Transcript Tonsillectomy Webinar Slides - Health Care Payment Improvement

Arkansas Payment Improvement Initiative (APII)
Tonsillectomy Episode
Statewide Webinar
August 12, 2013
0
Contents
▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy
Episode of Care
▪ Paula Miller – HP APII Analyst - Episode Reports
Today, we face major health care challenges in Arkansas
▪ The health status of Arkansans is poor: the
state is ranked at or near the bottom of all states
on national health indicators, such as heart
disease and diabetes
▪ The health care system is hard for patients to
navigate, and it does not reward providers who
work as a team to coordinate care for patients
▪ Health care spending is growing
unsustainably:
– Insurance premiums doubled for employers
and families in past 10 years (adding to
uninsured population)
2
Our vision to improve care for Arkansas is a comprehensive, patientcentered delivery system
Focus today
For
patients
Objectives
For
providers
How care is
delivered
Four
aspects of
broader
program
▪
▪
▪
Improve the health of the population
▪
▪
Reward providers for high quality, efficient care
Enhance the patient experience of care
Enable patients to take an active role in their care
Reduce or control the cost of care
Population-based care
▪ Medical homes
▪ Health homes
Episode-based care
▪ Acute, post-acute, or
select chronic conditions
▪
Results-based payment and reporting
▪
Health care workforce development
▪
Health information technology (HIT) adoption
▪
Consumer engagement and personal responsibility
3
Medicaid and private insurers believe paying for results, not just individual
services, is the best option to improve quality and control costs
This initiative
aims to…
This initiative
DOES NOT
aim to

Transition to a payment system that rewards value and patient
health outcomes by aligning financial incentives




Reduce payment levels for all providers regardless
of their quality of care or efficiency in managing costs
Pass growing costs on to consumers through higher premiums,
deductibles and co-pays (private payers), or higher taxes
(Medicaid)
Intensify payer intervention in decisions though managed
care or elimination of expensive services (e.g. through prior
authorizations) based on restrictive guidelines
Eliminate coverage of expensive services or eligibility
4
Principles of payment design for Arkansas
Patientcentered
Focus on improving quality, patient experience
and cost efficiency
Clinically
appropriate
Design based on evidence, with close input from
Arkansas patients and providers
Practical
Consider scope and complexity of implementation
Data-based
Make design decisions based on facts and data
5
Contents
▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director –Tonsillectomy
Episode of Care
▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports
Contents
▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy
Providers, Patients & Quality
▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy: key facts
What is a tonsillectomy?
▪ Surgical removal of the tonsils
▪ Commonly performed on children due to repeated infections of the tonsils
▪ Typically done as a same day surgery
Goals of episode
▪
▪
▪
▪
▪
Reduce multiple pre-op visits
Drive appropriate post-surgery observation period
Reduce inappropriate sleep study, antibiotic and pathology usage
Reduce readmissions
Create a model for ENTs to share practices and design even more effective care
9
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Patient journey for tonsillectomy/adenoidectomy
Pre-procedure –
(up to 90 days)
post-procedure admission
Post-procedure – 30 days
Procedure
Same-day recovery unit
Presents to ENT
specialist
Preprocedural
work-up in
hospital/out
patient
setting
Tonsillectomy
/adenoidectomy
performed
This episode excludes cases that
present through
inpatient/emergency department
setting
Operating
room2
Inpatient Care
and Recovery
Unit
Inpatient care and recovery
unit1
Follow-up care
Post-procedure
admission3
Follow-up care
1 Conditions for inpatient observation include Down syndrome, congenital heart defects, coagulopathies, platelet storage deficiency, or coagulation defects
2 Complications resulting in return to operating room include excessive bleeding, severe vomiting, or low oxygen saturation
3 Major causes for post-procedure admission include dehydration and excessive bleeding
SOURCE: American Academy of Otorhinolaryngology, Expert interviews
10
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Episode summary: Number of adenoidectomy, tonsillectomy,
and adeno-tonsillectomy in Arkansas
Medicaid
Total number of procedures
BCBS
3,498
Total number of procedures
1,311
Adenoidectomy
569
Adenoidectomy
176
Tonsillectomy
269
Tonsillectomy
361
Adeno-tonsillectomy
774
Adeno-tonsillectomy
Number of performing providers
2,660
61
Number of performing providers
SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010
Arkansas Blue Cross Blue Shield claims for patients with tonsillectomy/adenoidectomy between July 1, 2011 – June 30, 2012
74
11
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy/adenoidectomy episode design (1/2)
▪ Episode is triggered by select types of tonsillectomy/adenoidectomy procedures,
Episode
definition/
1 scope
of services
▪
including:
– All outpatient tonsillectomy, adenoidectomy, and adeno-tonsillectomy procedures (i.e.
