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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
▪ Paula Miller – HP APII Analyst - Episode Reports
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care
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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)
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Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery system
Episode-based care▪ Acute, post-acute, or
select chronic conditions
How care is deliveredHow care is delivered
Population-based care▪ Medical homes ▪ Health homes
ObjectivesObjectives
▪ Improve the health of the population
▪ Enhance the patient experience of care
▪ Enable patients to take an active role in their care
Four aspects of broader program
Four aspects of broader program
▪ Results-based payment and reporting
▪ Health care workforce development
▪ Health information technology (HIT) adoption
▪ Consumer engagement and personal responsibility
For patientsFor patients
For providersFor providers
Focus today
▪ Reward providers for high quality, efficient care
▪ Reduce or control the cost of care
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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
Transition to a payment system that rewards value and patient health outcomes by aligning financial incentivesTransition to a payment system that rewards value and patient health outcomes by aligning financial incentives
Eliminate coverage of expensive services or eligibilityEliminate coverage of expensive services or eligibility
Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)
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
Intensify payer intervention in decisions though managed care or elimination of expensive services (e.g. through prior authorizations) based on restrictive guidelines
Reduce payment levels for all providers regardlessof their quality of care or efficiency in managing costsReduce payment levels for all providers regardlessof their quality of care or efficiency in managing costs
This initiative aims to…
This initiative DOES NOT aim to
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Principles of payment design for Arkansas
Patient-centeredPatient-centered
Focus on improving quality, patient experience and cost efficiency
Clinically appropriateClinically appropriate
Design based on evidence, with close input from Arkansas patients and providers
PracticalPractical Consider scope and complexity of implementation
Data-basedData-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
▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director –Tonsillectomy Episode of Care
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Contents
▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative
▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Providers, Patients & Quality
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy: key facts
▪ 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
What is a tonsillectomy?
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Patient journey for tonsillectomy/adenoidectomy
1 Conditions for inpatient observation include Down syndrome, congenital heart defects, coagulopathies, platelet storage deficiency, or coagulation defects2 Complications resulting in return to operating room include excessive bleeding, severe vomiting, or low oxygen saturation3 Major causes for post-procedure admission include dehydration and excessive bleeding
SOURCE: American Academy of Otorhinolaryngology, Expert interviews
post-procedure admission
Post-procedure – 30 daysPre-procedure – (up to 90 days)
Follow-up careFollow-up careSame-day recovery unitSame-day recovery unit
Operating room2
Operating room2
Inpatient Care and Recovery Unit
Inpatient Care and Recovery Unit
Inpatient care and recovery unit1
Inpatient care and recovery unit1 Follow-up careFollow-up care
Presents to ENT specialistPresents to ENT specialist
ProcedureProcedure
Tonsillectomy/adenoidec-tomy performed
Pre-procedural work-up in hospital/outpatient setting
Post-procedure admission3
Post-procedure admission3
This episode excludes cases that present through inpatient/emergency department setting
This episode excludes cases that present through inpatient/emergency department setting
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Episode summary: Number of adenoidectomy, tonsillectomy, and adeno-tonsillectomy in Arkansas
SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010Arkansas Blue Cross Blue Shield claims for patients with tonsillectomy/adenoidectomy between July 1, 2011 – June 30, 2012
BCBS
Total number of proceduresTotal number of procedures 1,311
