detailed explanation of the 2011 bluecompare physician ....doc

Coming in 2011 - The New BlueCompare Physician Designation Program

Continued escalation of health care costs has driven premiums and medical expenses to higher and higher levels each year. This, in turn, has motivated employers and consumers to search for information about the value (quality and cost) they receive for their health care dollars. These stakeholders are asking Blue Cross and Blue Shield of Texas (BCBSTX) to support their purchasing decisions by identifying the providers who offer the best value (quality and cost). BCBSTX must pay attention to the needs of its employers and members.

BCBSTX understands the complexities of measuring provider quality and cost performance, both historical and current. Fortunately, we now have available both state and national published guidelines and requirements for provider transparency methodologies and programs. We have taken care to incorporate these guidelines and requirements into a redesigned BlueCompare Physician Designation program as we strive to meet the demand for information on provider performance. See Appendix A for more information on national guidelines.

Our redesigned BlueCompare Physician Designation program will measure physicians on both quality related performance and cost efficiency:

The quality related assessment will utilize Evidence Based Measures (EBMs) from nationally recognized entities such as the National Quality Forum (NQF), the Ambulatory Care Quality Alliance (AQA), and the National Committee for Quality Assurance (NCQA).

We have implemented a Bridges to Excellence® program to recognize and reward health care providers who demonstrate implementation of sound management of complex patients and deliver safe, timely, effective and efficient patient-centered care. Therefore, physicians in the BlueCompare measured Working Specialties that are currently recognized by the Bridges to Excellence® organization in their Diabetes Care Link or Cardiac Care Link programs will be recognized and display a BlueCompare Blue Ribbon.

The cost efficiency assessment will be based on an ‘Episodes of Care’ methodology.

Both the quality related and cost efficiency performance measurement will utilize two years of BCBSTX PPO incurred claims data.

The BlueCompare program will adhere to nationally recognized transparency methodology and program standards and guidelines (NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality) and will comply with Texas Insurance Code Chapter 1460.

This document contains detailed descriptions of the BCBSTX methodologies for assessment of both quality related performance on EBMs and cost efficiency.

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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Measured Specialties and Eligibility

The new BlueCompare Physician Designation Program will apply to the Working Specialties for which both quality related performance and cost efficiency can be measured. Physicians must practice in one of the measurable Working Specialties and be a contracted physician in good standing with the BCBSTX BlueChoice® provider network to be eligible for participation in the BlueCompare Physician Designation Program.

There are a select number of available EBMs for quality related measurement that meet nationally recognized standards (e.g. NQF, AQA and NCQA), and methodology adherence for quality measurement. BCBSTX will only measure cost efficiency on those Working Specialties where it can also measure quality related performance.

Thus, BCBSTX will apply quality related measurement, and in turn the cost efficiency assessment, to the following fourteen Working Specialties:

Allergy-Immunology NephrologyCardiovascular Disease-Non-Interventional NeurologyCardiovascular Disease-Interventional Obstetrics-GynecologyEndocrinology Pediatric Allergy-ImmunologyFamily Practice Pediatric Pulmonary DiseaseGeriatric Medicine PediatricsInternal Medicine Pulmonary Disease

BlueCompare EBM Assessment

BCBSTX will use claims and enrollment data to assess a physician’s adherence to nationally recognized EBMs when treating his/her qualifying patients. These measures cover significant areas of preventive care such as diabetes, cardiovascular disease, and other health care services. A complete list of the EBMs used in the evaluation, along with the clinical intent and sponsoring organizations, is contained in Appendix B of this document.

Physicians will be evaluated using only the EBMs that are considered relevant to their Working Specialty and relative to their specialty peers in Texas. All physicians within a common Practice Evaluation ID (typically the Tax Identification Number) and Working Specialty will be evaluated together, regardless of the level of individual physician contribution, and will be given the same BlueCompare EBM designation. For example, a group of physicians practicing under a common Tax Identification Number that is comprised of Internal Medicine, Family Practice, and Obstetrics-Gynecology specialties would receive three distinct evaluations and BlueCompare designations. A physician who practices under multiple Tax Identification Numbers can achieve different EBM evaluation results for each group and Working Specialty in which the physician is evaluated.