ED and inpatient tonsillectomies/adenoidectomies are excluded)
– Primary or second diagnosis (Dx1 and Dx2) indicating conditions that require
tonsillectomy/adenoidectomy (e.g. chronic tonsillitis, chronic adenoiditis, chronic
pharyngitis, hypertrophy of tonsils and adenoids, obstructive sleep apnea, insomnia,
peritonsillar abscess)
Episode time frame:
– Related services (including sleep studies, head and neck x-rays, laryngoscopy) within
90 days prior to procedure after and including initial consult with performing provider
– Related services within 30 days after procedure (i.e., inpatient and outpatient facility
services, professional services, related medications, treatment for post-procedure
complications)
– Post-procedure admissions within 30 days after procedure1
▪ Certain patients are excluded from this episode design, patients with:
– Select co-morbid conditions (e.g., Down syndrome, cancer, severe asthma, cerebral
Patient/ episode
2 exclusions
–
–
–
–
–
–
–
palsy, muscular dystrophy, myopathies)
Uvulopalatopharyngoplasty (UPPP) on date of procedure
Patients with BMI>502
Age younger than 3 or older than 21
Dual enrollment in Medicare/Medicaid (i.e., dual eligibles)
Inconsistent enrollment (i.e., not continuously enrolled) during the episode
Death in hospital during episode
Patient status of “left against medical advice” during episode
Parameters and codes may vary across different payers; the following algorithm and associated codes
sheet applies to Medicaid
1 Excludes post procedure admissions that are not related to the episode as determined by Bundled Payment for Care Improvement (BPCI). Covers entire
length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be included in episode)
12
2 Reported through provider portal
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy/adenoidectomy episode design (2/2)
3
Episode
adjustments
▪ Episode cost is adjusted based on:
– Risk factors (e.g. COPD, asthma)
– Episode types: (1) adenoidectomy (2) tonsillectomy/adeno-tonsillectomy
▪ Only providers with at least 5 episodes per year are eligible for gain
sharing/risk sharing
Quality/
4 utilization
metrics
▪ Quality metrics required for gain sharing payment:
– Percent of episodes with administration of intra-operative steroids1
▪ Metrics for reporting only:
– Quality: Post-operative primary bleed rate (i.e., post-procedure
admissions or unplanned return to OR due to bleeding within 24 hours of
surgery)
– Quality: Post-operative secondary bleed rate
– Utilization: Rate of antibiotic prescription post-surgery2
▪ For Medicaid, the Principal Accountable Provider (PAP) will be the primary
Principal
5 Accountable
Provider
provider performing the tonsillectomy/adenoidectomy. Other payers
independently determine the PAP by considering the following factors:
– Decision making responsibilities
– Influence over other providers
– Portion of episode cost
1 Reported through provider portal as an aggregate percentage across all of a PAP’s episode for a specific payor
2 American Academy of Otolaryngology – Head and Neck Surgery Tonsillectomy Guidelines for 2011 recommend against prescription of antibiotics
post-procedure
13
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
1 Design rationale: Episode definition / scope of services (1/4)
Episode begins
90 days preprocedure
Episode
definition:
▪ All related
The episode includes the following
services up to 90 services
days prior to
Preparatory visits (office/clinic,
(after and
or specialist consultation)
including initial
consult) and 30
Labs, imaging, and
days after
diagnostic tests
tonsillectomy/adenoidectomy
Professional claim
procedure,
for procedure
including
inpatient and
Inpatient or outpatient
outpatient facility
facility care
services,
professional
services, and
Medication
related
medications
30-day post-procedure admission1
▪ Complications
that occur after
the procedure
Trigger
Tonsillectomy/adenoidec
-tomy procedure
Episode ends
30 days postprocedure
▪ All claims within 90 days prior to procedure with
a diagnosis related to
adenoidectomy/tonsillectomy
– Claims must occur after initial consult with
