Optum Physical Health Provider Locator Cost & Quality Detailed Methodology

Transcription

1 Optum Physical Health Provider Locator Cost & Quality Detailed Methodology

2 Table of Contents Overview... 3 Provider Eligibility... 3 Geographic Areas Included In Assessment... 3 Specialties Included... 3 How Patients Are Attributed To Providers... 3 Provider Reconsiderations... 4 Public Displays... 4 Quality... 4 Overview... 4 Data Used for Assessment... 5 Data Sufficiency Requirements... 5 Measurement Error and Measure Reliability... 5 Quality and Risk Adjustment... 5 Statistical Analysis... 6 Cost Efficiency Overview...11 Data Used for Assessment...11 Data Sufficiency Requirements...11 Measurement Error and Measure Reliability...11 Statistical Analysis...12 Cost Effectiveness and Risk Adjustment...12 Important Program Information

3 Overview Optum Physical Health (Optum) is committed to assisting consumers in making more informed choices with respect to the quality and cost of health care services. One key component of this commitment is the online Provider Lookup Portal. This tool allows consumers to compare providers on quality and cost efficiency. This tool should only be used as a guide and not be the sole basis for selecting a provider. Provider Eligibility Individual providers and group practices are evaluated for quality (patient experience rating) and cost efficiency if they meet all of the following criteria: 1. Providers must participate in the Optum network (credentialed and/or contracted) and practice in a specialty included in the quality and efficiency assessment. There is no geographic preference; providers in all states are in scope if they meet the above criteria. 2. A minimum of 10 completed consumer experience surveys must be reported. Optum solicits the Consumer Assessment of Healthcare Providers and System (CAHPS ) survey, as a quality measurement from all members with a billed date of service during a defined time frame. 3. For cost efficiency, providers will have their cost data displayed if they have claims data on at least five patients, and where required, 10 or more patient surveys. Geographic Areas Included in Assessment Quality and cost assessment is available in all 50 states to providers meeting eligibility requirements. Specialties Included Specialties assessed may include acupuncture, chiropractic, dietician/nutritionist, massage therapy, naturopathy, physical therapy and occupational therapy. These specialties are compared with their professional peers at the state and national levels. The assessment of quality and cost is aligned with the contracting methodology of these specialties. For example, quality and cost assessments are performed at the individual level for chiropractors and individual or group/tax identification number (TIN) level for physical and occupational therapists. How Patients Are Attributed To Providers All Optum providers are assigned a unique provider identification number (ID) at initial contracting; even if they practice in the same office as other providers. Patients are identified once Optum is notified that a patient has obtained care from a provider. This may be through: Claims data, where a billed service is received. The CMS 1500 form identifies the unique member and the unique ID of the health care provider, who delivered the service. The receipt of a Patient Summary Form (PSF) from the provider s office. The PSF identifies the unique member and the unique ID of the health care provider, who delivered the service. 3

4 Provider Reconsiderations Network providers have the right to submit a request for correction or change (reconsideration) regarding their data on quality and cost efficiency. Providers may initiate a request for reconsideration or submit additional information for review on their quality and cost efficiency assessment by contacting their assigned support clinician. A written response will be provided within 30 days of the written request being received. Public Displays Once the number of surveys on file reaches 10, a provider s quality results may be posted for consumers to view. Providers will have their cost data displayed after they have claims data on at least 5 patients. In certain venues, cost data must be accompanied by quality reporting. In these venues, cost data will only be reported for providers having at least 10 patient surveys. The Provider Locator application can be searched for health care providers by a range of variables (name, location and specialty, gender, and languages spoken). The output of the search may include: Cost estimates Experience/satisfaction ratings by other patients How often this provider recommends an imaging procedure This information may be found on the following pages: Health Care Provider Search Results. This is where a list of available health care providers will be displayed. Health Care Provider Details. This is where information about a provider will be displayed. Health Care Provider Compare. This is where up to three health care providers may be displayed side-by-side. Additional details or definitions may be displayed by clicking on the question mark icons that appear within multiple areas of the Provider Locator. QUALITY Overview A key method for measuring care quality is to survey active health care consumers about their experiences with their health care providers and office-staff. Optum administers the Consumer Assessment of Healthcare Providers and System (CAHPS ) survey to assess and compare the quality of health care experience. The CAHPS Clinician & Group survey has been endorsed as a quality measurement tool by the National Quality Forum (NQF). The 4

