CAC achieves a TMC Performance Index of less than or equal to < 1.03 AND EBM Quality Index of greater than or equal to >0.99 will be assigned Cigna Care Designation. Episode Treatment Groups Nephrology severity level 4 episodes will be added for Nephrology specialists. Earlier versions excluded nephrology severity level 4 due to wide variation Specialty types Reviewed Colon and Rectal Surgery was removed as a specialty for assessment. Low volume of episodes Cost Display/Transparency Physician Practices Practices in the Top 34% will get 3 stars for cost. Practices in the Middle 33% will get 2 stars for cost. Practices in the Low 33% will get 1 star for cost. Cost and Quality Thresholds Physician Practices Practices in the top 40% for cost and quality will be assigned Cigna Care Designation. Additionally the top 34% for cost or top 34% quality if no cost or quality evaluated will be assigned Cigna Care Designation. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 22

23 Appendices Appendix 1: 2015 Cigna Care Designation Market Information Market Name Volume Reviewed Percent Designated Percent not Designated AR Arkansas 4, % 58.51% AZ Maricopa 7, % 51.33% AZ All Other 1, % 71.43% AZ Pima 2, % 55.30% CA North 1, % 84.84% CA South 25, % 62.31% CA Bay Area 10, % 49.74% CA Sacramento 2, % 65.31% CA Central Valley 2, % 65.09% CO Front Range 7, % 61.18% CT Connecticut 9, % 50.80% DE Delaware 2, % 50.57% FL Jacksonville 2, % 80.72% FL All Other 3, % 81.79% FL South Florida 9, % 68.33% FL Orlando 5, % 66.49% FL Tampa 8, % 59.79% GA Atlanta 8, % 48.97% GA All Other 4, % 56.98% IL Chicago Metro 15, % 33.13% IL Rockford 2, % 40.80% IN Indianapolis 4, % 50.30% KS KS/MO All Other 4, % 58.04% LA All Other 2, % 66.28% LA Baton Rouge 2, % 63.13% LA New Orleans 2, % 50.55% MA Western 4, % 66.96% MA Boston 16, % 70.94% MD Maryland 10, % 65.84% MD Northern VA 4, % 67.12% DC Metro North 5, % 68.33% ME Maine 3, % 49.63% NC Charlotte 4, % 80.91% NC East 3, % 64.46% NC Raleigh 4, % 69.84% NC Triad 3, % 66.26% NC West 2, % 69.81% NH New Hampshire 3, % 37.49% Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 23

24 Market Name Volume Reviewed Percent Designated Percent not Designated NJ North Jersey 10, % 61.11% NJ South Jersey 4, % 64.88% NV Nevada 3, % 67.75% NY Metro 26, % 39.72% OH Northern 9, % 38.38% OH Central 6, % 40.22% OH Southern 6, % 62.07% OH NW Ohio 2, % 62.87% OR Oregon 9, % 53.44% PA Philadelphia 10, % 46.11% PA All Other 10, % 47.79% PA Pittsburgh/Western 6, % 37.84% RI Rhode Island 2, % 69.86% SC Low Country 2, % 66.89% SC Midlands 2, % 59.04% SC Upstate 2, % 63.30% TN West 3, % 60.30% TN Central 5, % 67.34% TN East 5, % 68.40% TX Austin 3, % 62.53% TX Dallas/Ft. Worth 9, % 60.28% TX Houston 10, % 62.43% TX San Antonio 3, % 77.35% TX East Central 2, % 50.04% UT Wasatch Front 3, % 47.90% VA Hampton Roads 3, % 65.17% VA Richmond 2, % 62.13% VA Western 3, % 65.73% VT Vermont 1, % 47.47% WA Seattle 10, % 75.11% WA All Other 4, % 53.11% WI Milwaukee/Green Bay 7, % 47.77% WI All Other 3, % 49.61% WV West Virginia 3, % 57.52% Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 24