performing provider (initial consult is
included)
▪ All claims on day of procedure or within 30 days
post-procedure window with a diagnosis related
to tonsillectomy/adenoidectomy
▪ Complications are included in the 30 day post▪
▪
procedure window
All antibiotics, anti-emetics, narcotics, and
steroids prescribed in the 30 day post-procedure
window
Inpatient admission within 30 day post-procedure
window as defined by Bundled Payment for Care
Improvement (BPCI)
1 Covers entire length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be
included in episode)
14
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
1 Design rationale: Episode definition / scope of services (2/4)
Episode design decisions
▪
▪
▪
Trigger identification:
– Only outpatient tonsillectomies/adenoidectomies can be
potential triggers (i.e., tonsillectomies/adenoidectomies
which occur in the ER or inpatient are automatically
excluded as potential triggers)
– Episode is triggered by tonsillectomy/adenoidectomy
procedure and appropriate primary or secondary diagnosis
Pre-procedure window:
– Episode begins the day of the first PAP visit within a 90-day
window prior to procedure
▫ Any ER/Inpatient cost in pre-procedure window will be
excluded
▫ Any medications in pre-procedure window will be
excluded
Post-procedure window:
– Related services within 30 days after procedure (i.e.,
inpatient and outpatient facility services, professional
services, related medications, treatment for post-procedure
complications)
–
Inpatient post-procedure admission within 30 days after
procedure as defined by Bundled Payment for Care
Improvement (BPCI)
Rationale
▪
▪
▪
▪
▪
Detailed in following pages
Tonsillectomies/adenoidectomies which occur in the ER or inpatient often
have high variability in patient conditions, outcomes, and episode costs
(i.e., variability beyond the control of the PAP), and are therefore excluded
A list of CPT and ICD-9 Px codes for tonsillectomy, adenoidectomy, and
adeno-tonsillectomy are identified as triggers for an episode
An appropriate ICD-9 diagnosis code (Dx fields 1 and 2) must also
accompany a procedure code for the procedure to be considered a valid
trigger for an episode
Pre-procedure window is a maximum of 90 days prior to the procedure to
allow for capture of the first ENT consult with patient
ER/Inpatient and medication costs are not captured in pre-procedure
window since the tonsillectomy/adenoidectomy procedure is often
scheduled based on patient convenience, therefore giving some PAPs a
greater risk for higher ER/inpatient and medication cost that is beyond
PAP’s control
▪
Post procedure admissions due to complications, etc. are included in
episode cost calculations since reducing complications and treating them
effectively and efficiently is an identified value driver
▪
Bundled Payment for Care Improvement (BPCI) provides a list of
procedure codes which are not relevant to tonsillectomy/adenoidectomy
and these procedures would not be included in episode costs (i.e., if a
patient is treated for a condition that is not a complication or relevant to the
tonsillectomy/adenoidectomy procedure within 30 days after the procedure,
it will not be included in the episode cost calculations)
15
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
2 Design rationale: Patient exclusions (1/5)
Detailed in following pages
Patient exclusion design decision
Rationale
▪ Select co-morbid conditions within 365 days
▪ Patients with certain co-morbidities which may
prior to procedure or during episode
▪ Pregnant during episode
unfairly increase a PAP’s average episode cost due
to their inherent medical condition(s) within a year
prior to procedure or during the episode are excluded
(i.e., co-morbidities are factors beyond the PAP’s
control/influence)
▪ Tonsillectomies/adenoidectomies performed on women
who are known to be pregnant during an episode window
are excluded due to their potentially complex condition
▪ Age younger than 3 or older than 21
▪ Patients under 3 and older than 21 tend to be more
complicated procedures and are therefore excluded
▪ Dual enrollment in Medicare/Medicaid (i.e.,