5 CAHPS survey focuses on measures that are actionable by a provider that can assist in quality of care improvement. Using the CAHPS survey consumer experience is measured at a minimum annually. To achieve a larger sample size, Optum utilizes at least a rolling 24 month look back measurement period. Data Used for Assessment Specifications Used to Calculate Each Performance Measure Optum administers the CAHPS survey to assess provider quality through member experience of care with a specific provider and that provider s practice. The survey consists of a standard set of core questions that are crucial to ensure the collection of standardized data for making valid comparisons. Supplemental questions may be added to capture information about patients experiences for other specific aspects of care. To facilitate the interpretation of the data and comparisons across a specific unit of analysis (eg, provider or patient), questions measuring similar constructs are grouped together. These groups of questions are called composites. The use of composite measures, which are highly related both conceptually and statistically, is recommended by the CAHPS working group. The survey focuses on three composite scores and an overall rating score: Getting timely appointments, care, and information How well providers communicate with patients Helpful, courteous, and respectful office staff Overall rating of the health care provider Data Sufficiency Requirements Sufficient data for the quality assessment requires a minimum number of 10 surveys prior to a provider s consumer ratings information being released online. This minimal threshold includes surveys collected over at least a rolling two year period. Prior to Optum making the data available to consumers, providers are notified in advance. Survey data collected will be updated at least annually. Whenever required, cost and resource use (utilization) results are only presented in conjunction with quality results. Measurement Error and Measure Reliability A series of audits and quality checks are incorporated at key points in the survey collection and measurement phases. Initially, several audits are conducted to ensure the correct patient provider combination is maintained. State averages, composite scores and 90% CI s are calculated for the individual provider or group, once data collection has been completed. Quality and Risk Adjustment Optum incorporates retrospective risk adjustment with the use of the SAS statistical analysis program in calculating composite scores. The explanatory power of retrospective risk 5

6 adjustment is superior to that of prospective risk adjustment and is preferred for comparative reporting of performance measurement results. 1 Case-mix adjustment methods are consistent with the procedures recommended to minimize the effects of differences between entities in background characteristics by the CAHPS working group. The weighting algorithm for composites contributes to the validity of case-mix adjustment, because it causes the items of a composite to be weighted together in the same proportions, regardless of differences in the response rates to the different items at different plans. 2 Risk adjustment based on patients health status is not recommended for experience quality measures eg, CAHPS. 1 The intent is to assess patient-reported experience regardless of health status. 1 Knudson S, Heim C. Triple aim comparative reporting: guidelines and considerations for risk-adjusting, case-mixing, and segmentation. Health Partners, updated May 28, 2014; 2 CAHPS. Document No Instructions for analyzing data from CAHPS surveys, updated March 2, 2012; 54: Statistical Analysis Optum applies the standard methods of analysis as recommended by the CAHPS working group. The following is a description of how the CAHPS survey tool results are statistically assessed. Average Scoring A simple average scoring method has been utilized as the basis for calculating the results of the surveys. The average score is a calculation of the mean across all of the response categories in the survey. All response options are treated as points on a linear scale where the intervals between the options are equal (for example, the difference between Never and Sometimes is the same as the difference between Sometimes and Usually ). The average for each provider on that measure (question) would be based on the scores reported for each of the response categories. The analysis is performed by calculating the averages after converting the response options to a numerical scale. For example, the scale Never to Always becomes 1 to 4. Most questions utilize a 4 point scale, with 4 being the highest possible score. The average scoring method has numerous advantages over other scoring methods. The average score mirrors the full range of patients experiences with care. It also provides a more precise measure of performance and the 90% CI is narrower as compared to using top box scoring methods. Finally, consumers are getting a more accurate assessment of whether the performance of a given provider is truly above, at, or below average. Composite Measures All CAHPS surveys include a core set of items that must be included in the survey. The use of core items is crucial to ensure the collection of standardized data, which is needed in order to report comparable measures. CAHPS surveys collect consumers reports and ratings of a number of dimensions of health care. To summarize and simplify the interpretation of the 6