25 Appendix 2: 2015 Quality and Cost-Efficiency Display Markets Market Name Specialists Reviewed Market Name Specialists Reviewed AL Alabama ** 5,948 NC Charlotte 4,096 AR Arkansas 4,550 NH New Hampshire 3,980 AZ Maricopa 7,999 NJ North Jersey 10,573 AZ All Other 1,498 NJ South Jersey 4,322 AZ Pima 2,282 NV Nevada 3,575 CA North 1,689 NY Metro 26,758 CA South 25,538 OH Northern 9,210 CA Bay Area 10,808 OH Central 6,101 CA Sacramento 2,736 OH Southern 6,025 CA Central Valley 2,756 OH NW Ohio 2,168 CO All Other ** 1,714 OK Oklahoma ** 5,063 CO Front Range 7,911 OR Oregon 9,771 CT Connecticut 9,241 PA Philadelphia 10,838 DE Delaware 2,264 PA All Other 10,680 FL Jacksonville 2,350 PA Pittsburgh/Western 6,805 FL All Other 3,942 RI Rhode Island 2,402 FL South Florida 9,008 SC Low Country 2,341 FL Orlando 5,026 SC Midlands 2,041 FL Tampa 8,372 SC Upstate 2,670 GA Atlanta 8,652 TN West 3,184 GA All Other 4,765 TN Central 5,159 IL Chicago Metro 15,884 TN East 5,424 IL All Other ** 3,544 TX Austin 3,587 IL Rockford 2,620 TX Dallas/Ft. Worth 9,388 IN Indianapolis 4,690 TX East Central Texas 2,566 IN All Other ** 5,036 TX Houston 10,688 KS KS/MO All Other ** 4,542 TX San Antonio 3,196 KS KS/MO Kansas City 4,144 UT Wasatch Front 3,574 KY Kentucky ** 5,410 VA Hampton Roads 3,187 LA All Other 2,405 VA Richmond 2,717 LA Baton Rouge 2,376 VA Western 3,510 LA New Orleans 2,613 VT Vermont 1,934 MA Western 4,013 WA Seattle 10,134 MA Boston * 16,156 WA All Other 4,786 MD Maryland 10,063 WI Milwaukee/Green Bay 7,616 MD Northern VA 4,930 WI All Other 3,320 DC Metro North 5,674 WV West Virginia 3,776 ME Maine 3,822 MS Mississippi ** 3,524 NC Raleigh 4,374 NC Triad 3,068 NC West 2,153 NC East 3,450 * Indicates new market ** Indicates markets where physicians are assessed for Quality and Cost-Efficiency display only. Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 25

26 Appendix 3: EBM Rules Used for the 2015 Physician Evaluation Condition Adenoidectomy Source American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Summary Rule Description Patient(s) less than 18 years of age that had an adenoidectomy and met clinical criteria for this procedure. Applicable Specialist Otolaryngology Applicable Primary Care Specialty ADHD, Follow-Up Care for Children Prescribed ADHD Medication (NS) Forum/NCQA Patient(s) with an outpatient, intensive outpatient or partial hospitalization follow-up visit with a prescribing physician during the 30 days NA after the initial ADHD prescription, AND two follow-up visits during the 31 days through 300 days after the initial ADHD, Follow-Up Care for Children Prescribed ADHD Medication (NS) Forum/NCQA Patient(s) with an outpatient, intensive outpatient or partial hospitalization follow-up NA visit with a prescribing physician during the 30 days after the initial ADHD prescription. Adolescent Well- Care Visits (NS) NCQA Patient(s) years of age that had one comprehensive well-care visit with a PCP or an OB/GYN in the last 12 reported months. NA Antidepressant Medication Management (NS) Forum/NCQA Patient(s) with a new episode of major depression that remained on an NA antidepressant medication during the 12 week acute treatment phase. Antidepressant Medication Management (NS) Forum/NCQA Patient(s) with a new episode of major depression that remained on an NA antidepressant medication during the 6 month acute treatment phase. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 26