dual eligibles)
▪ Inconsistent enrollment with payer during
episode
▪ In order to reduce the possibility that costs within an
episode are not accurately and fully captured (i.e.,
costs partially covered by another program), patients
who have dual enrollment are excluded
▪ Consistent enrollment ensures that all costs
associated with an episode are accurately and fully
captured
16
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
2 Design rationale: Patient exclusions (2/5)
Patient exclusion design decision
Rationale
▪ Uvulopalatopharyngoplasty (UPPP) on date
▪ Patients with UPPP on date of procedure have a
of procedure
▪
▪ Patients with BMI>50
▪ Patients with BMI over 50 are higher risk and more
▪
▪ Death in hospital during episode
different clinical pathology than relevant
tonsillectomy/adeno-tonsillectomy
As a result, the severity of care and episode cost is
extremely different and variable as compared to
relevant episodes
complicated to operate on
The PAP cannot control this risk or the variability in
outcomes due to this patient condition
▪ Patients with death in hospital are clinical outliers
▪ Patient status of “left against medical advice” ▪ A PAP cannot be held responsible for outcomes and
during episode
resulting cost of care if patient leaves AMA
17
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
LIST OF EXCLUSION CO-MORBIDITIES
2 Design rationale: Patient exclusions (3/5)
Age on date of
procedure
Care
setting1
 Younger than 3  ED tonsillectomy/
 Older than 21
adenoidectomy
 Inpatient
tonsillectomy/
adenoidectomy
Severe/chronic diseases and procedures
(Exclusion period: 365 days pre-procedure and
during episode window)
 Sickle cell disease
 Blood disorders
 Cystic fibrosis
 Coagulopathies
 Severe asthma
 Down syndrome
 Congenital
anomalies
 Malignant
hypothermia
 ESRD (end-stage
 Congenital defects of the
renal disease)
circulatory system
 Uvulopalatopharyn
 Post obstructive
goplasty (UPPP)2
pulmonary edema
 Muscular dystrophy
 Myopathies
 Degenerative diseases of
CNS
 Severe mental retardation
1 Setting where patient presented with symptoms and received treatment
2 Exclusion applies only if performed on date of procedure
18
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
LIST OF EXCLUSION CO-MORBIDITIES
2 Design rationale: Patient exclusions (4/5)
Cancers
(Exclusion period: 365 days pre-procedure and during
episode window)
Other
(during episode
window)
 Bone cancer
 Ovarian cancer
 Pneumonia
 Brain cancer
 Pancreas cancer
 Fetal disturbances
 Bronchial/lung cancer
 Rectum/anus cancer
 Colon cancer
 Kidney/renal cancer
 Forceps or vacuum
extractor delivery
 Esophageal cancer
 Stomach cancer
 GI/peritoneum cancer
 Urinary organ cancer
 Liver cancer
 Gallbladder cancer
 Malignant neoplasm
 Secondary malignancy
 Neoplasm unspecified
 Other respiratory cancer
 Female genital cancer
 Other primary cancer
 Male genital cancer
 Malposition
 Other perinatal
diagnosis
 Umbilical cord
complications
 Spontaneous
abortion
 Suicide and
intentional selfinflicted injury
19
TOP-20 EXCLUSION CO-MORBIDITIES FROM 2010
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
2 Design rationale: Patient exclusions (5/5)
INDIVIDUAL PATIENT MAY HAVE
MORE THAN ONE CO-MORBIDITY
ICD9-Dx Description
486
493.92
289.3
Pneumonia, organism unspecified
Asthma, unspecified type, with (acute) exacerbation
Lymphadenitis, unspecified, except mesenteric
758.0
Down's syndrome
343.9
Infantile cerebral palsy, unspecified
745.4
Ventricular septal defect
331.4
Obstructive hydrocephalus
759.7
Multiple congenital anomalies
493.02
Extrinsic asthma with (acute) exacerbation
745.5
Ostium secundum type atrial septal defect
750.29
Other specified anomalies of pharynx
239.2
Neoplasm of unspecified nature of bone, soft tissue
482.9
Bacterial pneumonia, unspecified
519.11
282.5
2382
3181
74100
7423
2875
Acute bronchospasm
Sickle-cell trait
Neoplasm of uncertain behavior of skin
Severe mental retardation
Spina bifida with hydrocephalus, unspecified region
Congenital hydrocephalus
Thrombocytopenia, unspecified
SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010