7 data and enhance the reliability of the results, questions that measure similar topics are grouped together. These groups of questions are called composites. The survey focuses on three composite scores and an overall score which are detailed below. Getting timely appointments, care, and information How well doctors communicate with patients Helpful, courteous, and respectful office staff Overall rating of the health care provider Composite Score 1: Getting Timely Appointments, Care, and Information This composite consists of five questions; Q6, Q8, Q10, Q12 & Q13. The possible response options are scored as never, sometimes, usually, or always (1-4 point scale). Q6 In the last 12 months, when you phoned this provider s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed? Q8 In the last 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed? Q10 In the last 12 months, when you phoned this provider s office during regular office hours, how often did you get an answer to your medical question that same day? Q12 In the last 12 months, when you phoned this provider s office after regular office hours, how often did you get an answer to your medical question as soon as you needed? Q13 Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this provider within 15 minutes of your appointment time? Composite Score 2: How Well Providers Communicate with Patients This composite consists of six questions: Q14, Q15, Q17, Q18, Q19, & Q20. The possible response options are scored as never, sometimes, usually, or always (1-4 point scale). Q14 In the last 12 months, how often did this provider explain things in a way that was easy to understand? Q15 In the last 12 months, how often did this provider listen carefully to you? Q17 In the last 12 months, how often did this provider give you easy to understand information these health questions or concerns? Q18 In the last 12 months, how often did this provider seem to know the important information about your medical history? Q19 In the last 12 months, how often did this provider show respect for what you had to say? Q20 In the last 12 months, how often did this provider spend enough time with you? 7

8 Composite Score 3: Helpful, Courteous, and Respectful Office Staff This composite consists of two questions: Q24, & Q25. The possible response options are scored as never, sometimes, usually, or always (1-4 point scale). Q24 In the last 12 months, how often were clerks and receptionists at this provider s office as helpful as you thought they should be? Q25 In the last 12 months, how often did clerks and receptionists at this provider s office treat you with courtesy and respect? Overall Score: Overall Rating of the Health Care Provider This score consists of one question: Q23. The possible response options are scored on an 11- point scale (0-10 point scale). Q23 Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider? Composite Score Calculations Each of the composite scores is calculated separately. The process of tabulating the composite scores is listed below. The process is repeated for each of the three composite categories. Step 1: All of the questions in a category are cleansed. We ensure all of the data is relevant (all of the numbers have a value of 1-4). All of the questions that have an answer are isolated. Only questions that have a value are calculated. Non answered questions aren t factored into the scoring average. An example is shown below: Respondent Q24 Q25 A 3 4 B 2 All of the questions answered fall in a value of 1-4, so all the data entered is valid. Respondent B didn t answer Q25, so that question will not be considered in any future calculations. Since respondent B left an answer blank, their weighted average will be less than respondent A. Step 2: The scoring average is calculated for each individual respondent. Each respondent (patient) have their scores added together and a sum (total) is created. The sum for each respondent is divided by the number answers they complete and the average per respondent is calculated. An example is shown below: Respondent Q24 Q25 Average A B 2 2 8

9 Respondent A: 3+4/2= 3.5 Respondent B: 2/1= 2 Step 3: The scoring average is then calculated into a weighted average of the score. The weight is the number of questions answered by each respondent, divided by the overall total number of questions answered for a provider. The weight assigned to each respondent is multiplied by their scoring average. All of the individual results are then added together to reach the weighted average score. An example is shown below: Respondent Q24 Q25 Average Weight A B Formula: Na*Ma + Nb*Mb Na + Nb Na = 2 Ma = (3+4)/2= 3.5 Nb = 1 Mb = (2)/1= 2 (Respondent A s # of questions answered) (Respondent A s mean score) (Respondent B s # of questions answered) (Respondent B s mean score) Na*Ma + Nb*Mb 2* * = = ---- = 3 = Total weighted mean score Na + Nb The total weighted average is 3 out of 4, but it is then converted into a percent. So, the total weighted average is 75.00%. Step 4: The process in step 3 is repeated to find the total weighted average on the state level. All of the providers are organized in which state they reside and their results are put together to reach a state average for each of the 3 composite scores. The weight in this step is based on number of respondents and not on the number of questions answered like in the previous step. State Provider Total # of respondents Mean Weight MN A B C Weight Provider A: 10 responders/20 total responders =

