Transcript Colonoscopy Webinar Slides - Health Care Payment Improvement

Arkansas Payment Improvement Initiative (APII)
Colonoscopy Episode
Statewide Webinar
August 15, 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 – Colonoscopy
Episode of Care
▪ Debra Lovelace – 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 –Colonoscopy
Episode of Care
▪ Wanda Colclough and Paula Miller – HP Enterprises Technical
Consultant and HP APII Analyst - Episode Descriptions & Reports
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
For Medicaid, work has occurred on 15 Episodes, with 8 having gone live
Reporting Period
Start Date
Wave 1a
1
Upper Respiratory Infection
Spring 2012
July 2012
2
Attention Deficit Hyperactivity Disorder (ADHD)
Spring 2012
July 2012
3
Perinatal
Spring 2012
July 2012
Wave
1b
4
Congestive Heart Failure
November 2012
December 2012
5
Total Joint Replacement (Hip & Knee)
November 2012
December 2012
6
Colonoscopy
June 2013
July 2013
7
Cholecystectomy (Gallbladder Removal)
June 2013
July 2013
8
Tonsillectomy
June 2013
July 2013
9
Oppositional Defiance Disorder (ODD)
August 2013
October 2013
10
Coronary Artery Bypass Grafting (CABG)
August 2013
October 2013
11
Percutaneous Coronary Intervention (PCI)
August 2013
October 2013
12
Asthma
August 2013
October 2013
13
Chronic Obstructive Pulmonary Disease (COPD)
August 2013
October 2013
14
ADHD/ODD Comorbidity
September 2013
January 2014
15
Neonatal
Q1 CY 2014
1st-half CY 2014
Wave 2b2
Legislative
Review
Wave 2a
Pending legislative
review
Episode
Wave 2c
(not started)
Wave 2
Wave 1
Live
In Development
Multipayer
Participation1,3
1 Participation includes development and rollout of episode
2 Subject to legislative approval. Wave 2b has been approved by Public Health Committee; further approvals expected during August 2013
3 Qualchoice is a Qualchoice of Arkansas; The cross and shield represent Blue Cross Blue Shield of Arkansas
0
Contents
▪ Dawn Zekis, Medicaid Health Innovation Unit Director Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Colonoscopy
Providers, Patients & Quality
▪ Debra Lovelace –HP APII Analyst - Episode Descriptions &
Reports
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Colonoscopy: key facts
What is a colonoscopy?
▪ Camera guided imaging of the lower intestines that aims to identify abnormalities
▪ Recommended for adults 50 years and older
▪ Preferred every 10 years as a routine procedure and within 3-5 years if a polyp is
found
▪ A successful colonoscopy provides quality imaging of the colon with well controlled
sedation and short term amnesia for the patient
▪ Complications during colonoscopy are rare
Goals of episode
▪
▪
▪
▪
Reduce complications such as bleeding
Curb unnecessary pre-procedure office visits
Reduce variation in expensive sedation techniques
Monitor effectiveness of additional procedures such polypectomy
9
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Colonoscopy: Patient journey
Screening
Pre-procedure – up to 30
days
Presents to
PCP
Procedure
Provider
conducts
preprocedure
work-up
Colonoscopy
performed
Diagnostic
Presents to GI
specialist /
surgeon
Presents to
PCP
Provider
conducts
preprocedure
work-up
Post-procedure – 30 days
Sameday
recovery
unit
Follow-up
phone call
from
physicians
Inpatient
care
and
recovery
unit
Outpatient
follow-up
w/ provider
who
performed
procedure
Hospital
operating
room
Inpatient
care
and
recovery
unit
Colonoscopy
performed
Presents to
ED
SOURCE: Society of Gastrointestinal Endoscopy guidelines, expert/clinician interviews
10
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Colonoscopy episode design (1/2)
▪ Episode is triggered by select types of outpatient colonoscopy procedure, including:
– Balloon, diagnostic, tumor removal, polypectomy, and
– Primary or secondary diagnosis indicating conditions that require a colonoscopy
▪
Episode
definition /
1
scope
of services
(e.g., colorectal bleeding, hemorrhoids, anal fistula, neoplasm of unspecified nature)
Episode time frame:
– Colonoscopies with and without additional procedures: Episode begins the day of
the first PAP visit within a 30-day window prior to procedure (includes inpatient and
outpatient facility services, professional services, related medications, etc.)
▫ Any ER/Inpatient cost on day of first PAP visit will be excluded
– Screening colonoscopies1: beginning day of procedure
– 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 procedure2, excluding those
defined by BPCI
▪ Certain patients are excluded from this episode design:
– Select co-morbid conditions within 365 days prior to procedure or during episode
Patient
2
exclusions
–
–
–
–
–
–
(e.g., inflammatory bowel disease, cancer, suicide, select transplants)
Pregnant during episode
Age younger than 18 or older than 64
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
1 Not currently applicable to Medicaid
2 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)
11
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Colonoscopy episode design (2/2)
3
Episode
adjustments
▪ Episode cost is adjusted based on:
– Risk factors (e.g., renal failure, diabetes)
– Episode types: (1) colonoscopies with additional procedures, (2)
▪
4
Quality
metrics
colonoscopies without additional procedures
Only providers with at least 5 episodes per year will be eligible for gain