TonsillectomyTonsillectomy 361
AdenoidectomyAdenoidectomy 176
Number of performing providersNumber of performing providers 74
Adeno-tonsillectomyAdeno-tonsillectomy 774
Medicaid
Total number of proceduresTotal number of procedures 3,498
Adenoidectomy Adenoidectomy 569
TonsillectomyTonsillectomy
2,660
Number of performing providersNumber of performing providers 61
Adeno-tonsillectomyAdeno-tonsillectomy
269
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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 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
Episode definition/ scope
of services
Episode definition/ scope
of services
▪ 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>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
Patient/ episode exclusionsPatient/ episode exclusions
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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)
2 Reported through provider portal
Parameters and codes may vary across different payers; the following algorithm and associated codes sheet applies to Medicaid
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Tonsillectomy/adenoidectomy episode design (2/2)
▪ 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
Episode adjustmentsEpisode adjustments33
▪ 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
Quality/ utilization metrics
Quality/ utilization metrics
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▪ 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
Principal Accountable Provider
Principal Accountable Provider
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1 Reported through provider portal as an aggregate percentage across all of a PAP’s episode for a specific payor2 American Academy of Otolaryngology – Head and Neck Surgery Tonsillectomy Guidelines for 2011 recommend against prescription of antibiotics
post-procedure
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Episode definition / scope of services (1/4)
30 days post-procedure
90 days pre- procedure
Tonsillectomy/adenoidec-tomy procedure
The episode includes the following services
MedicationMedication
Preparatory visits (office/clinic, or specialist consultation)Preparatory visits (office/clinic, or specialist consultation)
Professional claimfor procedureProfessional claimfor procedure
Labs, imaging, and diagnostic testsLabs, imaging, and diagnostic tests
Inpatient or outpatient facility careInpatient or outpatient facility care
Episode ends
30-day post-procedure admission130-day post-procedure admission1 ▪ Inpatient admission within 30 day post-procedure window as defined by Bundled Payment for Care Improvement (BPCI)
▪ 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
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
TriggerEpisode begins
1
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)
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Episode definition / scope of services (2/4)
Episode design decisions 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
▪ 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 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
▪ 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 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
▪ 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)
Detailed in following pages
▪ 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)
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Patient exclusions (1/5)
Patient exclusion design decision 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)
▪ Select co-morbid conditions within 365 days prior to procedure or during episode
▪ Tonsillectomies/adenoidectomies performed on women who are known to be pregnant during an episode window are excluded due to their potentially complex condition
▪ Pregnant during episode
▪ Patients under 3 and older than 21 tend to be more complicated procedures and are therefore excluded
▪ Age younger than 3 or older than 21
▪ 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
▪ Dual enrollment in Medicare/Medicaid (i.e., dual eligibles)
▪ Consistent enrollment ensures that all costs associated with an episode are accurately and fully captured
▪ Inconsistent enrollment with payer during episode
Detailed in following pages2
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Patient exclusions (2/5)
Patient exclusion design decision 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
▪ Uvulopalatopharyngoplasty (UPPP) on date of procedure
▪ 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
▪ Patients with BMI>50
▪ Patients with death in hospital are clinical outliers▪ Death in hospital during episode
