MN DEPARTMENT OF HEALTH PROVIDER PEER GROUPING (PPG) ADVISORY GROUP DEFINING PARAMETERS ANN ROBINOW

Transcription

1 MN DEPARTMENT OF HEALTH PROVIDER PEER GROUPING (PPG) ADVISORY GROUP DEFINING PARAMETERS ANN ROBINOW MEETING 2: JUNE 26, 2009

2 Introduction Comments and changes to meeting summary? Review of questions or comments since last meeting Public purchasing population Report Technical Advisory Group responses since last meeting Request for roster and agenda Meeting summary handout

3 Reminder: What Are We Trying to Achieve? Enable comparisons of how provider entities perform on: Management of cost and quality for their entire patient population (aka total cost of care) Management of cost and quality of care for specific conditions Uses of information: Consumer choice of providers Provider improvement Plan contracting and product development TODAY S TOPIC: DEFINING PARAMETERS

4 Total Care: What is It? Representation of all covered medical services (physician, hospital, ancillary, and Rx) for all medical conditions incurred by an insured member over a defined time period, usually one year. Primary Care groups are often held responsible for Total Care. Hospitals are often also held responsible for the total hospital portion of Total Care. Quality Indicators for Total Care are usually related to patient experience, safety process measures, clinical preventive & chronic measures.

5 Condition Specific Care: What is It? Similar to Total Care but only includes covered medical services related specifically to a defined medical condition incurred by an insured member over a defined period. Can be a time period, eg 12 months of care, or a clinically defined period. Examples: Diabetes, Coronary Artery Disease, Maternity, Knee Replacement Identification of patients and services with defined medical condition are generally based on diagnosis codes from insurer claims. Condition Specific Care is often a way to include specialists in the peer grouping process. Clinical Quality Indicators are more developed for some prevalent conditions such as Diabetes, CHF, CAD Asthma.

6 Context For Today s Discussion High Level Steps in Peer Grouping

7 Questions for Today s Meeting 1. Who will be measured? 2. How do we define the entity to be measured (unit of analysis)? 3. What is a peer group (and are these the same or different for total cost of care v. condition specific measures)? 4. What services are included and excluded from this analysis? 5. How many and which specific medical conditions will be measured?

8 What Provider Entity Will be Measured for Total Cost of Care?

9 How Will Hospitals be Measured for Total Cost of Care of Care?

10 Provider Unit of Analysis Examples

11 Provider Unit of Analysis

12 Provider Unit of Analysis Examples

13 Provider Unit of Analysis: Hospital

14 Unit of Analysis Current Practices Who will be Measured? MN plans have used Total Cost to tier Primary Care groups and Care Systems. Plans have also used the hospital component of Total Cost to tier hospitals. Some plans tier specialists by practice and analyze specialty practices for cost and quality for the conditions for which they provide care. Unit of Analysis- Physician: Most plans compare at the medical group level due to data validity but see more value to compare at the clinic level. Plans have also compared physicians at the group level in order to be consistent with available quality measures. MN Community Measure reports most quality measures at medical group level but has started to report some conditions at the clinic level. Plans sometimes internally profile and analyze at the individual physician level but do not share this publicly. Unit of Analysis Hospital: Most plans compare at the individual hospital level. Publically available quality data is also reported at the individual hospital level.

15 Provider Peer Groups Health plans in MN have put geographic parameters around defining provider network peer groups in order to ensure all tier levels are available across all regions.

16 Services To Be Included and Excluded: Current Practices Law requires claim data on only MN residents. Law requires adjustment for catastrophic and outlier cases (to be discussed in meeting 3 or 4). Identification of services incurred usually compiled from retrospective insurer claims data that has been fully processed and completed. Usually includes pharmacy services even though these claims and benefits may be processed and managed by a separate entity. Does not include services not covered by the insurer such as nursing home care, over the counter meds, non-covered benefits (i.e. cosmetic surgery).