sharing/risk sharing
▪ Quality metrics required for gain sharing payment1:
– Cecal intubation rate reported by provider on an aggregated quarterly basis
– Average withdrawal time reported by provider on an aggregated quarterly
▪
basis
Quality metrics for reporting only:
– Perforation rate
– Post polypectomy/biopsy bleed rate
▪ For Medicaid, the Principal Accountable Provider (PAP) will be the primary
Principal
5 Accountable
Provider
provider performing the colonoscopy. 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
12
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
1 Colonoscopy episode overview
Episode begins
Max. 30 days
pre- procedure1
Episode
definition:
▪ All related
services up to
30 days prior to
and 30 days
after
colonoscopy
procedure,
including
inpatient and
outpatient facility
services,
professional
services, and
related
medications
▪ Complications
that occur after
the procedure
Trigger
Colonoscopy
procedure
Episode ends
30 days postprocedure
The episode includes the following
services
Preparatory visits (office/clinic,
or specialist consultation)
Labs, imaging, and
diagnostic tests
Professional claim
for procedure
▪ All claims with a diagnosis code related to
colonoscopy, or procedure code related to
preparation, delivery, recovery, and
complications of colonoscopy2
▪ Complications are included in the post-procedure
period
Inpatient or outpatient
facility care
Medication
30-day post-procedure admission3
▪ All medications related to delivery, recovery, and
complications of procedure
▪ Inpatient post-procedure admission within 30
days post procedure as defined by BPCI
1 Screening colonoscopy episodes begin the day of the procedure (i.e., not 30 days pre-procedure). Medicaid does not currently reimburse for
screening colonoscopies; 2 Some procedure codes are sufficient to warrant inclusion of a claim in the episode, while others must be accompanied
by a diagnosis code related to the procedure; 3 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)
13
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
1 Design rationale: Episode definition / scope of
services
Episode design decisions
▪
Trigger identification:
– Only outpatient colonoscopies can be potential triggers (i.e.,
colonoscopies which occur in the ER or inpatient are
automatically excluded as potential triggers)
– Episode is triggered by select colonoscopy procedures and
appropriate primary or secondary diagnosis
Rationale
▪
▪
▪
▪
Pre-procedure window:
– Diagnostic colonoscopies: Episode begins the day of the
first PAP visit within a 30-day window prior to procedure
▫ Any ER/Inpatient cost on day of first PAP visit will be
excluded
–
▪
Screening colonoscopies: begins day of procedure
Post-procedure window:
– Related services within 30 days after procedure1 (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 BPCI
Detailed in following pages
▪
▪
Colonoscopies which occur in the ER or inpatient often have patient
conditions, outcomes, and costs which are often significantly variable (i.e.,
many factors beyond the control of the PAP), and are therefore excluded
A list of CPT and ICD-9 Px codes for colonoscopies with and without
additional procedures are identified as triggers for an episode
An appropriate ICD-9 diagnosis code 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 30 days prior to the procedure to
accommodate scheduling practices (e.g., private practice vs. hospital)
ER/Inpatient costs are not captured on the day of the first PAP visit since
the ER/Inpatient visit may have occurred earlier in the day before the PAP
visit (i.e., the PAP may not have had an influence on an ER/Inpatient visit
before meeting the patient)
▪
Screening colonoscopies generally do not involve significant pre-procedure
costs and therefore a decision was made not to establish a pre-procedure
window
▪
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
▪
BPCI provides a list of procedure codes which are not relevant to
colonoscopies 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 colonoscopy procedure within 30 days after the procedure,
it will not be included in the episode cost calculations)
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
2 Design rationale: Patient exclusions (1/4)
Detailed in following pages
Patient exclusion design decision
Rationale
▪ Select co-morbid conditions within 365 days
▪ Patients with certain co-morbidities which may
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)
prior to procedure or during episode
▪ Pregnant during episode
▪ Colonoscopies performed on women who are known
to be pregnant during an episode window are
excluded due to their potentially complex condition
▪ Age younger than 18 or older than 64
▪ Patients under 18 and older than 64 tend to be more
▪
▪ Dual enrollment in Medicare/Medicaid (i.e.,
dual eligibles)
▪ Inconsistent enrollment with payer during
episode
complicated procedures and are therefore excluded
Patients under 18 may also be billed differently than
adults and patients over 64 are often “dual eligibles”
▪ 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
15
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
SUMMARY OF EXCLUSIONS
2 Design rationale: Patient exclusions (2/4)
Age on date of
procedure
Care setting
Major medical procedures
and complications
 Younger than 18
 ER colonoscopies