27 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Asthma, Use of Appropriate Medications (NS) Forum/NCQA Patient(s) between the ages of 12 and 50 with presumed Allergy/Immunology persistent asthma using an Pulmonology inhaled corticosteroid or acceptable alternative. Asthma, Use of Appropriate Medications (NS) Forum/NCQA Patient(s) between the ages of 5 and 11 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative. Allergy/Immunology Pulmonology Atrial Fibrillation Breast Cancer - Part I American College of Cardiology/American Heart Association American Society of Clinical Oncology Patient(s) taking warfarin that had 3 or more prothrombin time tests in last 6 reported months. Patient(s) that had an annual physician visit. Cardiology Hematology/Oncology OB/GYN Breast Cancer - Part II Ingenix - consensus opinion of experts was the primary source Patient(s) newly diagnosed with breast cancer that received radiation or chemotherapy treatment or Hematology had medical oncology or OB/GYN radiation oncology consultation within 120 days of the diagnostic procedure. Bronchitis, Acute, Avoidance of Antibiotic Treatment Forum/NCQA in Adults (NS)*++ Patient(s) with a diagnosis of acute bronchitis that did not have a prescription for an antibiotic on or three days after the initiating visit. Otolaryngology (Ear, Nose and Throat) Pulmonology Cardiac Surgery (name changed from "Cardiac Surgery (NS)") American College of Cardiology/American Heart Association Patient(s) 18 years of age and older hospitalized for a CABG procedure that have evidence of a CVA during the hospitalization or within seven days of discharge. Cardiology Cardio-Thoracic Surgery Cardiac Surgery (NS) American College of Cardiology/American Heart Association Patient(s) 18 years of age and older hospitalized for a CABG procedure taking a lipid-lowering medication at admission or within seven days of discharge. Cardiology Cardio-Thoracic Surgery by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 27

28 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Cardiac Surgery (NS) American College of Cardiology/American Heart Association Patient(s) 18 years of age and older hospitalized for a Cardiology CABG procedure taking a Cardio-Thoracic beta-blocker at admission or Surgery within seven days of discharge. Cerebral Vascular Accident & Transient Cerebral Ischemia American College of Cardiology/American Heart Association Patient(s) taking warfarin that had 3 or more prothrombin time tests in last 6 reported months. Neurology Neurosurgery Cerebral Vascular Accident & Transient Cerebral Ischemia Forum/Ingenix Patient(s) with a recent emergency room encounter Neurology for a transient cerebral Neurosurgery Cardioischemic event that had any Thoracic Surgery physician visit within 14 days of the acute event. N/A Cervical Dysplasia Children and Adolescents' Access to Primary Care Practitioners (NS) Children and Adolescents' Access to Primary Care Practitioners (NS) Children s' Access to Primary Care Practitioners (NS) Ingenix - Based on guideline recommendations Gynecologists (2-4) and expert opinion NCQA NCQA NCQA Patient(s) with cervical dysplasia that had a PAP smear, hysterectomy, or other cervical procedure within 12 months of the initial diagnosis. Patient(s) 7-11 years of age that had a PCP visit during the report period. Patient(s) years of age that had a PCP visit during the report period. OB / GYN N/A Patient(s) 25 months to 6 years of age that had a PCP N/A visit during the report period. OB/GYN Children s Access to Primary Care Practitioners (NS) NCQA Patient(s) months of age that had a PCP visit during the report period. NA Chlamydia Screening (NS)* Forum/NCQA Patient(s) years of age that had a chlamydia screening test in last 12 reported months. OB/GYN by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 28

29 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Chlamydia Screening (NS)* Cholesterol Management for Patients with Cardiovascular Conditions (NS) Cholesterol Management for Patients with Cardiovascular Conditions (NS) Forum/NCQA NCQA NCQA Patient(s) years of age that had a chlamydia screening test in last 12 reported months. Patient(s) with lab results with a LDL cholesterol level < 100 mg/dl. Patient(s) with a LDL cholesterol test during the report period. OB/GYN Cardiology Cardio-Thoracic Surgery Cardiology Cardio-Thoracic Surgery Chronic Kidney Disease Ingenix - Expert consensus from K/DOQI guidelines Patient(s) meeting the threshold of CrCl < 60ml/min, Cr >= 1.5mg/dL for women or Cr >= Nephrology 2.0mg/dL for men that had a serum phosphorus in last 12 reported months. Chronic Kidney Disease Ingenix - Expert consensus from K/DOQI guidelines Patient(s) meeting the threshold of CrCl < 60ml/min, Cr >= 1.5mg/dL for women or Cr >= Nephrology 2.0mg/dL for men that had a serum calcium in last 12 reported months. Chronic Kidney Disease Ingenix - Expert consensus from K/DOQI guidelines Patient(s) meeting the threshold of CrCl < 30ml/min, Cr >= 2.0mg/dL for women or Cr >= 2.5mg/dL for men, that had a serum PTH test in last 12 reported months. Nephrology Chronic American Thoracic Obstructive Society Pulmonary Disease Patient(s) with problematic COPD control that had a PFT in last 12 reported months. Pulmonology Ingenix/ NCCN Practice Patient(s) newly diagnosed Colon Cancer - Part Guidelines in with colon cancer that had a Gastroenterology II Oncology full colonoscopy. Hematology/Oncology Comprehensive Ischemic Vascular Disease Care (NS) NCQA (similar) Patient(s) with lab results with a LDL cholesterol level < 130 mg/dl. Cardiology Cardio-Thoracic Surgery N/A by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 29

