© 2006, carevariance "quality-based purchasing in public and private employer health insurance...
TRANSCRIPT
© 2006, CareVariance
"Quality-based Purchasing in Public and Private Employer Health Insurance Programs"
Health Plan Quality Transparency Efforts
Mark C. Rattray, MDPresident
CareVariance
Washington State Conference onQuality-Based Health Care Purchasing
December 4-5, 2006Seattle, Washington
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Health plan quality transparency motivators
• Purchasers• Differentiation in the marketplace• Accrediting bodies (NCQA)• Presidential transparency mandate• Consumer Directed Health Plans
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Health plan quality data collection methods
• Internal claims-based algorithms• Limited augmentation by external data feeds –
lab results, pharmacy, mental health
• Physician or physician group self-reported data
• External certifying or recognizing entities• Mix of the above
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Internal claims-based algorithms
Like HEDIS, a numerator/denominator approach:• Numerator: number of patients where
compliant care was rendered• Denominator: number of patient
candidates for recommended care
• Generates raw and sometimes weighted, risk adjusted compliance rates
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Specialty Quality Measures
• Specialties are creating quality measures through AQA, Physician Consortium for Performance Improvement – often rely on review of clinical record
• Some quality measure vendors and plans have created procedural claims-based quality indicators through expert panels / specialist advisory boards / existing specialty guidelines
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Vendor / plan specialty measures example
q. Orthopedic (total joint, disorders of upper and lower extremities, spine)
• Total cases: This is listed on the right most column of the scorecard and reflects the total number of physician cases for a procedure category. The scorecard measures only complete episodes of care and uses claims data for 2002-2003, where patients have enrollment with UnitedHealthcare for a minimum of 180 days prior and 400 days post procedure.
• % of Total physician cases: This is listed on the left most column of the scorecard and is the number of UnitedHealthcare cases the physician has performed of a particular procedure type divided by the total number of UnitedHealthcare cases for that physician.
• Procedure less than 30 days: Measures the % of a physician’s UnitedHealthcare patients who receive a surgical procedure fewer than 30 days after the initial diagnosis is made. This diagnosis does not have to be originally made by the treating surgeon.
• Pre-Surgery injection or physical therapy (PT) rate: Measures the % of a physician’s UnitedHealthcare patients who have had at least one PT session OR injection within 1-180 days prior to a surgical procedure.
(excerpt from UnitedHealth PremiumSM Program Methodology, June 2005)
7© 2006, CareVariance
Physician or physician group self-reported data
• Used by IHA in California• IPA’s paying their own claims (capitated) and or
groups with robust EHR / registries• Used as backup method to claims data
• Physicians may augment claims data• Plans must report at individual patient / indicator
basis and allow augmentation
• Medical record based indicators require this
• Employers may be reluctant unless audit processes in place
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External certifying or recognizing entities
• Board Certification historically used as quality indicator• Maintenance of Certification programs
increasingly are requiring compliance self-assessment
• NCQA Practice Recognition Programs• Health plans may display certification /
recognition in directories• Plans may give “extra credit” in internal
programs
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Public transparency of plan measurement
From www.unitedhealthcare.com
10© 2006, CareVariance
Employer / plan challenges
• Speed to (often national) market of quality and episodic cost measures
• Specialty measurement• Desire for “High Performing Networks”
• “Performance Differentiated Network” – all providers included, differentiated by performance and resulting employee benefits
• “Narrowed Network” – subset of existing network comprised of “higher performing” providers
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Employer / plan challenges, cont.
• Plan / employer intermediaries limiting direct, open, fully informed dialogue
• Potential dominance of sales/marketing in development and deployment of high performance networks
• Inadequate investment (money and time) in stakeholder preparation
• Lack of “line of sight” benefit alignment for each stakeholder group
12© 2006, CareVariance
Thank you!
www.carevariance.com