10 Weight Provider B: 6 responders/20 total responders = 0.30 Weight Provider C: 4 responders/20 total responders = 0.20 Formula: Na*Ma + Nb*Mb + Nc*Mc Na + Nb + Nc Na = 10 Ma = (3+4)/2= 3.5 Nb = 6 Mb = (2+3)/2= 2.5 Nc = 4 Mc = (4+4)/2= 4 (Provider A s # of respondents) (Provider A s mean score) (Provider B s # of respondents) (Provider B s mean score) (Provider C s # of respondents) (Provider C s mean score) Na*Ma + Nb*Mb + Nc*Mc 10* * *4 66 Total weighted = = ---- = 3.30 = mean score Na + Nb + Nc for state of (MN) The total weighted average is 3.30 out of 4, but it is then converted into a percent. So, the total weighted average is 82.50%. Step 5: The confidence interval is calculated for each of the 3 composite scores and for the overall rating of the health care provider. The average is used as a middle number and an upper and lower limit is tabulated. The range between the upper and lower limit is the confidence interval. We are utilizing a 90% confidence interval, so there is a 90% chance your experience will be in that range. The confidence interval of your score is calculated by utilizing the following formula: = (Sample Mean) S = (Standard Deviation) N = (Sample Size) t = (t-value) wi= (Weight) α = (Significance Level/Maximum level of chance tolerated) The confidence interval of success rate is calculated by utilizing Wilson confidence limits for the binomial proportion, which has good performance even for a small number of trials and/or an extreme probability. 10

11 = (Sample Probability) Z (Z= 1.645, for 90% CI) n (Sample size of response at question level) COST EFFICIENCY Overview As consumers assume greater financial responsibility for their care through greater out-ofpocket expenses it s important for them to be able to make more informed decisions about their care, and compare the cost efficiency between providers. Optum uses an approach to benchmarking cost efficiency by proxy using a claims dataset. Data Used for Assessment Specifications Used to Calculate Each Performance Measure Cost efficiency data is refreshed at least annually. Optum utilizes cost data that is based on allowed claims across the provider s patient population, over a calendar year, to assess the various components of cost efficiency with care. The components measured for each Optum provider are the number of unique patients treated identified by a claim on file, percent of patients receiving imaging (example X-rays), the cost of care per visit and total costs of care for patient with this provider for all conditions treated during a calendar year. All dollar cost figures are calculated using allowed dollars, which represent the actual amount allowed for the services rendered (based on the reimbursement schedule). This approach assists in the analysis and understanding of the cost of services patients receive by removing any differences in patient benefit design. Data Sufficiency Requirements The public reporting of cost-efficiency data requires a minimum threshold of five patients during the previous full calendar year. Where required, cost and resource use (utilization) results are only presented in conjunction with quality results. Measurement Error and Measure Reliability Measurement error and reliability are considered for cost data by displaying costs using three values: an average and a number on each side of the average creating a range and utilizing a confidence interval. The value to the left of the average is the lower bound, representing the lowest cost, while the value to the right of the average, the upper bound represents the highest cost. A 90% confidence interval describes the range or precision of the cost estimate. This means that 9 times out of 10 the actual cost is somewhere within this range. 11

