Transcript Tonsillectomy Webinar Slides - Health Care Payment Improvement
Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar August 12, 2013
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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 –
▪ Dr. William Golden, Medicaid Medical Director –
▪ Paula Miller – HP APII Analyst -
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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, patient centered delivery system
Focus today
Objectives For patients
▪ ▪ ▪
Improve the health of the population Enhance the patient experience of care Enable patients to take an active role in their care
For providers
▪ ▪
Reward providers for high quality, efficient care Reduce or control the cost of care
How care is delivered Four aspects of broader program 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
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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…
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
This initiative DOES NOT aim to
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 Patient centered
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
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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 –
▪ Dr. William Golden, Medicaid Medical Director –
▪ Paula Miller – HP APII Analyst -
Episode Descriptions & Reports
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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 –
▪ Dr. William Golden, Medicaid Medical Director –
Tonsillectomy Providers, Patients & Quality
▪ Paula Miller – HP APII Analyst -
Episode Descriptions & Reports
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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
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Patient journey for tonsillectomy/adenoidectomy
Pre-procedure – (up to 90 days) Procedure
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
post-procedure admission Post-procedure – 30 days Same-day recovery unit Follow-up care Presents to ENT specialist
Pre procedural work-up in hospital/out patient setting Tonsillectomy /adenoidec tomy performed
Operating room 2 Inpatient Care and Recovery Unit Post-procedure admission 3 This episode excludes cases that present through inpatient/emergency department setting Inpatient care and recovery unit 1 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 Adenoidectomy Tonsillectomy Adeno-tonsillectomy 3,498 569 269 2,660 BCBS Total number of procedures Adenoidectomy Tonsillectomy Adeno-tonsillectomy 1,311 176 361 774 Number of performing providers 61 Number of performing providers 74 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 11
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy/adenoidectomy episode design (1/2)
▪ Episode is triggered by select types of tonsillectomy/adenoidectomy procedures, 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
Episode definition/
pharyngitis, hypertrophy of tonsils and adenoids, obstructive sleep apnea, insomnia, peritonsillar abscess)
1 scope of services
▪ 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 procedure 1 ▪
2 Patient/ episode exclusions
Certain patients are excluded from this episode design, patients with: – Select co-morbid conditions (e.g., Down syndrome, cancer, severe asthma, cerebral palsy, muscular dystrophy, myopathies) – – – – – – – Uvulopalatopharyngoplasty (UPPP) on date of procedure Patients with BMI>50 2 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 29 th day post discharge would be included in episode) 2 Reported through provider portal 12
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy/adenoidectomy episode design (2/2)
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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 4
Quality/ utilization metrics
▪ ▪ Quality metrics required for gain sharing payment: – Percent of episodes with administration of intra-operative steroids 1 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-surgery 2 5
Principal Accountable Provider
▪ For Medicaid, the Principal Accountable Provider (PAP) will be the primary 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
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Episode definition / scope of services (1/4)
Episode begins Trigger Episode ends Episode definition:
▪ All related services up to 90 days prior to (after and including initial consult) and 30 days after tonsillectomy/ad enoidectomy procedure, including inpatient and outpatient facility services, professional services, and related medications ▪ Complications that occur after the procedure
90 days pre procedure The episode includes the following services Preparatory visits (office/clinic, or specialist consultation) Labs, imaging, and diagnostic tests Professional claim for procedure Inpatient or outpatient facility care Medication 30-day post-procedure admission 1 Tonsillectomy/adenoidec -tomy procedure
▪ ▪ ▪ ▪ ▪
30 days post procedure
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 29 th day post discharge would be included in episode) 14
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
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Design rationale: Episode definition / scope of services (2/4)
Detailed in following pages
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
Rationale
▪ ▪ ▪ 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: – 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 ▪ ▪ 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 window: – 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 due to complications, etc. are included in episode cost calculations since reducing complications and treating them effectively and efficiently is an identified value driver – Inpatient post-procedure admission within 30 days after procedure as defined by Bundled Payment for Care Improvement (BPCI) ▪ 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
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Design rationale: Patient exclusions (1/5)
▪
Patient exclusion design decision
Select co-morbid conditions within 365 days prior to procedure or during episode ▪ Pregnant during episode Detailed in following pages ▪
Rationale
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) ▪ 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
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Design rationale: Patient exclusions (2/5)
▪
Patient exclusion design decision
Uvulopalatopharyngoplasty (UPPP) on date of procedure ▪ Patients with BMI>50 ▪ ▪ ▪ ▪
Rationale
Patients with UPPP on date of procedure have a 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 Patients with BMI over 50 are higher risk and more complicated to operate on The PAP cannot control this risk or the variability in outcomes due to this patient condition ▪ Death in hospital during episode ▪ Patients with death in hospital are clinical outliers ▪ Patient status of “left against medical advice” during episode ▪ A PAP cannot be held responsible for outcomes and resulting cost of care if patient leaves AMA 17
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
LIST OF EXCLUSION CO-MORBIDITIES
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Design rationale: Patient exclusions (3/5)
Age on date of procedure
Younger than 3 Older than 21
Care setting 1
