Maternity Multi‐Stakeholder Action Collaborative Session 7:
Data Sharing and Infrastructure
Table of Contents
U.S. Women’s Health Alliance Presentation ......................................................................................... 3
Sample Provider Reports ................................................................................................................... 46
Ohio Department of Medicaid, Payment Innovation ............................................................................. 47
Tennessee Health Care Innovation Initiative .......................................................................................... 51
New York Delivery System Reform Incentive Payment Program ........................................................... 57
Guide for Interpreting Arkansas’ Episode of Care Report .................................................................... 58
Community Health Choice Provider Submitted Quality Data Spreadsheets ........................................ 63
Quality Data Collection Template ........................................................................................................... 64
Example Maternity Scorecards ............................................................................................................... 65
U.S. Women’s Health Alliance Presentation
INTRODUCTION: USWHA MATERNITY EOC
Jack Feltz, MD
March 10, 1876
Alexander Graham Bell
Better, More Affordable Care for Women
Lower Cost for Health Plans & Employers
Fulfilled and Thriving Providers
USWHA National Maternity Episode of Care
USWHA Maternity Episode of Care Smart
Not so Smart
Easy to Use Hard to Use
Success through
Simplicity
Achieving the Quadruple Aim
Triple Aim + All Stakeholders Thriving in a New Healthcare Environment
WHY?
Medical Errors are 3RD most common
cause of death
Medical Error 251K
Although considered mainly as problems of the developing world, maternal mortality and morbidity remain a challenge in the United States of America (USA).1 Between 1990 and 2013, the maternal mortality ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births1 and the country has now a higher ratio than those reported for most high-income countries. About half of all maternal deaths in the USA are preventable. Each year an estimated 1,200 women in the USA suffer complications during pregnancy or childbirth that prove fatal and 60,000 suffer complications that are near-fatal – even though costs of maternity care in the USA in 2012 exceeded 60 billion United States dollars.
Three factors are probably contributing to the upward trend in maternal mortality and morbidity in the USA. First, there is inconsistent obstetric practice. Hospitals across the USA lack a standard approach to managing obstetric emergencies and the complications of pregnancy and childbirth are often identified too late. Nationally endorsed plans to manage obstetric emergencies and updated training and guidance on implementing these plans is a serious and ongoing need. A second factor is the increasing number of women who present at antenatal clinics with chronic conditions, such as hypertension, diabetes and obesity, which contribute to pregnancy-related complications. Many of these women could benefit from the closer coordination of antenatal and primary care – including case management and other community-based services that help them access care and overcome cost and other obstacles. In the USA, women who lack health insurance are three to four times more likely to die of pregnancy-related complications than their insured counterparts
Another factor is the general lack of good data – and related analysis – on maternal health outcomes. Only half the USA’s states have maternal mortality review boards and the data that are collected are not systematically used to guide changes that could reduce maternal mortality and morbidity. There is no national forum for the states to share either their best practices for reviewing maternal deaths or the relevant lessons that they may have learned. There is a growing effort by physicians, nurses and community organizations to address these three factors. Hospitals are beginning to implement standard approaches to managing obstetric emergencies so that, wherever a woman gives birth, she receives appropriate evidence-based care. Community initiatives are coordinating care for high-risk women to ensure good health and management of chronic conditions during and beyond pregnancy. More states are establishing or strengthening maternal mortality review boards.
Although maternal mortality is relatively rare in the USA, one preventable maternal death is one too many. All states need to mobilize health providers, policy-makers and communities to make maternal health a priority. With increased awareness of maternal mortality and life-threatening events – and concrete actions to ensure that pregnant women get the quality care they need – many fatal and near-fatal complications could be prevented.
PROJECT DESIGN
Jack Feltz, MD
An Episode of Care is a value-based model designed to engage specialists
PROJECT COMPONENTS
Project Components
Episode Design
Episode Contracting
Member Readiness
Data Analytics
Medical Policy &
Guidelines
Project Leadership & Design
Project Coordination
EPISODE DESIGN
Lili Brillstein, MPH
Mark Cone, MD Jack Feltz, MD
Mission To create a Maternity
Episode of Care model design that can used by USWHA partners in their
respective markets, in collaboration with payers
and other stakeholders, that will reward excellent outcomes, patient
experience, and most efficient cost of care.