Abortion complications
 Older than 64
 Inpatient

Complications from organ
Severe/chronic
diseases

ESRD (end-stage
renal disease)
transplants

Perinatal jaundice

Dialysis

Respiratory distress

Ileostomy

Inflammatory bowel

Colostomy and enterostomy

Colonoscopy via colotomy

Colostomy or skin level
colonoscopies
disease
cecostomy

Laparoscopic surgical
colostomy

Select organ transplants
(kidney, heart)
16
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
SUMMARY OF EXCLUSIONS
2 Design rationale: Patient exclusions (3/4)
Cancers
Other

Bone cancer

Ovarian cancer

Fetal disturbances

Brain cancer

Pancreas cancer

Forceps or vacuum

Bronchial/lung cancer

Rectum/anus cancer

Colon cancer

Kidney/renal cancer

Malposition

Esophageal cancer

Stomach cancer

Other perinatal

GI/peritoneum cancer

Urinary organ cancer

Liver cancer

Gallbladder cancer

Malignant neoplasm

Secondary malignancy

Neoplasm unspecified

Other respiratory cancer

Spontaneous abortion

Female genital cancer

Other primary cancer

Suicide and intentional

Male genital cancer
extractor delivery
diagnosis

Umbilical cord
complications
self-inflicted injury

Perinatal diagnoses or
procedures
17
COMMON EXCLUSION CO-MORBIDITIES FROM 2010
2 Design rationale: Patient exclusions (4/4)
ICD9-Dx
Malignant neoplasm; colon, unspecified
556.9
Ulcerative colitis unspecified
V62.84
Suicidal Ideation
V58.11
Encounter for antineoplastic chemotherapy
V100.5
INDIVIDUAL PATIENT MAY HAVE
MORE THAN ONE CO-MORBIDITY
Description
153.9
555.9
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Regional enteritis of unspecified site
History of malignant neoplasm, large intestine
23.52
Neoplasm of uncertain behavior
154.0
Malignant neoplasm of rectosigmoid junction
154.1
Malignant neoplasm of rectum
585.6
End stage renal disease
V27.0
Outcome of delivery, single liveborn
V58.0
Encounter for; radiotherapy
197.7
Secondary malignant neoplasm; liver
199.1
Syncope and collapse
153.3
Malignant neoplasm of sigmoid colon
162.9
Malignant neoplasm of bronchus and lung
555.1
Regional enteritis of large intestine
V71.1
Observation for suspected malignant neoplasm
239.0
Neoplasm of unspecified nature of digestive system
In 2010, 553 out of 2,254 procedures (25%) were excluded for co-morbidities
SOURCE: From all valid colonoscopies with and without additional procedures in 2010
18
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
4 Design rationale: Quality metrics
Quality metrics design decision
Rationale
▪ Quality metrics required for gain sharing
▪ To qualify for gain sharing, providers or their staff
payment:
– Cecal intubation rate meets threshold
– Average withdrawal time meets threshold
▪ Quality metrics for reporting only:
– Perforation rate
– Post polypectomy/biopsy bleed rate
▪
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, e.g.:
– Cecal intubation rate reported by provider on an
aggregated quarterly basis
– Average withdrawal time reported by provider on
an aggregated quarterly basis
▪ Other quality metrics have been identified as
▪
important and will be collected through claims data or
the online portal), however, this information will not
affect gain or risk sharing
These quality metrics may identify value drivers for
future consideration
19
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 colonoscopy since they are
in the position to influence the most decisions and
costs
Medicaid has announced that its
PAP will be the primary provider
performing the colonoscopy
20
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 – Colonoscopy
