© 2006, CareVariance

"Quality-based Purchasing in Public and Private Employer Health Insurance Programs"

Health Plan Quality Transparency Efforts

Mark C. Rattray, MDPresident

CareVariance

Washington State Conference onQuality-Based Health Care Purchasing

December 4-5, 2006Seattle, Washington

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Health plan quality transparency motivators

• Purchasers• Differentiation in the marketplace• Accrediting bodies (NCQA)• Presidential transparency mandate• Consumer Directed Health Plans

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Health plan quality data collection methods

• Internal claims-based algorithms• Limited augmentation by external data feeds –

lab results, pharmacy, mental health

• Physician or physician group self-reported data

• External certifying or recognizing entities• Mix of the above

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Internal claims-based algorithms

Like HEDIS, a numerator/denominator approach:• Numerator: number of patients where

compliant care was rendered• Denominator: number of patient

candidates for recommended care

• Generates raw and sometimes weighted, risk adjusted compliance rates

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Specialty Quality Measures

• Specialties are creating quality measures through AQA, Physician Consortium for Performance Improvement – often rely on review of clinical record

• Some quality measure vendors and plans have created procedural claims-based quality indicators through expert panels / specialist advisory boards / existing specialty guidelines

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Vendor / plan specialty measures example

q. Orthopedic (total joint, disorders of upper and lower extremities, spine)

• Total cases: This is listed on the right most column of the scorecard and reflects the total number of physician cases for a procedure category. The scorecard measures only complete episodes of care and uses claims data for 2002-2003, where patients have enrollment with UnitedHealthcare for a minimum of 180 days prior and 400 days post procedure.

• % of Total physician cases: This is listed on the left most column of the scorecard and is the number of UnitedHealthcare cases the physician has performed of a particular procedure type divided by the total number of UnitedHealthcare cases for that physician.

• Procedure less than 30 days: Measures the % of a physician’s UnitedHealthcare patients who receive a surgical procedure fewer than 30 days after the initial diagnosis is made. This diagnosis does not have to be originally made by the treating surgeon.

• Pre-Surgery injection or physical therapy (PT) rate: Measures the % of a physician’s UnitedHealthcare patients who have had at least one PT session OR injection within 1-180 days prior to a surgical procedure.

(excerpt from UnitedHealth PremiumSM Program Methodology, June 2005)

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Physician or physician group self-reported data

• Used by IHA in California• IPA’s paying their own claims (capitated) and or

groups with robust EHR / registries• Used as backup method to claims data

• Physicians may augment claims data• Plans must report at individual patient / indicator

basis and allow augmentation

• Medical record based indicators require this

• Employers may be reluctant unless audit processes in place

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External certifying or recognizing entities

• Board Certification historically used as quality indicator• Maintenance of Certification programs

increasingly are requiring compliance self-assessment

• NCQA Practice Recognition Programs• Health plans may display certification /

recognition in directories• Plans may give “extra credit” in internal

programs

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Public transparency of plan measurement

From www.unitedhealthcare.com

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Employer / plan challenges

• Speed to (often national) market of quality and episodic cost measures

• Specialty measurement• Desire for “High Performing Networks”

• “Performance Differentiated Network” – all providers included, differentiated by performance and resulting employee benefits

• “Narrowed Network” – subset of existing network comprised of “higher performing” providers

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Employer / plan challenges, cont.

• Plan / employer intermediaries limiting direct, open, fully informed dialogue

• Potential dominance of sales/marketing in development and deployment of high performance networks

• Inadequate investment (money and time) in stakeholder preparation

• Lack of “line of sight” benefit alignment for each stakeholder group

12© 2006, CareVariance

Thank you!

www.carevariance.com