Episodes of Care
23
Value-based model designed to engage specialists.
Full SPECTRUM of services related to and delivered for a specific medical condition, illness, procedure or health care event during a defined time period. Coordination, communication, collaboration across the continuum.
Pre-Trigger Services e.g., labs, radiology
Trigger Event/Diagnosis e.g., delivery/pregnancy
Post-trigger services
e.g., postpartum visits, hospital
Readmission, extended use of opioids
Day 1 Last Day
Keys to Success
• Partnership & Collaboration at Every Level – Defining episode construct, intent, launch – Establishing metrics – Creating workable model – Fluidity, Willingness to change
• Simplicity • Respect
– Physicians are the clinical experts in charge of the care – Providers make clinical care decisions – Payers track and share data – Payers help identify opportunities
• Patient is center stage
How to Make It Work
• Be open to the possibilities • Work to Build Trust/Share Information • Communicate and collaborate regularly • Be flexible, willing to make changes • Know that it won't be perfect • Follow USWHA established guidelines
Guidelines Make the Model Work
Success occurs when data is shared and studied between payer and providers, and clinical partners use the information to develop guidelines for optimizing care, which they then communicate and enforce in their practice.
MEDICAL POLICY AND GUIDELINES
Genevieve Fairbrother, MD Rhona Magaril, MD
Medical Guidelines & EOC: What’s the Advantage
Value = quality/cost
• Consistent high quality care • Predictable and affordable costs • Data analytics • Guidelines insure we can reach the quality metric goal
and success in EOC
Guideline Development Process • Task force: diverse group of volunteer alliance members • Topics:
– Standard testing – High risk conditions
• Sources: – ACOG practice bulletins – ACOG committee opinions – Journal review articles
• Review process: – Committee members assigned to topic – Reviewed sample guideline documents – Edited documents – Presented to committee for approval
Medical Guidelines Committee Report
• Five Primary Categories Addressed by Task Force: 1. Laboratory: agreeing on a basic set of intake labs 2. Hospital Stays: based on uncomplicated PP course, learning from
Members what the usual SOC is. 3. Pharmacy: provide recommendation of OTC and prescription PNV based
on committee’s experience 4. Guidelines: creating guidelines for high risk conditions 5. Induction & Labor Management: share and review protocols from
hospitals to produce a consensus • Categories 1 – 3 are completed
– Recommendation for Standard Laboratory Testing • Category 4 completed in draft (8 high-risk conditions) • Return on Investment
– Consensus among a diverse group of providers – Maternity Episode of Care ready to launch
High Risk Guideline Topics
1. Hypertensive Diseases in Pregnancy 2. Diabetes in Pregnancy 3. Pre-Term Labor, Pre-Term, Premature Rupture of
Membranes 4. Multiple Gestation 5. Advanced Maternal Age 6. History of Thromboembolic Phenomenon or
Hypercoaguable States 7. Obesity 8. Abnormal Placentation
UTILIZATION OF GUIDELINES
Utilization of Guidelines
• Distribute document to providers • Embed document in EHR for ease of use • Guideline specific order sets (ensure consistent high
quality care that produces reproducible results) • Consider online course on management of high risk
conditions (e.g. Gnosis)
Guidelines to Improve Data Collection
• Guidelines recommend documentation in EHR • Order sets allow collection of recommended laboratory
and imaging testing • Data collection by the provider important for adjudication
with data collected by insurance companies
EPISODE CONTRACTING
Mark Cone, MD
Jack Feltz, MD
Elements of the Contract
• Purpose / Mission • Definitions • Analytics • Quality Metrics • Shared Savings • Contract Term • Budget • Episode Type
MEMBER READINESS
Jack Feltz, MD Heather Schueppert
Member Readiness • Define eligible groups • Meet with participating groups • Establish team roles within group
– Project leader – Project coordinator – Medical leader – IT leader
• Track data – Claims data – Quality data – Physician performance data
• Define shared savings distributions in group • Group retreat to educate and prepare for launch
Member Readiness
• Host and promote regular webinars on changes and progress
• Continued USWHA support • Continued health plan support • Continued communication between Alliance
groups to share progress and experiences
CLOSING COMMENTS
Jack Feltz, MD
“It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most
adaptable to change.”