30 Condition Comprehensive Ischemic Vascular Disease Care (NS) Congestive Heart Failure Source Forum/NCQA American College of Cardiology/American Heart Association Summary Rule Description Applicable Specialist Cardiology Patient(s) with a lipid profile Cardio-Thoracic test during the report period. Surgery Patient(s) currently taking a beta-blocker specifically recommended for CHF management. Cardiology Applicable Primary Care Specialty N/A Congestive Heart Failure Congestive Heart Failure (NS) American College of Cardiology/American Heart Association Forum/AMA/PCPI Patient(s) currently taking a beta-blocker. Patient(s) with CHF and atrial fibrillation currently taking warfarin. Cardiology Cardiology COPD Exacerbation, Pharmacotherapy Management (NS) NCQA Patient(s) 40 years of age and older with COPD exacerbation that received a Pulmonology systemic corticosteroid within 14 days of the hospital or ED discharge. COPD Exacerbation, Pharmacotherapy Management (NS) NCQA Patient(s) 40 years of age and older with COPD exacerbation that received a Pulmonology bronchodilator within 30 days of the hospital or ED discharge. Coronary Artery Disease (NS) Forum/ AMA-PCPI Patient(s) prescribed lipidlowering therapy during the measurement year. Cardiology Cardio-Thoracic Surgery Coronary Artery Disease (NS) Forum/ AMA-PCPI Patient(s) with CAD and diabetes and/or CHF prescribed ACE-inhibitor or angiotensin II receptor antagonist therapy during the measurement year. Cardiology Cardio-Thoracic Surgery Coronary Artery Disease (NS) Forum/ AMA-PCPI Patient(s) with a lipid profile (or ALL component tests) during the measurement year. Cardiology Cardio-Thoracic Surgery Coronary Artery Disease (NS) Forum/ AMA-PCPI Patient(s) with a prior myocardial infarction prescribed beta-blocker therapy during the measurement year. Cardiology Cardio-Thoracic Surgery Diabetes Care (NS) NCQA (similar) Patient(s) years of age with lab results with most recent LDL result <100 mg/dl. Endocrinology by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 30

31 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Diabetes Care (NS) NCQA (similar) Patient(s) years of age with lab results with most recent HbA1c result value less than 8.0%. Endocrinology Diabetes Care (NS) NCQA (similar) Patient(s) years of age with lab results that have evidence of poor diabetic control, defined as the most recent HbA1c result value greater than 9.0%. Endocrinology Diabetes Care (NS) NCQA (similar) Patient(s) years of age with lab results with most recent LDL result <130 mg/dl. Endocrinology Diabetes Care (NS) NCQA (similar) Patient(s) years of age that had annual Endocrinology screening for nephropathy OB/GYN or evidence of nephropathy. Diabetes Care (NS) AQA/NCQA Patient(s) years of Endocrinology age with an LDL cholesterol OB/GYN in last 12 months. Diabetes Care (NS) Forum/NCQA Patient(s) years of age that had an HbA1c test in last 12 reported months. Endocrinology OB/GYN Diabetes Care (NS)* NCQA (similar) Patient(s) years of age that had an annual screening test for diabetic retinopathy. Endocrinology OB/GYN Ophthalmology Diabetes Care NS Forum/NCQA Patient(s) 5-17 years of age that had an HbA1c test in last 12 reported months. Endocrinology OB / GYN Diabetes Mellitus Forum/Ingenix Adult(s) that had a serum creatinine in last 12 reported Endocrinology months. Disease- Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis (NS) Forum/NCQA Patient(s) who had a prescription, dispensed for a disease modifying antirheumatic drug (DMARD) Rheumatology during the report period. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 31

