CLINICAL PROCESS IMPROVEMENT INITIATIVE (CPII) EFFICIENCY REPORT EXPLANATION January 4, 2016

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1 CLINICAL PROCESS IMPROVEMENT INITIATIVE (CPII) EFFICIENCY REPORT EXPLANATION January 4, 2016 WHAT IS AN EPISODE OF CARE? An episode of care is a grouping of a patient s health care claims for a unique occurrence of a particular illness or injury, or a year of claims for a chronic condition. The claims that are grouped include the medical, ancillary, ambulatory surgical, other hospital, emergency, inpatient, and pharmacy services that are involved in diagnosing and treating the patient s condition. The diagnosis codes on these claims also describe a patient s underlying clinical conditions related to the episode and complications and comorbidities. The services within an episode may be provided by more than one physician; the episode is attributed to a single provider based on an evaluation of the claims data to determine which provider was responsible for the overall management of the care that the patient received during the course of his or her treatment for that illness, injury, or chronic condition. WHAT IS AN EPISODE TREATMENT GROUP (ETG)? ETGs are a clinical condition classification methodology that categorizes clinically homogeneous episodes into groups. Each episode is assigned to a unique group (an episode treatment group) and its severity level is assessed (reflecting the primary clinical condition for the episode and the complications, comorbidities and patient characteristics that impact treatment). For more information see the white paper written by Optum, who developed the Symmetry ETG Grouper used by CPII, by going to >> Information For Providers >> Scoring Methodology and access the link under Efficiency Score. EFFICIENCY REPORTS There may be up to three (3) different Efficiency Reports included in your reporting package. You will receive a Summary of Episode Treatment Groups (ETGs) report (Report A) that summarizes the top ten (10) ETGs that contribute to your overall Efficiency Score. If you were less efficient than you peers in any of your top five (5) ETGs shown on this report, you will also receive an ETG Summary report (Report B) and an ETG Detail report (Report C). The flow chart included in this package shows how these reports relate to each other. An explanation of each report including some key terms follows. A. Summary of Episode Treatment Groups (ETGs) This report summarizes the ETGs that contribute to your Efficiency Score. At the top of the report you will see your overall Efficiency Score. In the middle of the report are two (2) charts. The pie chart displays your top five (5) ETGs in terms of cost relative to all other ETGs contributing to your 1

2 Efficiency Score. The bar chart displays these same top five (5) ETGs in terms of your Proxy Cost as compared to peer Proxy Costs for the same ETG. At the bottom of the report, you will see your top ten (10) ETGs having the highest Proxy Cost, broken out and compared to the Proxy Costs of your peers for the same number of ETGs. Also shown is your performance relative to your peers in the form of an abacus chart. Using Total Unweighted Proxy Cost, these abacus charts show your percentile rank within your specialty, where the middle of the chart represents the median cost for the ETG. B. ETG Summary If you receive an ETG Summary report, it is because you scored as less efficient than your peers for the particular ETG. This report focuses on six (6) service categories: Medical/Professional, Ambulatory Surgery, Outpatient, Emergency, Inpatient and Pharmacy. There are two (2) charts on this report. The first chart displays your total Proxy Cost in each service category for the ETG and compares to peer Proxy Costs. The second chart shows how much more or less your Proxy Costs were than those of your peers in each of these service categories for this ETG. C. ETG Detail If you receive an ETG Detail report, it is because you were scored as less efficient than your peers for the particular ETG. This report focuses on the Medical/Professional Services category for the ETG. At the top of the report you will see your overall Efficiency Score and the count of this ETG that was attributed to you. In the middle of the report are two (2) charts. The pie chart displays the top five (5) procedures in terms of Proxy Cost relative to all other procedures contributing to the Medical/Professional Services total. The bar chart displays these same top five (5) procedures in terms of your Proxy Cost as compared to peer Proxy Cost. At the bottom, you will see your top ten (10) procedures having the highest Proxy Cost, broken out and compared to the Proxy Costs of your peers. Also shown is your performance relative to your peers in the form of an abacus chart. Using Total Unweighted Proxy Cost, these abacus charts show your percentile rank within your specialty, where the middle of the chart represents the median cost for the same service. The claims data that we analyze for this project include the most recent three years of commercial claims data from the GIC s six health plans. Occasionally, a procedure code is retired and is deleted from the current CPT-ICD9 manual, but, because we are still using this data, the procedure code appears as del_ Since the report includes the top procedures by frequency impacting that specific episode, a procedure with a retired code may appear on the report. Additionally, the procedure code and/or Procedure Description may be unavailable as well, resulting in a blank space. Definition of Terms Used In Efficiency Reports: Medical/Professional: The total proxy price amount for claims identified as professional, supplemental or auxiliary services based on CPT/HCPCS codes for a particular episode type. 2