ED tonsillectomy/ 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 Congenital anomalies Severe asthma Malignant hypothermia Down syndrome Congenital defects of the circulatory system Post obstructive pulmonary edema ESRD (end-stage renal disease) Uvulopalatopharyn goplasty (UPPP) 2 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
LIST OF EXCLUSION CO-MORBIDITIES
2
Design rationale: Patient exclusions (4/5)
Cancers (Exclusion period: 365 days pre-procedure and during episode window)
Bone cancer Ovarian cancer Brain cancer Bronchial/lung cancer Colon cancer Pancreas cancer Rectum/anus cancer Kidney/renal cancer Esophageal cancer GI/peritoneum cancer Liver cancer Malignant neoplasm Stomach cancer Urinary organ cancer Gallbladder cancer Secondary malignancy Neoplasm unspecified Female genital cancer Male genital cancer Other respiratory cancer Other primary cancer
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Other (during episode window)
Pneumonia Fetal disturbances Forceps or vacuum extractor delivery Malposition Other perinatal diagnosis Umbilical cord complications Spontaneous abortion Suicide and intentional self inflicted injury 19
TOP-20 EXCLUSION CO-MORBIDITIES FROM 2010
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Design rationale: Patient exclusions (5/5)
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
INDIVIDUAL PATIENT MAY HAVE MORE THAN ONE CO-MORBIDITY 486 493.92
289.3
758.0
343.9
745.4
331.4
759.7
493.02
745.5
750.29
239.2
482.9
519.11
282.5
2382 3181 74100 7423 2875
ICD9-Dx Description
Pneumonia, organism unspecified Asthma, unspecified type, with (acute) exacerbation Lymphadenitis, unspecified, except mesenteric Down's syndrome Infantile cerebral palsy, unspecified Ventricular septal defect Obstructive hydrocephalus Multiple congenital anomalies Extrinsic asthma with (acute) exacerbation Ostium secundum type atrial septal defect Other specified anomalies of pharynx Neoplasm of unspecified nature of bone, soft tissue Bacterial pneumonia, unspecified 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
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Design rationale: Quality metrics
A
▪
Quality metrics design decision
Quality metrics required for gain sharing payment: – Rate of administration of inta-operative steroids ▪ ▪
Rationale
To qualify for gain sharing, providers or their staff 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
B
▪ Quality/utilization metrics for reporting only: – 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 ▪ ▪ ▪ A bleed within 24-hours post-surgery (primary bleed) 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
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Design rationale: Principal Accountable Provider (PAP)
▪
PAP design decision
Payers independently determine the PAP by considering the following factors: – – – Decision making responsibilities Influence over other providers Portion of episode cost
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
▪
Rationale
Medicaid has publicly announced that the Principal 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
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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 –
▪ Dr. William Golden, Medicaid Medical Director –
▪ Paula Miller –HP APII Analyst -
Episode Descriptions & Reports
23
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 24
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 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
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Medicaid Little Rock Clinic 123456789 April 2013
Performance summary
1 Quality of services and cost summary Quality Episode of Care of Service Average Episode Cost Your Gain/Risk Share 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 Not met Met Met Met Not met Met Met Met N/A N/A Not met N/A Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Acceptable Not acceptable Acceptable Commendable Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Not eligible for gain sharing Subject to risk sharing Not eligible for gain sharing Will receive gain sharing Across these Episodes of Care You are Subject to Risk Sharing: Share Amount $0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
-$3,844.50
$0.00
$349.50
Stop-loss was applied -$3,000.00
The figures in this report are preliminary and are subject to revision
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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 Acceptable $974 to $1,003 Not acceptable 3 Quality summary
You achieved selected quality metrics
Linked to gain sharing
Intra-op steroid Rx rate
100%
Post-procedure primary bleed rate
100% 50% There are no quality metrics 50% You data submitted on the Provider Portal will generate additional quality metrics for future reports.
0% You Avg
Post-procedure secondary bleed
100% 50% Series 0% You
Post-op Abx Rx rate
100% Avg Total episodes excluded: 29 Gain/Risk share You $0 All providers Cost summary You will not receive gain or risk sharing
Selected quality metrics: N/A Average episode cost: Acceptable 4
Your average cost is acceptable
Your total cost overview, $ 512,000 466,000 Average cost overview, $ 2,000 1,750 You (non adjusted) You (adjusted) Your episode cost distribution 100 50
15 23 28 84
You
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<$899 $899 $974 $974 $984 $984 $993 $993 $1003 Distribution of provider average episode cost 7500 5000 2500 All providers
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$1,003 $1,542
18
>$1,542 50% 0% You Commendable Acceptable Percentile Not acceptable You Avg 5 Key utilization metrics Surgical pathology utilization rate You All providers 30% 17%
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Medicaid Little Rock Clinic 123456789 April 2013 Quality and utilization detail – Tonsillectomy You Metric linked to gain sharing 1 Metric Quality metrics: Performance compared to provider distribution You 25th Percentile 50th 75th 0 Minimum standard for gain sharing 25 Percentile 50 75 Post-procedure primary bleed rate Post-procedure secondary bleed Post-procedure Abx Rx 1% 0% 25% 0% 1% 1% 2% 20% 30% 2% 4% 40% 100
-
You achieved selected quality metrics 2 Metric Utilization metrics: Performance compared to provider distribution Percentile You 25th 50th 75th 0 25 Percentile 50 75 100
-
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Medicaid Little Rock Clinic 123456789 April 2013
Cost detail – Tonsillectomy Total episodes included = 233 Care category Outpatient professional Pharmacy Emergency department Outpatient lab Outpatient radiology / procedures Inpatient professional Inpatient facility Outpatient surgery Other # and % of episodes with claims in care category 233 230 221 184 21 16
100% 100% 99% 99% 95% 97% 79% 77% 75% 80% 78% 75%
12 1 7
5% 3% <1% <1% 3% 4%
Average cost per episode when care category utilized,
$ 550 500 2,415 2,400 76 76 81 81 117 95 70 75 69 62 97 84 25 27 You All provider average
Total vs. expected cost in care category, $
128,150 116,500 555,450 552,000 16,796 16,796 14,904 14,904 2,457 1,995 1,120 1,200 828 744 97 84 175 189 30
Questions
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For more information talk with provider support representatives… Online
▪
More information on the Payment Improvement Initiative 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
▪
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]
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