EBM performance will be attributed to physicians based upon their involvement in treating the BCBSTX PPO members who qualify for the measures, according to HEDIS standards. The number of members who qualify for the EBMs (denominator) will be compared to the number

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of members who were provided services satisfying the EBM criteria (numerator). A minimum of thirty denominator events must be attributed to the physician or specialty group to qualify for an evaluation. Although two calendar years of PPO claims data will be commonly used, some EBMs will use five years of claims data. The methods for determining the specific denominators and numerators differ by measure. These details are available at www.bcbstx.com/provider/ebi_2010.htm

EBM Performance Scoring Details A physician group's performance score is derived from the following factors:

• A count of qualifying events, which defines a denominator. An example is the continuously enrolled diabetic patients for whom a specified test or other service is expected.

• A count of the clinical responses to the qualifying events, which defines the numerator. An example is the number of diabetic patients in the denominator who receive the expected test or service.

• The weighting associated with the applicable indicator. This is determined by the statistical reliability of a measure, as determined by its variance.

The composite performance score for a physician group is derived by applying and aggregating the above factors. This score is used to assess the group’s performance relative to its peers. The composite score will be considered valid only if a physician group has a minimum of thirty denominator events across all indicators.

Performance will be aggregated across all relevant EBMs. Each EBM will be weighted by the inverse of the variance of the measure, resulting in a weighted average that reflects both the total number of denominator events and the variability of performance by peers. This methodology decreases the impact of differences in the number of denominators that occur from practice to practice, and summarizes performance on individual measures into a single EBM score.

The practice EBM scores are distributed for a specialty wide comparison of performance. A system based on statistical methods is used to identify a performance threshold within this distribution. Practices with scores that are at or above the performance threshold will be recognized. Practices with a score more than two standard deviations from the mean, compared to the peer average, are considered outliers.

An external statistician, with extensive experience in biostatistics, reviewed and validated the EBM scoring methodology for appropriateness. A more detailed explanation of the scoring methodology can be found in Appendix C of this document.

Where there are no measures present for a specialty, insufficient data is available, or threshold performance on the EBMs is not met, an appropriate designation will be assigned to the physician. For more information on designations, see BlueCompare Designation section contained later in this document.

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http://www.bcbstx.com/provider/ebi_2010.htm

This EBM measurement is the quality related component of the BlueCompare Physician Designation Program. It must be satisfied for a physician to be eligible for the cost efficiency evaluation.

BlueCompare Physician Cost Assessment (PCA)

Consistent with national guidelines (NCQA PHQ), BCBSTX will first assess a physician for performance on quality related measures. Pending that outcome, BCBSTX will review the physician for cost efficiency. A cost-efficiency assessment will only be performed if the specialty-specific quality related criteria are met. BCBSTX engaged physicians currently in clinical practice to assist us in building this new PCA methodology as described below.

To assess a physician’s cost efficiency, BCBSTX will analyze claims based on the Episodes of Care that are attributable to the physician. Thompson Reuters MEG (Medical Episode Grouper) software will be utilized for the Episode of Care analysis.

PCAs will be performed using two incurred years of outlier trimmed claims data. Similar to the BlueCompare quality related assessment, the PCA will be performed at the Practice Evaluation ID/Working Specialty level. PCA Peer Comparisons will also take into account the disparate costs in the geographic area in which the physician practices. BCBSTX has twenty-two different Peer Comparison areas for which physician cost efficiency can be assessed as depicted below.

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Episodes of CareAn Episode of Care will be built by linking sets of health care services provided to a patient over time to treat a specific disease or health status, and can be composed of one or more encounters or visits, procedures or inpatient admissions. The episode continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status.

Episode Grouping Logic example:

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The example above demonstrates how a complete episode ranges in time between the lab test and the final office visit. A lab or X-ray cannot initiate an episode; however, the look-back period can incorporate such services.

Physician Episode of Care AttributionOnly one physician per episode will be considered to be the “responsible physician.” The responsible physician is assigned as follows:

Physician who performs procedures with the highest total RVUs billed; if none, then Physician with the greatest number of E&M services billed; if none, then Physician with the highest allowed dollars.

This logic helps to ensure that primary care physicians are not inappropriately attributed high cost cases for which they are not primarily responsible. The responsible physician will be determined without regard to the physician’s contract status with BCBSTX. Episodes attributed to non-contracted physicians will be removed from the analysis during the data trimming process.

Episode of Care Data TrimsA trim is an exclusion to the data set done prior to calculation of the PCA. BCBSTX will make several data trims to the base episode of care data to help ensure that the results are not influenced by patient Severity, case mix or burden of illness. BCBSTX will use only complete episodes of care that are risk and Severity adjusted. Listed below are the trims that will be made to the data before the PCA calculation is performed.