3 Ambulatory Surgery: The total proxy price amount for claims identified for surgical or related purposes primarily based on revenue codes for a particular episode type. Outpatient: The total proxy price amount for claims identified for hospital services based on revenue codes, but not categorized as Inpatient, Ambulatory Surgery or Emergency for a particular episode type. Emergency: The total proxy price amount for claims identified for emergency room services based on revenue codes for a particular episode type Inpatient: The total proxy price amount for claims identified for inpatient services based on revenue codes for a particular episode type. Pharmacy: The total proxy price amount for claims submitted for prescription drugs for a particular episode type Efficiency Score Your Efficiency Score is created by comparing the consumption of resources (office visits, labs, medications, etc.) used in treating your patients to that of your peers treating patients with similar clinical conditions, adjusted for the severity of your patient case mix. Resource use is measured by Proxy Cost (see explanation below). The most efficient providers have lower Efficiency Scores; lessefficient providers have higher scores. Proxy Cost The unweighted costs shown for each ETG are derived using standardized costs (or proxy values) for each service included in the ETG, rather than the actual amount paid. This proxy value removes the influence of differing contract terms across health plans. The proxy values shown in these reports are not severity-adjusted (see Unweighted Total Cost below); however, each provider s ETGs are severityadjusted as part of the process of calculating the Efficiency Score. Unweighted Total Cost When determining a provider s Efficiency Score, up to three (3) years of historical data are used and the most recent year is weighted the most heavily. Additionally, a provider s raw score is adjusted for the severity of their patient case mix. Unweighted Total Cost represents the data where each year receives the same weighting and there is no severity adjustment. 3

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8 Quality Detail Report Provider Name: Provider Specialty: NON-INTERVENTIONAL CARDIOLOGY Provider ID: IS Your Overall Score: Measure ID Name and brief description of measure Lipid Rx noncompliance (NQF) This measure identifies patients on a lipid medication who have remained adherent to taking the medication regularly. 174 Hypertension avoid SA DHP calcium channel blocker This measure identifies the percentage of patients with hypertension diagnosed before the measurement year who had fewer than 2 prescription claims for short-acting dihydropyridine calcium channel blockers (SA DHP CCB) within the past 6 months. 185 Dyslipidemia new med 3 month lipid panel (NQF) This measure identifies patients who started lipid-lowering medication during the measurement year and had a lipid panel checked within 3 months after starting drug therapy. 395 HEDIS ACEI or ARB annual potassium and creatinine This measure identifies patients age 18 or older who received at least 180 days suppy for ACE inhibitors or ARBs during the measurement year who had at least 1 serum potassium and either a serum creatinine or a blood urea nitrogen (BUN) test during the measurement year. 175 CHF avoid DHP calcium channel blocker This measure identifies patients with HF who are not taking a non-dihydropyridine calcium channel blocker (non-dhp CCB) HTN had creatinine test This measure identifies patients with hypertension and receiving an ACE inhibitor or ARB, who had a serum creatinine test during the measurement year Atrial fibrillation and stroke risk on warfarin (NQF) This measure identifies patients with atrial fibrillation and other stroke risk who are taking oral anticoagulants. 172 Diabetes and hypertension or nephropathy patients on ACE-I or ARB This measure identifies patients with diabetes plus hypertension or nephropathy who are taking an ACE inhibitor or ARB during the measurement year. 398 CHD post-mi on ACE inhibitor (NQF) This measure identifies patients with ST elevation MI (STEMI), or non-st elevation MI (NSTEMI) plus a history of hypertension, HF, and/or diabetes prior to the measurement year who are taking an ACEI or an ARB during the measurement year CHD cholesterol management This measure identifies patients years old discharged alive for acute myocardial infarction (AMI), coronary bypass graft (CABG), or percutaneous transluminal coronary angioplasty (PTCA) during the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during or in the year prior to the measurement year, who had a LDL-C check during the measurement year. Your number of observations for this measure Your Compliance Rate 1 Peer Compliance Rate 2 Your Percentile Rank % 88.98% 1st % 99.97% 1st 4 25% 43.34% N/A % 88.48% N/A 3 100% 91.33% N/A % 92.98% N/A 2 100% 84.58% N/A 2 100% 77.4% N/A 2 100% 68.42% N/A 2 100% 89.45% N/A 1 How often you follow the measure 2 How often your peers followed the measure 3 The percentage of your peers whose compliance rate was lower than yours