20
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
4 Design rationale: Quality metrics
Quality metrics design decision
A▪ Quality metrics required for gain sharing
payment:
– Rate of administration of inta-operative
steroids
B ▪ Quality/utilization metrics for reporting only:
Rationale
▪ To qualify for gain sharing, providers or their staff
▪
▪ A bleed within 24-hours post-surgery (primary bleed)
– Post-operative primary bleed rate (i.e.,
post-procedure admissions or unplanned
return to OR due to bleeding within 24
hours of surgery)
– Post-operative secondary bleed rate
– Utilization: Rate of antibiotic prescription
post-surgery
must report quality metrics through an online provider
portal since some quality metrics cannot be extracted
from claims data
Providers must meet minimum quality standards
agreed upon by a clinical advisory board
– Example:
▫ Average rate of intra-operative steroid
administration
▪
▪
is related to surgeon technical skill and can drive
post-procedure admissions as well as unplanned
return to the operation room
A bleed within 2-14 days post-procedure is less
related to physician efficiency but should still be
monitored as it can drive post-procedure admissions
The Academy of Otolaryngology has recommended
against post procedure antibiotic prescription in the
revised tonsillectomy guidelines from 2011
21
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
5 Design rationale: Principal Accountable Provider (PAP)
PAP design decision
Rationale
▪ Payers independently determine the PAP by
▪ Medicaid has publicly announced that the Principal
considering the following factors:
– Decision making responsibilities
– Influence over other providers
– Portion of episode cost
Accountable Provider (PAP) will be the primary
provider performing the tonsillectomy/adenoidectomy
since they are in the position to influence the most
decisions and costs
Medicaid’s PAP will be the provider performing
the tonsillectomy/adenoidectomy
22
Contents
▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy
Episode of Care
▪ Paula Miller –HP APII Analyst - Episode Descriptions & Reports
Medicaid
Little Rock Clinic
123456789
April 2013
Arkansas Health Care Payment Improvement Initiative
Provider Report
Medicaid
Report date: April 2013
Historical performance: January 1, 2012 – December 31, 2012
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program.
The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. The figures
in this report are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org
Division of Medical Services
P.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437
501-683-4120 · Fax: 501-683-4124
Dear Medicaid provider,
This is an update on the Arkansas Health Care Payment Improvement Initiative (APII) – a payment system developed with input from hundreds of health
care providers, patients and family members. Our goal is to support and reward providers who consistently deliver high-quality, coordinated, and costeffective care.
As a reminder, a core component of this multi-payer initiative is episodes of care. An episode is the collection of care provided to treat a particular condition
over a given length of time. Since July of 2012, Arkansas Medicaid has introduced new episodes, including Upper Respiratory Infection (URI), Perinatal
(colloquially, called “pregnancy”), Attention Deficit/Hyperactivity Disorder (ADHD), and more. To see the most up to date list of episodes visit the APII
website at www.paymentinitiative.org.
For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the
Principal Accountable Provider (PAPs). For some episodes in the period covered in the attached report, you were identified as the PAP. After appropriate
risk-adjustments and exclusions, your average quality and cost was compared with previously announced thresholds. This determines any potential sharing
of savings or excess cost indicated in the report. Note that all information described throughout your report is based on claims already submitted and all
providers should continue to submit and receive reimbursement for claims as they do today.