▪ A PAP cannot be held responsible for outcomes and resulting cost of care if patient leaves AMA
▪ Patient status of “left against medical advice” during episode
2
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Younger than 3 Older than 21
ED tonsillectomy/
adenoidectomy Inpatient
tonsillectomy/ adenoidectomy
Age on date of procedureAge on date of procedure Care setting1Care setting1
Sickle cell disease
Cystic fibrosis
Coagulopathies
Severe asthma
Down syndrome
Congenital defects of the circulatory system
Post obstructive pulmonary edema
Muscular dystrophy
Myopathies
Degenerative diseases of CNS
Severe mental retardation
Severe/chronic diseases and procedures(Exclusion period: 365 days pre-procedure and during episode window)
Severe/chronic diseases and procedures(Exclusion period: 365 days pre-procedure and during episode window)
Blood disorders
Congenital anomalies
Malignant hypothermia
ESRD (end-stage renal disease)
Uvulopalatopharyngoplasty (UPPP)2
1 Setting where patient presented with symptoms and received treatment2 Exclusion applies only if performed on date of procedure
2
LIST OF EXCLUSION CO-MORBIDITIES
Design rationale: Patient exclusions (3/5)
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Other(during episode window)
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
Bone cancer
Brain cancer
Bronchial/lung cancer
Colon cancer
Esophageal cancer
GI/peritoneum cancer
Liver cancer
Malignant neoplasm
Neoplasm unspecified
Female genital cancer
Male genital cancer
Cancers(Exclusion period: 365 days pre-procedure and during episode window)
Cancers(Exclusion period: 365 days pre-procedure and during episode window)
Ovarian cancer
Pancreas cancer
Rectum/anus cancer
Kidney/renal cancer
Stomach cancer
Urinary organ cancer
Gallbladder cancer
Secondary malignancy
Other respiratory cancer
Other primary cancer
2
LIST OF EXCLUSION CO-MORBIDITIES
Design rationale: Patient exclusions (4/5)
21
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Congenital hydrocephalus
Spina bifida with hydrocephalus, unspecified region
Severe mental retardation
Neoplasm of uncertain behavior of skin
Sickle-cell trait
Acute bronchospasm
Bacterial pneumonia, unspecified
Neoplasm of unspecified nature of bone, soft tissue
Other specified anomalies of pharynx
Ostium secundum type atrial septal defect
Extrinsic asthma with (acute) exacerbation
Multiple congenital anomalies
Ventricular septal defect
Down's syndrome
Lymphadenitis, unspecified, except mesenteric
Asthma, unspecified type, with (acute) exacerbation
Pneumonia, organism unspecified
Description
486
493.92
289.3
758.0
745.4
759.7
493.02
745.5
750.29
239.2
482.9
519.11
282.5
2382
3181
74100
7423
ICD9-Dx
Infantile cerebral palsy, unspecified343.9
Obstructive hydrocephalus331.4
Thrombocytopenia, unspecified2875
SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010
2
TOP-20 EXCLUSION CO-MORBIDITIES FROM 2010
Design rationale: Patient exclusions (5/5) INDIVIDUAL PATIENT MAY HAVEMORE THAN ONE CO-MORBIDITY
22
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Quality metrics
Quality metrics design decision 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
▪ Quality metrics required for gain sharing payment:
– Rate of administration of inta-operative steroids
▪ 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
▪ 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
AA
BB
4
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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Design rationale: Principal Accountable Provider (PAP)
PAP design decision 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
▪ Payers independently determine the PAP by considering the following factors:
– Decision making responsibilities
– Influence over other providers
– Portion of episode cost
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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
▪ Paula Miller –HP APII Analyst - Episode Descriptions & Reports
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update
▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care
25
Arkansas Health Care Payment Improvement InitiativeProvider Report
MedicaidReport date: April 2013
Historical performance: January 1, 2012 – December 31, 2012
Medicaid Little Rock Clinic 123456789 April 2013
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
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Division of Medical ServicesP.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, PhDMedicaid 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.
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Table of contents
Performance summary