Episodes will be removed if they: are incomplete are high or low cost outliers are attributed to members with fewer than nine member months for the time period of the

episode belong to a MEG/Sub stage with low volume represent an episode where the responsible physician has less than 80% of the RVUs

driving utilization contain Emergency Room revenue codes or place of service are for preventive care are in MEG categories not typically provided by a particular Working Specialty

After these data trims are done, the result is a set of qualified episodes. Only qualified episodes will be used in calculating the PCA.

Physician Cost Assessment CalculationThe PCA will be calculated based on the average cost of qualified episodes partitioned by: episode group Severity of illness for the episode relative risk of the patient time period of the episode Working Specialty of the physician geographic area of the physician

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The PCA will be calculated by comparing the Actual Allowed Cost of the physician’s Episodes of Care to an Expected Allowed Cost for the physician’s episodes of care in their Working Specialty.

Determination of Physician Cost Efficiency Performance LevelConsistent with national guidelines, BCBSTX will use a Confidence Interval methodology to determine if physicians meet cost efficiency performance thresholds for a Working Specialty within a geographic market. Specifically:

PCA results will be cited at the physician/practice, Working Specialty level in conjunction with a 90% Confidence Interval relative to 1.00.

If the lower bound of the Confidence Interval is higher than 1.00, then the physician/practice will be determined to have costs that are higher than their peers and will therefore not have met the cost efficiency designation performance threshold.

If a physician/practice’s Confidence Interval contains 1.00, then the physician/practice will not be determined to have costs that are either higher or lower than their peers. Therefore, costs are similar to their peers and the physician will have met the cost efficiency designation performance threshold.

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In the example below, the PCA is 1.16 with a confidence interval from .92 to 1.41. Because the lower bound of the confidence interval is below 1.00, the physician in this example would meet the cost efficiency performance threshold.

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0.5 1.0 1.5

Lower bound of 90% PCA confidence interval: 0.92

Upper bound of 90% PCA confidence interval: 1.41

PCA = 1.16

PCA 90% Confidence Interval

5% 5%

BlueCompare Designations

Results of the BlueCompare Physician Designation Program will be displayed by using the online Provider Finder ® tool at bcbstx.com. When members search for providers in the BlueChoice network, search results will include one of the following symbols/designations next to the physician’s name:

Meets or exceeds expected quality related performance compared to other doctors.

Meets or exceeds expected quality related and cost efficiency performance compared to other doctors.

Performance measures are not available for this specialty.

There is not enough data to measure performance or this doctor is new to the network. Re-evaluations are conducted periodically.

Meets or exceeds expected quality related performance compared to other doctors, but there is not enough BCBSTX claims data to measure cost efficiency performance.

This doctor requested to not participate in the BlueCompare program.

Physicians that are in a measured Working Specialty but do not meet the required quality related and cost efficiency recognition threshold will not have a symbol in Provider Finder.

The BlueCompare tool is provided for informational purposes only. Physician selection is a personal choice, and consumers are informed that they should not base decisions solely on information displayed in BlueCompare. BlueCompare designations are based on claims from BCBSTX PPO membership records and may not be indicative of the physician’s overall practice.

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http://bcbstx.com/onlinedirectory/index.htm

The Review Process

Affected physicians who are dissatisfied with their BlueCompare results have the right to request a review in writing. In addition to the written fair review reconsideration process, BCBSTX also provides a fair reconsideration proceeding as described below:

• When a physician requests a review, BCBSTX will provide a fair reconsideration proceeding. This proceeding will be conducted by teleconference or in person, at the physician’s option.

• A physician requesting a review has the right to provide information, to have a representative participate, and to submit a written statement at the conclusion of the reconsideration proceeding.

• BCBSTX will communicate the outcome of the reconsideration proceeding in writing, including the specific reason(s) for the final determination.

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Appendix A - National Guidelines

1. NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality: http://www.ncqa.org/tabid/740/Default.aspx

2. Ambulatory Care Quality Alliance http://www.aqaalliance.org/performancewg.htm

3. National Quality Forum http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.aspx

4. Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf

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http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf%20

http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.aspx

http://www.aqaalliance.org/performancewg.htm

http://www.ncqa.org/tabid/740/Default.aspx%20

Appendix B - Evidence Based Measures

The following Evidence Based Measures will be used in the BlueCompare quality related assessment.