This report contains episodes currently in the ‘preparatory phase’ and so the data and analyses for these reports are historical only (i.e. they are not data
from the time period that you will be measured against). To see “performance” reports (i.e., containing episodes eligible for gain or risk sharing) for episodes
launched earlier, log onto the provider portal at www.paymentinitiative.org to download a separate report.
To aid you in your role as a PAP for future episodes, we have been working hard with providers and other payers to design a set of reports that give you
detailed data about the quality and cost of your care as well as how this compares with previously announced thresholds and the range of performance of
other providers. As each payer will send a report covering their patients, you may receive similar reports from Arkansas Blue Cross Blue Shield and / or
QualChoice.
We encourage you to log onto the provider portal to access your current and previous ‘preparatory period’ and ‘performance period’ reports. As a PAP for
select episodes, you should begin using this portal to enter selected quality metrics for each patient with an episode of care starting. To see which episodes
have quality metrics linked to gain sharing visit the APII website.
We have been working diligently to solicit feedback from the provider community and will continue in our efforts to respond to all questions, comments and
concerns raised in a timely and consistent manner. For answers to frequently asked questions regarding the initiative and episodes, please refer to the
payment initiative website (www.paymentinitiative.org) You can also call us at 1-866-322-4696 or locally at 501-301-8311 with questions or email
[email protected]. Additionally, be sure to check the website regularly for updates on upcoming informational WebEx sessions, other resources, or to sign up
for alerts.
Sincerely,
Andy Allison, PhD
Medicaid Director
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is
neither intended nor suitable for other uses, including the selection of a health care provider. These figures are preliminary and are subject to revision. For
more information, please visit www.paymentinitiative.org.
Medicaid
Little Rock Clinic
123456789
April 2013
Table of contents
Performance summary
Attention Deficit/Hyperactivity Disorder (ADHD) – Level I
Attention Deficit/Hyperactivity Disorder (ADHD) – Level II
Cholecystectomy
Colonoscopy
Congestive Heart Failure
Oppositional Defiance Disorder
Perinatal
Tonsillectomy
Total Joint Replacement
Upper Respiratory Infection – Non-specific URI
Upper Respiratory Infection – Pharyngitis
Upper Respiratory Infection – Sinusitis
Glossary
Appendix: Episode level detail
Medicaid
Little Rock Clinic
123456789
April 2013
Performance summary
1
Quality of services and cost summary
Quality
of Service
Average
Episode Cost
Attention Deficit / Hyperactivity Disorder
(ADHD) – Level I
Not met
Acceptable
Not eligible for gain
sharing
$0.00
Attention Deficit / Hyperactivity Disorder
(ADHD) – Level II
Met
Acceptable
$0.00
Cholecystectomy
Met
Acceptable
Not eligible for gain
sharing
Not eligible for gain
sharing
Colonoscopy
Met
Acceptable
Not eligible for gain
sharing
$0.00
Congestive Heart Failure
Not met
Acceptable
Not eligible for gain
sharing
$0.00
Oppositional Defiance Disorder
Met
Acceptable
Not eligible for gain
sharing
$0.00
Perinatal
Met
Acceptable
Not eligible for gain
sharing
$0.00
Tonsillectomy
Met
Acceptable
Not eligible for gain
sharing
$0.00
Total Joint Replacement
N/A
Acceptable
Not eligible for gain
sharing
$0.00
N/A
Not acceptable
Subject to risk sharing
-$3,844.50
Not met
Acceptable
Not eligible for gain
sharing
$0.00
N/A
Commendable
Will receive gain sharing
$349.50
Episode of Care
Upper Respiratory Infection – Nonspecific URI
Upper Respiratory Infection –
Pharyngitis
Upper Respiratory Infection – Sinusitis
Across these Episodes of Care You are Subject to Risk Sharing:
Your Gain/Risk Share
Stop-loss was applied
Share
Amount
$0.00
-$3,000.00
The figures in this report are preliminary and are subject to revision
Medicaid
Little Rock Clinic
123456789
April 2013
Summary – Tonsillectomy
1
Overview
Total episodes: 262
2
Total episodes included: 233
Cost of care compared to other providers
Commendable
< $974
3
Total episodes excluded: 29
Acceptable
$974 to $1,003
Gain/Risk share
Not acceptable
>>$1,003
$4000
Quality summary
$0
You
All providers
4
Cost summary
You achieved selected quality metrics
Your average cost is acceptable
Linked to gain sharing
50%
There are no quality metrics
0% to gain sharing generated
linked
from claims
quality
Youdata. Selected
Avg
data submitted on the Provider
Portal will generate additional
quality metrics for future reports.