17 Specific Conditions Overview compare provider performance on cost and quality of care for specific conditions Different animal from baskets of care Baskets create common base definition Baskets invite voluntary price quote across payers Providers take risk on services included in basket Current discussion Specific conditions measures all applicable providers for all related services (analyzed by grouper technology) Requires no provider action Does not establish financial risk or pricing commitment Metrics on cost and quality to be included

18 How Many and Which Specific Conditions Will Be Measured? How many conditions? 15 conditions drive 56% of costs Baskets of Care 7 conditions Prometheus pilots 10 conditions AHRQ 10 conditions AQA 7 conditions Medicare 8 conditions MN Quality Incentive 6 conditions Bridges to Excellence 3 conditions

19 Selected Conditions by Entity Condition MN QI AQA CMS BTE Baskets of Care Diabetes X X X X Heart Failure X X X Low back pain X X Coronary artery disease X X X X Depression X X X Heart attack X X X Pneumonia X X Asthma X X Hypertension Total knee X Adult preventive X Child preventive X Maternity X Prostate cancer X UTI X Hip fracture X Cholecystitis X COPD X

20 Selected Condition Criteria Condition Quality Metrics Choice of Provider AHRQ Most $$ Hi Cost per Episode Commercial Prevalence Hi Variation Diabetes X X X X X X Heart Failure X* X X X? X Low back pain X X X X X Coronary artery disease X X X X? X Depression X X X X X X Heart attack X* X X? X Pneumonia X* X? X Asthma X X X X X X Hypertension X X X X X X Total knee X X? X Adult preventive X X X X Child preventive X X X X Maternity X X X X X Prostate cancer X X? X UTI X X? Hip fracture? X?? Cholecystitis???? COPD X X X? X * inpatient measure

21 Who Will Be Measured for Specific Conditions?

22 Questions for Today s Meeting 1. Who will be measured? 2. How do we define the provider entity to be measured (unit of analysis)? 3. What is a peer group and are these the same or different for total cost of care v. condition specific measures? 4. What services are included and excluded from this analysis? 5. How many and which specific medical conditions will be measured?

23 Who Will Be Measured? Entity Total Cost of Care Specific Conditions Primary Care Specialists Care Systems Hospitals

24 How Do We Define Unit of Analysis? Unit of Analysis Total Cost of Care Specific Conditions Individual physician Clinic site Care System Hospital

25 What is a Peer Group? Peer Group Limitation Total Cost of Care Specific Conditions Same provider type, e.g. primary care, specialists Same provider size, e.g. less than 3 physicians Same geographic area, e.g. rural, urban Same structure, e.g. single specialty, multispecialty, pediatrics only

26 What Services Are Included? Services Total Cost of Care Specific Conditions MN residents X X Adjust for outliers, catastrophics Discuss in Meeting 3 and 4 Discuss in Meeting 3 and 4 Covered services X X Pharmacy X X Exclude non-covered services X X

27 Which Specific Medical Conditions? Diabetes Heart Failure Low back pain Coronary artery disease Depression Heart attack Pneumonia Asthma Hypertension Total knee Adult preventive Child preventive Maternity Prostate cancer UTI Hip fracture Cholecystitis COPD Other

28 Preview of Next Meetings 3 & 4: Cost Measurement Cost comparison How much does it cost for different provider organizations to deliver care for similar patient populations/medical conditions? What is cost? How should resource use be determined? How should price be determined? How should these be combined into a cost comparison? Patient attribution Why are patients attributed? Which providers are really managing which patients? Can/should every patient be attributed? Can/should patients be attributed to more than one physician?

29 Meeting 3 & 4:Cost Measurement Risk adjustment Why is risk adjustment important? How can/should methodology account for differences in patient populations? How do illness burdens differ and how does that affect cost? How do patient demographics differ and how does that affect cost? How does payer mix differ and what affect does that have on costs? What tools are available to make adjustments for risk differences? Outlier Issues Why should we consider outliers? What is and isn t an outlier? How should methodology account for differences in frequency and cost of outliers?