32 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Epilepsy Ingenix/The National Collaborating Centre for Primary Care guidelines Patient(s) with one or more hospitalizations or two or more emergency room encounters for epilepsy that had neurology consultation in last 3 reported months. Neurology Epilepsy Ingenix/The National Patient(s) that had an Collaborating Centre for annual physician visit. Primary Care guidelines Neurology Hepatitis C Ingenix/AHRQ Patient(s) with cirrhosis that had a liver imaging test in last 12 reported months. Gastroenterology Hepatitis C Ingenix/AHRQ Patient(s) 18 years and older that had an annual physician visit. Gastroenterology Hepatitis C Ingenix/AHRQ Patient(s) with indications that had gastroenterology consultation in last 12 reported months. Gastroenterology Hypertension* Forum/Ingenix Patient(s) that had a serum creatinine in last 12 reported months. Cardiology Endocrinology Nephrology Neurology Inflammatory Bowel Disease Ingenix - consensus opinion of experts was the primary source Patient(s) with inflammatory bowel disease complications Gastroenterology that had gastroenterology General Surgery consultation in last 3 reported months. N/A Knee Replacement++ Knee Replacement Ingenix/ AAOS Ingenix/ AAOS Adults(s) that had a knee MRI prior to knee replacement surgery. Adults(s) that had a knee x- ray prior to knee replacement surgery. Orthopedics and Surgery Orthopedics and Surgery Low Back Pain, Use of Imaging Studies (NS)++ Forum/NCQA Patient(s) with uncomplicated low back pain that did not have imaging studies. Orthopedics and Surgery Rheumatology Migraine Headache Ingenix/American Academy of Neurology Patient(s) with frequent ER encounters or frequent acute medication use that had an office visit in last 6 reported months. Neurology OB/GYN by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 32

33 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Migraine Headache Forum/ Ingenix/ American Academy of Neurology Adult patient(s) with frequent use of acute medications that also received prophylactic medications. Neurology OB/GYN Multiple Sclerosis Ingenix - consensus opinion of experts was the primary source of this recommendation Patient(s) with more than one magnetic resonance imaging (MRI) scan of the head in last 12 reported months (excluding patient(s) Neurology with neurologic manifestations or complications suggesting a new disease state). Obesity and Overweight Obesity and Overweight Ingenix/Clinical research and the consensus opinion of experts was the primary source Ingenix/Clinical research and the consensus opinion of experts was the primary source Osteoporosis Management in Women Who Had a Forum/NCQA Fracture (NS) Otitis Externa, Acute* Otitis Media, Acute* Forum/Ingenix/ American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Ingenix/American Academy of and American Academy of Family Physician Patient(s) with bariatric surgery who had a defined complication during hospitalization or 30 days after discharge. Patient(s) with bariatric surgery who had a defined complication during hospitalization or 180 days after discharge. Women 67 years of age or older who were treated or tested for osteoporosis within six months of a fracture. Patient(s) 2 years of age and older with acute otitis externa who were NOT prescribed systemic antimicrobial therapy. Patient(s) on antibiotic therapy with acute otitis media that received amoxicillin, a first line antibiotic. Endocrinology General Surgery Endocrinology General Surgery OB/GYN Orthopedics and Surgery Otolaryngology (Ear, Nose and Throat) Otolaryngology (Ear, Nose and Throat) Persistence of Beta-Blocker Treatment after a Heart Attack (NS) Forum/NCQA Patient(s) hospitalized with an acute myocardial Cardiology infarction (AMI) persistently Cardio-Thoracic taking a beta- blocker for six Surgery months after discharge. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 33