Evidence Based Measure Clinical Intent Guideline Sponsoring Organization(s)

Strength of Evidence1

Specialty Attribution

Cervical Cancer Screening

To ensure that all women ages 21-64 receive a cervical cancer screening test during the measurement year or the 2 years prior.

U.S. Preventive Services Task Force (USPSTF), Screening for Cervical Cancer, 2003http://www.ahrq.gov/clinic/uspstf/uspscerv.htm

United States Preventive Services Task Force (USPSTF), American Cancer Society, American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Preventive Medicine, American Medical Assn. (AMA), Canadian Task Force on Preventive Health Care, American Academy of Pediatrics, NCQA (HEDIS 2009 Technical Specification), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A Family Practice, Internal

Medicine, Obstetrics-Gynecology

Colorectal Cancer

Screening

To ensure that members 50–80 years of age received appropriate screening for colorectal cancer.

ASGE Guideline: Colorectal Cancer Screening and Surveillance. 2006http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10162&nbr=5347#s24

NCQA (HEDIS 2009 Technical Specification), United States Preventive Services Task Force (USPSTF), American Cancer Society, American College of Obstetricians and Gynecologists (ACOG), American Academy of Family Physicians (AAFP), American Gastroenterological Association, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A Family Practice, Geriatric Medicine, Internal


Diabetic Retinal Exam (Annual)

To ensure that all diabetic members ages 18-75 receive at least 1 retinal or dilated eye exam during the measurement year.

American Diabetes Association, Texas Department of State Health Services-Minimum Practice Recommendations for Diabetes. Revised 1/8/09http://www.dshs.state.tx.us/diabetes/hcstand.shtmThe National Quality Measures Clearinghouse™ (NQMC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Serviceshttp://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=4078

NCQA (HEDIS 2009 Technical Specifications), American Diabetes Association, American Academy of Ophthalmology, American College of Physicians, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

B Endocrinology,Family Practice,

Geriatric Medicine, Internal

Medicine, Nephrology

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http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=4078



http://www.dshs.state.tx.us/diabetes/hcstand.shtm


http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10162&nbr=5347%23s24



http://www.ahrq.gov/clinic/uspstf/uspscerv.htm

http://www.ahrq.gov/clinic/uspstf/uspscerv.htm




Glycosylated Hemoglobin

(HbA1c) Test for Diabetics (Annual)

To ensure that all diabetic members ages 18-75 receive at least 1 glycosylated hemoglobin test during the measurement year.

American Diabetes Association, Texas Department of State Health Services-Minimum Practice Recommendations for Diabetes. Revised 1/8/09http://www.dshs.state.tx.us/diabetes/hcstand.shtm

American Diabetes Association, American Association of Clinical Endocrinologists, American College of Endocrinology, Centers for Disease Control and Prevention, Veterans Affairs Administration, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

B Endocrinology, Family Practice,



Appropriate Treatment for Children with

Upper Respiratory

Infection (URI)

To ensure that children, ages 3 months to 18 years old as of the end of the measurement year, diagnosed with nonspecific upper respiratory infections are not being inappropriately treated with antibiotics.

CDC - Get Smart: Know When Antibiotics Workhttp://www.cdc.gov/getsmart/specific-groups/healthcare-providers.html

Centers for Disease Control and Prevention, American College of Physicians, American Society of Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, Infectious Diseases Society of America, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

B Allergy-Immunology,

Family Practice, Pediatrics,

Pediatric Allergy and Immunology

LDL Monitoring for Diabetes

(Annual)

To ensure that all members age 18-75 years old with diabetes receive LDL monitoring during the measurement year.


American Diabetes Association, NCEP-ATP-III Guidelines, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

B (for most adults with diabetes) C (for adults with

low-risk lipid values [LDL <

100mg/dl, HDL > 50mg/dl, and triglycerides <

150mg/dl])

Cardiovascular Disease - Non-Interventional, Cardiovascular

Disease - Interventional, Endocrinology, Family Practice,



Mammography Screening

To ensure that all eligible women age 40-69 receive a mammography screening test during the measurement year or year prior.