12 Statistical Analysis The efficiency of care assessment considers costs for services reported by the health care provider and/or group. Cost efficiency is calculated at the individual provider, group, state, and specialty-specific levels. Costs associated with other providers treating the same patient for the same condition during the same timeframe are not included in the analysis. The process (described below) creates a state-specific, specialty-specific average cost, which is then used for comparisons among providers. All costs are calculated using allowed dollars, which represent the actual dollar amounts based on the reimbursement schedule for the services rendered. Cost Efficiency and Risk Adjustment Optum incorporates retrospective risk adjustment when calculating cost efficiency. The explanatory power of retrospective risk adjustment is superior to that of prospective risk adjustment and is preferred for comparative reporting of performance measurement results. 1 Cost efficiency risk adjustment is accomplished using segmentation (stratification) by payer type. By dividing a provider s patient population into payer segments, the potential confounding effects of different policies and reimbursement methods are not co mingled in the results across payer types. Segmentation of costs of care and utilization metrics, when reported by payer, allow health plan members to make the most relevant decisions. 1 If multiple payers comprise the claims dataset they will be noted. The segmented populations by health status are typically too small to permit reliable assessments. 1 Knudson S, Heim C. Triple aim comparative reporting: guidelines and considerations for risk-adjusting, case-mixing, and segmentation. Health Partners, updated May 28, 2014; Estimated Cost Measures The cost measures show how same specialty health care providers compare to one another on the cost of their care. Cost information is based on the accepted reimbursement schedule, which includes copays, deductibles and coinsurance. This amount reflects the cost before member benefits are applied. Estimated Cost per Visit This displays the average cost of care for all services and treatments performed during a single visit to this health care provider. The average cost of care per visit is calculated according to the formula below: Average Cost per Visit = Total cost of care for all patients seen during a specific calendar year Total number of unique patient visits during the same calendar year 12

13 Estimated Total Cost This displays the average total cost of care for all services and treatments performed by this health care provider per unique patient during a calendar year. This encompasses all conditions treated for a patient that remained under treatment before complaints were either resolved, could be self-managed, or appropriate referral was made. The average total cost of care per patient is calculated according to the formula below: Average Total Cost = Total cost of care for all patients seen during a specific calendar year Total number of unique patients treated during the same calendar year The average cost information is displayed in ranges, which are color-coded to highlight the different groupings. Range 1 represents lower costs. Range 2 shows medium costs. Range 3 and 4 indicate higher costs. Cost ranges were identified by first calculating the mean (or average) cost per visit and total cost per patient for the entire group of providers within a specialty and state. Only those providers who treated at least five members during the 12-month period reviewed were included in the analysis. Cost ranges were then identified according to the following methodology: Range 1: Less than the mean level of cost Range 2: More than or equal to the mean and less than mean + 1 standard deviation* Range 3: More than or equal to the mean + 1 standard deviation* and less than the mean + 2 standard deviations* Range 4: More than or equal to the mean + 2 standard deviations* *A statistical measure of the spread of the outcomes around the mean (or average) Estimated Imaging Cost For most individuals seeking treatment for spine-related complaints, X-rays are not routinely necessary. Health care practitioners whose care patterns are aligned with best practices will use the information from a patient s history and examination to selectively determine if an X-ray study is likely to be helpful in determining the cause of complaints. The cost shown here represents the average cost for all imaging services (example X-rays) performed and billed by this health care provider per unique patient receiving imaging during a calendar year. The average imaging cost per patient is calculated according to the formula below: 13

14 Average Imaging Cost = Total cost of imaging during a specific calendar year Total number of unique patients receiving imaging during the same calendar year Note: It is important to know cost efficiency results are based on each provider s actual population and not on standardized data. The cost information displayed for each provider reflects the average cost range for care provided to all their patients during the previous full calendar year. Depending on a patient's condition and needs, such as severity of illness and complexity of the procedure performed costs may vary. The information outlined here does not predict any single individual's cost of care experience. Important Notes about Estimated Costs and Patient Ratings Estimated Costs and Patient Ratings are only a guide to choosing a provider and should not be the sole factor in selecting a provider but may be used as one of many factors you consider when choosing the provider from whom you receive care. Your actual costs may be higher or lower than these costs estimates. You may want to check with this provider and your health plan details to confirm the costs that you may be charged for a service or procedure. You are responsible for costs that are not covered by your health plan. Neither payments nor benefits are guaranteed. If you already have a provider, you may also wish to confer with him or her for advice on selecting other providers. As with all programs that collect feedback from consumers, there is a risk of error as the responses are subjective in nature and therefore should not be the sole basis for selecting a provider. It is important that you consider many factors and information from as many sources as possible when selecting a provider. The patient rating of a provider does not guarantee the quality of health care services you will receive from a provider and does not guarantee the outcome of any health care services you will receive. This site is not a substitute for medical or health care advice and does not serve as a recommendation for a particular provider or type of medical or health care. The information within this document is subject to change. 14

15 I All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. 15