34 Condition Source Pharyngitis, Appropriate Testing Forum/NCQA for Children (NS)* Pneumonia, Community- Acquired Bacterial (CAP) Ingenix/AMA/PCPI (similar) Summary Rule Description Applicable Specialist Patient(s) treated with an antibiotic for pharyngitis that Otolaryngology (Ear, had a Group A Nose and Throat) streptococcus test. Adult(s) with communityacquired bacterial pneumonia who have a CXR. Pulmonology Applicable Primary Care Specialty Potentially Harmful Drug- Disease Interactions in the Elderly (NS) NCQA Elderly patients with dementia who took a tricyclic antidepressant or anticholinergic agent after the earliest record of dementia (HEDIS criteria). N/A Potentially Harmful Drug- Disease Interactions in the Elderly (NS) Pregnancy Management* Pregnancy Management* Pregnancy Management Pregnancy Management* Pregnancy Management* NCQA Forum/Ingenix/ American College of Obstetricians and Gynecologist/ USPST Forum/ Ingenix Ingenix/American College of Obstetricians and Gynecologists Forum/Ingenix/ American College of Obstetricians and Gynecologist/ USPSTF Elderly patients who had an accidental fall or hip fracture who took a tricyclic antidepressant antipsychotic or sleep agent after the incident (HEDIS criteria). Pregnant women that had syphilis screening. Pregnant women that had HIV testing. Pregnant women less than 25 years of age that had chlamydia screening. Pregnant women that had HBsAg testing. Ingenix/American Pregnant women that College of Obstetricians received rubella immunity and Gynecologists screening. N/A OB/GYN OB/GYN OB/GYN OB/GYN OB/GYN Pregnancy Management* Ingenix/American Pregnant women that had College of Obstetricians hemoglobin testing. and Gynecologists OB/GYN Prenatal Care (NS)* NCQA Women with deliveries of live births that received a OB/GYN prenatal care visit in the first trimester. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 34

35 Condition Source Summary Rule Description Applicable Specialist Applicable Primary Care Specialty Prostate Cancer - Part I Ingenix/American Urological Association Patient(s) that had a Hematology/Oncology prostate specific antigen test Urology in last 12 reported months. Prostate Cancer - Part I Ingenix/American Urological Association Patient(s) that had an annual physician visit. Hematology/Oncology Urology Prostate Cancer - Part II Ingenix/The consensus opinion of experts was the primary source Patient(s) newly diagnosed with prostate cancer that had medical oncology, radiation oncology or urology consultation in last 6 reported months. Hematology/Oncology Urology Rheumatoid Arthritis Ingenix/American College of Rheumatology (NQF Patient Safety) Patient(s) taking methotrexate, sulfasalazine, gold, or leflunomide that had a CBC in last 3 reported months. Rheumatology Rheumatoid Arthritis Ingenix - EBM Connect consultant panel process Patient(s) taking chronic corticosteroids that had rheumatology consultation in last 6 reported months. Rheumatology Rheumatoid Arthritis Ingenix/American College of Rheumatology Patient(s) with complex RA treatment regimens or complications that had rheumatology consultation in last 6 reported months. Rheumatology Rheumatoid Arthritis Ingenix/American College of Rheumatology (NQF Patient Safety) Patient(s) taking methotrexate, sulfasalazine, or leflunomide that had Rheumatology serum ALT or AST test in last 3 reported months. Rheumatoid Arthritis Ingenix/American College of Rheumatology Patient(s) taking hydroxychloroquine (Plaquenil) that had an eye exam in last 12 reported months. Rheumatology Rheumatoid Arthritis Ingenix/American College of Rheumatology (NQF Patient Safety) Patient(s) taking methotrexate or sulfasalazine that had a serum creatinine in last 6 reported months. Rheumatology by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 35

36 Condition Sickle Cell Anemia Source Ingenix - consensus opinion of experts was the primary source/american Academy of Summary Rule Description Patient(s) that had a reticulocyte count in last 12 reported months. Applicable Specialist Hematology/Oncology Applicable Primary Care Specialty Sickle Cell Anemia Ingenix - consensus opinion of experts was the primary source/american Academy of Patient(s) that had a hemoglobin/hematocrit in last 12 reported months. Hematology/Oncology Sinusitis, Acute Ingenix - Sinus and Allergy Health Partnership Patient(s) treated with an antibiotic for acute sinusitis that received a first line antibiotic. Otolaryngology (Ear, Nose and Throat) Pulmonology Allergy/Immunology Sinusitis, Acute Ingenix - Sinus and Allergy Health Partnership Patient(s) that had a sinus computerized axial tomography (CT) or magnetic resonance imaging (MRI) test. Otolaryngology (Ear, Nose and Throat) Pulmonology Allergy/Immunology Tonsillectomy Ingenix/American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Patient(s) less than 21 years of age that had a tonsillectomy and met Otolaryngology clinical criteria for this procedure. Tympanostomy Tube Placement Ingenix/American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Patient(s) less than 12 years of age that had tympanostomy tube Otolaryngology placement and met clinical criteria for this procedure. Upper Respiratory Infection (URI), Appropriate Treatment for Children (NS)* Forum/NCQA Patient(s) with a diagnosis of upper respiratory infection (URI) that did not have a Otolaryngology (Ear, prescription for an antibiotic Nose and Throat) on or three days after the initiating visit. * Measures requiring one office visit in the most recent 12 months of the review period. ++ Atypical rule measure indicates over-utilization of services. Compliance for the measure requires absence of the service. Compliance rates are inverted for reporting and comparison purposes. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 36