Screening Mammography for Breast Cancer: American College of Preventive Medicine Practice Policy Statement, 1996.http://www.acpm.org/breast.htm

United States Preventive Services Task Force (USPSTF), Canadian Task Force on Preventive Health Care, American Academy of Family Physicians (AAFP), American College of Preventive Medicine, American Medical Assn. (AMA), American College of Obstetricians and Gynecologists (ACOG), American College of Radiology, American Cancer Society, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A (50 to 69) B (40 to 49)

Family Practice, Geriatric Medicine, Internal


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http://www.acpm.org/breast.htm

http://www.acpm.org/breast.htm



http://www.cdc.gov/getsmart/specific-groups/healthcare-providers.html








Treatment of Cardiovascular

Conditions: Monitoring Lipid Levels (Annual)

To ensure that members with cardiovascular conditions receive lipid level monitoring at a clinically appropriate frequency.

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update http://guidelines.gov/summary/summary.aspx?doc_id=9373

NCQA (HEDIS 2009 Technical Specifications), Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III), American College of Cardiology, American Heart Association, National Cholesterol Education Program, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A Cardiovascular Disease – Non -Interventional, Cardiovascular

Disease - Interventional,


Medicine

Appropriate Use of Imaging in

Low Back Pain Assessment

To ensure that all members diagnosed with lower back pain did not receive a clinically inappropriate imaging study.

National Committee for Quality Assurance (NCQA). HEDIS 2009 American College of Radiology (ACR) http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=13671

Agency for Healthcare Research and Quality, Institute for Clinical Systems Improvement, American Academy of Family Physicians, American College of Physicians, American College of Radiology, American Pain Society, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A Family Practice, Geriatric Medicine, Internal

Medicine, Neurology

Follow-up After Initial Diagnosis and Treatment of Colorectal Cancer: CEA

To ensure that all eligible members with colorectal cancer who are status post colon resection receive follow up CEA test at least every 6 months to monitor for cancer reoccurrence.

NCCN National Comprehensive Cancer Network, Clinical Practice Guidelines in Oncology - Colon Cancer, 2007http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf

American Society of Clinical Oncology, National Comprehensive Cancer Network

B Family Practice,Geriatric Medicine, Internal

Medicine,

X-ray Prior to MRI/CAT Scan

in the Evaluation of Lower Back

Pain

To ensure that an x-ray is conducted prior to an MRI for eligible members diagnosed with lower back pain.

American College of Physicians, American Pain Society http://www.annals.org/cgi/reprint/147/7/478.pdf

Agency for Healthcare Policy and Research, American Academy of Family Physicians, American Academy of Neurology, American College of Physicians, American Pain Society, Institute for Clinical Systems Improvement.

B Family Practice, Internal

Medicine, Geriatric Medicine, Neurology

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http://www.annals.org/cgi/reprint/147/7/478.pdf

http://www.annals.org/cgi/reprint/147/7/478.pdf

http://www.nccn.org/professionals/physician_gls/PDF/colon.pdf



http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=13671



http://guidelines.gov/summary/summary.aspx?doc_id=9373






Use of Long-Term Control

Drugs for Persistent Asthma

To ensure that members with persistent asthma receive medication appropriate for long term control of asthma.

National Heart, Blood and Lung Institute, National Asthma Education and Prevention Program, Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma, Section 3 & 4, 2007http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

The National Asthma Education and Prevention Program, The Joint Council of Allergy, Asthma and Immunology, National Heart, Lung and Blood Institute, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed

A (inhaled corticosteroid or

inhaled corticosteroid

combos) B (other classes of

medication [i.e., mast cell

stabilizers, leukotriene modifiers,

methylxanthines])

Allergy – Immunology,


Medicine, Pediatrics,

Pediatric Allergy and

Immunology, Pediatric

Pulmonary Disease,

Pulmonary Disease

Chlamydia Screening for

Women

To ensure that sexually active women 16-25 years of age had at least one screening test for chlamydia during the measurement year.

U.S. Preventive Services Task Force (USPSTF), Screening for Chlamydia, 2007http://www.ahrq.gov/clinic/uspstf/uspschlm.htm

American Academy of Family Physicians, Centers for Disease Control and Prevention and U.S. Preventive Services Task Force (USPSTF), NCQA (HEDIS 2009 Technical Specification), National Quality Forum (NQF) endorsed measure

A (for women 24 years and younger)

C (for women 25 years)

Educational: Family Practice,

Internal Medicine, Obstetrics-Gynecology

Monitoring for Diabetic

Nephropathy

To ensure diabetic members ages 18-75 receive a diabetic nephropathy screening test during the measurement year.