Upper Respiratory Infection – Pharyngitis
Upper Respiratory Infection – Sinusitis
Upper Respiratory Infection – Non-specific URI
Perinatal
Attention Deficit/Hyperactivity Disorder (ADHD) – Level I
Total Joint Replacement
Congestive Heart Failure
Glossary
Appendix: Episode level detail
Colonoscopy
Oppositional Defiance Disorder
Cholecystectomy
Attention Deficit/Hyperactivity Disorder (ADHD) – Level II
Medicaid Little Rock Clinic 123456789 April 2013
Tonsillectomy
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Performance summary
Episode of CareQuality of Service
Share Amount
Average Episode Cost Your Gain/Risk Share
Upper Respiratory Infection – Pharyngitis
Not met $0.00Acceptable Not eligible for gain sharing
Upper Respiratory Infection – Sinusitis N/A Commendable Will receive gain sharing $349.50
Perinatal Met $0.00Acceptable Not eligible for gain sharing
Attention Deficit / Hyperactivity Disorder (ADHD) – Level II
Met $0.00Acceptable Not eligible for gain sharing
Quality of services and cost summary1
Total Joint Replacement N/A $0.00Acceptable Not eligible for gain sharing
Congestive Heart Failure Not met $0.00Acceptable Not eligible for gain sharing
Upper Respiratory Infection – Non-specific URI
N/A Not acceptable Subject to risk sharing -$3,844.50
Colonoscopy Met $0.00Acceptable Not eligible for gain sharing
Cholecystectomy Met $0.00Acceptable Not eligible for gain sharing
Tonsillectomy Met $0.00Acceptable Not eligible for gain sharing
Attention Deficit / Hyperactivity Disorder (ADHD) – Level I
Not met $0.00Acceptable Not eligible for gain sharing
Medicaid Little Rock Clinic 123456789 April 2013
Oppositional Defiance Disorder Met $0.00Acceptable Not eligible for gain sharing
The figures in this report are preliminary and are subject to revision
Across these Episodes of Care You are Subject to Risk Sharing: -$3,000.00Stop-loss was applied
29
Cost summary
Key utilization metrics
Overview
Cost of care compared to other providers
1
2
4
5
Summary – Tonsillectomy
You (non- adjusted)
512,000
You (adjusted)
466,000
All providers
1,750
You
2,000Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Your average cost is acceptable
Selected quality metrics: N/A Average episode cost: Acceptable
#
ep
iso
de
sC
os
t,
$
Commendable Not acceptableAcceptable> $4000
You
You will not receive gain or risk sharing
$0
Percentile
Gain/Risk share
All providers
Not acceptableAcceptableCommendableYou
< $974 > $1,003$974 to $1,003
7500
5000
2500
>$1,542
Quality summary3
Linked to gain sharing
Post-procedure primary bleed rate
Post-op Abx Rx rate
100%
50%
0%AvgYou
Intra-op steroid Rx rate
Stan
da
rd
for g
ain
s
harin
g
You achieved selected quality metrics
100%
50%
0%AvgYou
100%
50%
0%Series
AvgYou
Medicaid Little Rock Clinic 123456789 April 2013
Post-procedure secondary bleed
100%
50%
0%AvgYou
182342
84
282315
100
50
$1,003-$1,542
$993-$1003
$984-$993
$974-$984
$899-$974
<$899
There are no quality metrics linked to gain sharing generated
from claims data. Selected quality data submitted on the Provider Portal will generate additional
quality metrics for future reports.
30%17%
Surgical pathology utilization rate You All providers
30
Quality and utilization detail – Tonsillectomy
5025Percentile
Metric You 25th
Metric 25th 50th
50th 75th
You 75th 5025Percentile
Percentile
Percentile
0
0
100
100
75
75
Metric linked to gain sharingYou Minimum standard for gain sharing
Quality metrics: Performance compared to provider distribution
Utilization metrics: Performance compared to provider distribution
1
2
1% 0%1% 2%Post-procedure primary bleed rate
0% 1%2% 4%Post-procedure secondary bleed
25% 20% 30% 40%Post-procedure Abx Rx
You achieved selected quality metrics
Medicaid Little Rock Clinic 123456789 April 2013
---
-
31
189
175
84
97
744
828
1,200
1,120
1,995
2,457
14,904
14,904
16,796
16,796
552,000
555,450
116,500
128,150
Cost detail – Tonsillectomy
Care category
All provider averageYou
4%
3%
<1%
<1%
3%
5%
75%
78%
80%
75%
77%
79%
97%
95%
99%
99%
100%
100%
27
25
84
97
62
69
75
70
95
117
81
81
76
76
2,400
2,415
500
550
Medicaid Little Rock Clinic 123456789 April 2013
Total episodes included = 233
233
230
221
184
21
16
12
1
7
# and % of episodes with claims in care category
Total vs. expected cost in care category, $
Average cost per episode when care category utilized, $
Outpatient professional
Pharmacy
Emergency department
Inpatient professional
Inpatient facility
Outpatientsurgery
Other
Outpatient lab
Outpatientradiology / procedures
33
For more information talk with provider support representatives…
▪ 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
Online
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]