Episode of Care
▪ Debra Lovelace –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
2
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 cost-effective 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 riskadjustments 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.
2
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
2
Medicaid
1
Little Rock Clinic
123456789
April 2013
Performance summary
Quality of services and cost summary
Quality
of Service
Average
Episode Cost
Your Gain/Risk Share
Share
Amount
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
Not eligible for gain sharing
$0.00
Cholecystectomy
Met
Acceptable
Not eligible for gain sharing
$0.00
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
Episode of Care
Upper Respiratory Infection – Non-specific
URI
Upper Respiratory Infection – Pharyngitis
N/A
Not acceptable
Subject to risk sharing
-$3,844.50
Not met
Acceptable
Not eligible for gain sharing
$0.00
Upper Respiratory Infection – Sinusitis
N/A
Commendable
Will receive gain sharing
$349.50
Across these Episodes of Care You are Subject to Risk Sharing:
Stop-loss was applied
-$3,000.00
The figures in this report are preliminary and are subject to revision
2
Medicaid
Little Rock Clinic
123456789
April 2013
Summary – Colonoscopy
Overview
Total episodes: 262
2
Total episodes included: 233
Cost of care compared to other providers
Commendable
< $796
3
Total episodes excluded: 29
Acceptable
$796 to $886
Gain/Risk share
Not acceptable
$886
>>$4000
Quality summary
Standard
for gain
sharing
Cecal
intubation rate
100%
Standard
for gain
sharing
50%
There are no quality metrics
0% to gain sharing generated
linked
from claims
quality
Youdata. Selected
Avg
Avgdata
withdrawal
timeon(min.)
submitted
the Provider
10
Portal
will generate additional
quality metrics for future reports.
5
0
Avg
Your average cost is acceptable
Your total cost overview, $
2.0
1.5
1.0
0.5
0%
You
Avg
Post-polypectomy bleed rate
2.5
2.0
1.5
1.0
0.5
0%
270,000
230,000
You (nonadjusted)
You
(adjusted)
Average cost overview, $
1,200
1,150
You
All providers
Your episode cost distribution
100
50
84
15
23
28
<$756
$756$796
$796$826
42
$826$856
$856$886
23
$886$2,038
18
>$2,038
Distribution of provider average episode cost
You
Avg
7500
5000
2500
You
5
You will not receive gain or risk sharing
 Selected quality metrics: N/A
 Average episode cost: Acceptable
Cost summary
Cost,
$
You
All providers
4
You achieved selected quality metrics
Linked to gain sharing
Perforation rate
$0
You
# episodes
1
Commendable
Acceptable
Percentile
Not acceptable
Key utilization metrics
Anesthesiologist rate
17%
You
All providers
30%
2
Medicaid
Little Rock Clinic
123456789
April 2013
Quality and utilization detail – Colonoscopy
You
1
Metric linked to gain sharing
Minimum standard for gain sharing
Quality metrics: Performance compared to provider distribution
Metric
You
Percentile
50th
25th
75th
Perforation rate
.01%
.01% .015%
.02%
Post-polypectomy bleed rate
2.5%
2.1%
3.5%
2.9%
0
25
Percentile
50
75
100
-
You achieved selected quality metrics
2
Utilization metrics: Performance compared to provider distribution
Metric
Anesthesiologist rate
You
4.6%
25th
Percentile
50th
4.1% 33.4%
75th
1.2%
0
25
Percentile
50
75
100
-
2
Medicaid
Little Rock Clinic
123456789
April 2013
Cost detail – Colonoscopy
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, $
750
700
174,750
163,100
290
275
66,700
63,250
76
76
16,796
16,796
14,904
14,904
184
79%
77%
81
81
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
2
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]