American Diabetes Association, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed

B Educational: Endocrinology, Family Practice,


Medicine

1Strength of Evidence Definitions: A. Recommendation based on consistent and good-quality patient-oriented evidence.B. Recommendation based on inconsistent or limited-quality patient-oriented evidence. C. Recommendation based on consensus, usual practice, disease-oriented evidence, case series for

studies of treatment or screening, and/or opinion.

Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature http://www.aafp.org/afp/20040201/548.html

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http://www.aafp.org/afp/20040201/548.html



http://www.ahrq.gov/clinic/uspstf/uspschlm.htm

http://www.ahrq.gov/clinic/uspstf/uspschlm.htm

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

Appendix C – Details on Calculating EBM Scores

For each relevant EBM indicator category, a physician p-score is calculated as the ratio of the number of occasions on which the indicated service was provided by the physician to the number of eligible patient encounters.

The aggregate p-score for a physician is the weighted average over all relevant indicators of the physician’s p-scores. Before summing, each p-score is multiplied by the inverse of its approximate variance. This weighting factor explicitly takes into account the number of eligible patient encounters within each indicator for the physician so that p-scores based on a large number of encounters are more influential in determining the aggregate score than p-scores based on a smaller number of encounters.

The statewide p-score for the indicator is the ratio of the total number of occasions in the state on which the indicated service was provided to the total number of eligible patient encounters, all within the indicator category. The same inverse-variance weighting factors are used, so the numbers of eligible patient encounters within each indicator category are again taken into account. The expected p-score for the physician is the weighted sum over all relevant indicators of the statewide p-scores.

The physician EBM score is the ratio of the physician’s aggregate p-score to the corresponding statewide p-score, divided by the approximate standard deviation of the ratio. The EBM score may be positive or negative, indicating that the physician’s overall rate of performance of indicated services falls above or below statewide rate.

To determine the practice group EBM score, each member physician’s EBM score is weighted by the inverse of its variance, and then aggregated across the relevant indicators. This results in a weighted average that reflects both the total number of patient encounters for each physician and the variability of the EBM score. EBM scores based on many patient encounters are weighted more heavily than those based on fewer encounters. This methodology takes into account differences in the numbers of patient encounters for both individual physicians and for practice groups.

The specialty ratio for a practice group is the ratio of the number of occasions on which the indicated service was provided to the number of eligible patient encounters, aggregated over all physicians in the group. A physician group is evaluated using only those indicators which are considered relevant to the specialty. Thirty or more patient encounters across all indicators must be attributed to the physician group to be included in the assessment. A group's performance is assessed relative to other physicians in the same specialty within the BCBSTX network.

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Definitions

Actual Allowed Cost: This is the allowed cost (physician payment and patient liability) for all services provided by all physicians, ancillary providers and facilities related to the episodes of care attributed to the physician.

Confidence Interval: The probability at a 90% level of confidence that a PCA lies within a specified range.

Expected Allowed Cost: This is based on the average allowed cost of qualified episodes partitioned by MEG, severity, comorbidity group, and time period for a specialty in a geographic region.

Episode of Care: An episode of care is composed of one or more encounters or visits, procedures or inpatient admissions. It is built by linking sets of health care services provided to a patient over time to treat a specific disease or health status. It continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status.

MEG (Medical Episode Group): The Thomson Reuters Medical Episode Group numeric code identifying a clinically homogenous episode of care.

PCA: Total cost of all qualified episodes attributed to the Practice Evaluation ID (for a Working Specialty) divided by the total expected cost for those episodes.

Peer Comparison: All comparisons are made to specialty peers in the same geographic area on episodes in the same Medical Episode Group (MEG) at the same level of severity, in the same Comorbidity Group and during the same time period.

Practice Evaluation ID: The Tax Identification Number for group providers or other unique identifier for solo providers.

Severity: Indicates the level of severity observed in episodes of a specific clinical condition (Medical Episode Group). Subdivisions (x.xx) indicate more precise classification. For some Medical Episode Groups, severity is further classified using age, gender and type of episode.

0 History of a significant predisposing factor for the disease, but no current pathology, e.g. history of carcinoma or neonate born to mother suspected of infection at time of delivery

1 Conditions with no complications or problems with minimal severity2 Problems limited to a single organ or system; significantly increased risk of

complications than Stage 13 Multiple site involvement; generalized systemic involvement; poor prognosis

Working Specialty: A specialty designation derived by utilizing the physician’s primary, secondary and tertiary specialties on record, practice limitations, physician type, and in certain cases, primary place of service.

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detailed explanation of the 2011 bluecompare physician ....doc

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