Post-procedure primary bleed rate
100%
50%
You (nonadjusted)
0%
You
Avg
Post-procedure secondary bleed
100%
100
50
You
Avg
Post-op Abx Rx rate
100%
50%
You
(adjusted)
You
5
Avg
All providers
84
15
23
28
<$899
$899$974
$974$984
42
$984$993
$993$1003
23
18
$1,003$1,542
>$1,542
7500
5000
2500
0%
You
1,750
Distribution of provider average episode cost
Cost,
$
Series
2,000
Your episode cost distribution
50%
0%
Average cost overview, $
Your total cost overview, $
512,000
466,000
#
episodes
Standard
for gain
sharing
Intra-op steroid Rx rate
100%
You will not receive gain or risk sharing
 Selected quality metrics: N/A
 Average episode cost: Acceptable
You
Commendable
Acceptable
Percentile
Not acceptable
Key utilization metrics
Surgical pathology utilization rate
17%
30%
You
All providers
Medicaid
Little Rock Clinic
123456789
April 2013
Quality and utilization detail – Tonsillectomy
You
1
Metric linked to gain sharing
Minimum standard for gain sharing
Quality metrics: Performance compared to provider distribution
Metric
You
25th
Percentile
50th
75th
Post-procedure primary bleed rate
1%
0%
1%
2%
Post-procedure secondary bleed
0%
1%
2%
4%
25%
20%
30%
40%
Post-procedure Abx Rx
0
25
Percentile
50
75
100
-
You achieved selected quality metrics
2
Metric
Utilization metrics: Performance compared to provider distribution
You
25th
Percentile
50th
75th
0
25
Percentile
50
75
100
-
Medicaid
Little Rock Clinic
123456789
April 2013
Cost detail – Tonsillectomy
Total episodes included = 233
Care category
Outpatient
professional
Pharmacy
Emergency
department
You
# and % of episodes with claims
in care category
233
100%
100%
230
99%
99%
221
95%
97%
Average cost per episode
when care category
utilized, $
All provider average
Total vs. expected cost in
care category, $
550
500
128,150
116,500
2,415
2,400
555,450
552,000
76
76
16,796
16,796
184
79%
77%
81
81
14,904
14,904
Outpatient
radiology /
procedures
21
75%
80%
117
95
2,457
1,995
Inpatient
professional
16
78%
75%
70
75
1,120
1,200
Outpatient lab
Inpatient facility
Outpatient
surgery
Other
12
5%
3%
69
62
828
744
1
<1%
<1%
97
84
97
84
7
3%
4%
25
27
175
189
Questions
For more information talk with provider support representatives…
▪ More information on the Payment Improvement Initiative
Online
can be found at www.paymentinitiative.org
– Further detail on the initiative, PAP and portal
– Printable flyers for bulletin boards, staff offices, etc.
– Specific details on all episodes
– Contact information for each payer’s support staff
– All previous workgroup materials
Phone/ email
▪ Medicaid: 1-866-322-4696 (in-state) or 1-501-301-8311 (local
and out-of state) or [email protected]
▪ Blue Cross Blue Shield: Providers 1-800-827- 4814, direct to EBI 1-888-800-3283,
[email protected]
▪ QualChoice: 1-501-228-7111, [email protected]