37 Appendix 4: Appeals Process for Colorado Health Care Professionals Procedures to Obtain Additional Information To review additional quality and cost-efficiency information, obtain a full description of the methodology and data that our decisions were based on or declined, the physician should submit the request by at [email protected] or by faxing the request to A Network Clinical Manager will contact the physician to provide additional details about the process and the results. If the request is regarding the methodology and data that the designation decisions were based on or declined, we will provide the physician or physician group with this information within 45 days of our receipt of the request. Where the law or our contractual obligations with a third party prevents disclosure of the data required to be disclosed, we will provide sufficient information to allow the physician or physician group to determine how the withheld data affected the designation. After disclosure of the description of the methodology described above, the physician or physician group may request further information related to the designation decisions. Such further information, if it exists and has not been previously disclosed, will be provided by us within 30 days of the request. The Cigna Care Designation and Physician Quality and Cost-Efficiency Profiles Methodology is available on the Cigna for Health Care Professionals website at CignaforHCP.com. Request an Appeal of the Designation Decision To request an appeal of Cigna Care designation and quality and cost-efficiency displays in Colorado (including the opportunity for a face-to-face meeting), have corrected data relevant to the designation decision considered, and have the applicability of the methodology used in the designation decision considered, or to submit additional information, the physician should contact the or fax number noted above. A Network Clinical Manager will contact the physician or physician group to provide additional details about the process and the results. The National Selection Review Committee, who review all appeal requests, is a national committee that reviews appeal and reconsideration requests with Cigna participants in locations other than Colorado. The committee participants are listed below: Voting Committee Participants National Medical Director for Network Clinical Performance and Improvement (Chair) Physician representatives from the four regions, their alternates, and ad hoc physicians Non-voting Committee Participants Assistant Vice President, Provider Measurement and Performance National Network Business Project Senior Analyst Network Management Health Data Senior Specialist, Clinical Insights Provider Metrics Marketing Product Senior Specialist Network Clinical Managers Non-voting and Ad hoc Committee Participants Network Product Integration Lead when a reconsideration is pertinent to their market Market Medical Executive when a reconsideration is pertinent to their market Upon request, the physician will be provided with the name, title, qualifications, and relationship to Cigna of the persons participating on the National Selection Review Committee who are responsible for making a determination on the physician s appeal. If requested, a face-to-face meeting will be arranged at a location reasonably convenient to the physician; other participants can join the meeting using teleconference. The physician has the right to be assisted by a representative. The physician should provide the name and credentials of the representative to the Network Clinical Manager at least two weeks in advance of the scheduled Selection Review Committee meeting. If the physician requests an explanation of the designation decision which is the subject of the appeal to be considered as part of the appeal, it will be included. The physician or physician group will receive a written decision regarding the physician s appeal that states the reasons for upholding, modifying, or rejecting the physician s appeal. The appeal process will be completed within 45 days from the date the data and methodology are disclosed unless otherwise agreed to by the parties to the appeal. No change or modification of a designation that is the subject of an appeal shall be implemented or used until the appeal is final. We will update any changes to designations previously disclosed publicly within 30 days after the appeal is final. by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 37

38 Abbreviations List Abbreviation Organization Abbreviation Organization AAP American Academy of HEDIS Healthcare Effectiveness Data Information Set ACC American College of Cardiology HOPE Heart Outcomes Prevention Evaluation Study ACOG American College of Obstetrics and Gynecology ICSI Institute for Clinical Systems Improvement ACP-ASIM The American College of Physicians- American Society of IDSA Infectious Diseases Society of America ADA American Diabetes Association K/DOQI Kidney Disease Outcomes Quality Improvement AHA American Heart Association NHLBI National Heart Lung Blood Institute AHRQ Agency for Healthcare Research and Quality NIH National Institutes of Health AMA American Medical Association NQF Forum AMA-PCPI American Medical Association- Physician Consortium for Performance Improvement USPHS United States Preventive Health Service FDA Food and Drug Administration by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. THN Cigna. Some content provided under license. 38