Charles Darwin 1809 - 1882
Sample Provider Reports
Quality metrics
HIV screening
GBS screening
C-section
Follow-up visit within 60 days
30%
60%
30%
70%
You achieved 3 of 4 quality metrics linked to gain sharing
Q4 ‘15 Q2 ‘16Q1 ‘16Q3 ‘15
Performance period 2016Reporting period 2015
Key performance
1315 13 15 28
51%55% 36% 5% 16%
Weightedaverage
$3,400$3,110
$2,696 $2,888$3,307
Avg adjusted episode spend
# of includedepisodes
Your spendpercentile
Rolling four quarters
Acceptable ($4,405)
Commendable ($3,169)
Gain Sharing Limit ($1,235)
Not acceptableAcceptableCommendable
You are here$2,888
Risk adjusted average spend per episodeDistribution of provider average episode spend (risk adj.)
Avg.
adj
. epi
sode
spe
nd ($
,000
) 7
6
5
4
3
2
1
0
Episodes included, excluded & adjusted
Total episodes: 40
Episodes 30% Excluded12
Episodes 70% Included28
of your episodes have been risk adjusted 71%
IncludedExcluded
You are currently not eligible for gain or risk-sharing because you have less than 5 episodes during this period. If you realize at least five episodes by the end of the performance period, you will be eligible. Eligibility requirements for gain or risk-sharing payments
This report is informational only. Eligibility for gain or risk-sharing will be determined at the end of the performance period and any applicable payments will be calculated at that time.i
Quality: You are not currently eligible for gain-sharing because you have not passed all quality metrics linked to gain-sharing.!
Spend: Your average risk-adjusted spend per episode is below the commendable threshold.
Episode volume: You have at least 5 episodes in the current performance period.
EPISODE of CARE PROVIDER REPORT PERINATAL Q1 + Q2 2016
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports are neither intended nor suitable for other uses, including the selection of a health care provider. The figures in these reports are preliminary and are subject to revision. For more information, please visit http://medicaid.ohio.gov/Providers/PaymentInnovation.aspx.
PAYER: Ohio - Medicaid FFS PROVIDER: ABC Womens Health CenterPROVIDER ID: 0000000000
Reporting period covering episodes that ended between January 1, 2016 to June 30, 2016
Gain/risk sharing calculationGain / risk sharing component You Description
1. Total spend across included episodes
2. Total # of included episodes
3. Avg. episode spend (non adj.)
4. Risk adjustment ratio (avg.)
5. Average risk-adjusted spend per episode
Total of all associated claims submitted paid during this cycle, excluding medical education and capital portions of the hospital base rates
Net of episodes excluded for clinical or operational considerations
Average spend before risk adjustment; Equals line (1) divided by line (2)
Average adjustment to raw claims to account for clinical variability(set by payers)
Adjusted spend per episode; Equals line (3) multiplied by line (4)
$129,979
28
$4,642
0.6222
$2,888
1N/A6. Commendable spend threshold per episode Commendable threshold
9. Total spend eligible for gain sharing
10. Gain sharing proportion
Equals line (1) times line (8)
Proportion of spending eligible for gain you share in
7. Risk-adjusted spend per episode below threshold
8. Percentage of spend subject to gain sharing
The smaller of the difference between adjusted spend and commendable spend or adjusted spend and the gain sharing limit; equals line (6) minus line (5) or line (6) minus the gain sharing limit ($1,235)
Difference between adjusted spend and commendable spend aspercentage of adjusted spend; equals line (7) divided by line (5)
11. Total gain share Total gain-sharing payment; equals line (9) times line (10)
1N/A
1N/A
1N/A
1N/A
1N/A
Episodes
Your episode spend distribution (risk adjusted)
Episodes included: 28Each bar represents one episode
Your average$2,888
Not acceptableAcceptableCommendable
6
5
4
3
2
1
0
Ris
k-ad
just
ed e
piso
de s
pend
($,
000
)
PERINATAL Q1 + Q2 2015
EPISODE of CARE PROVIDER REPORT
PAYER: Ohio - Medicaid FFS PROVIDER: ABC Womens Health CenterPROVIDER ID: 0000000000
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports are neither intended nor suitable for other uses, including the selection of a health care provider. The figures in these reports are preliminary and are subject to revision. For more information, please visit http://medicaid.ohio.gov/Providers/PaymentInnovation.aspx.
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1 Eligibility for gain or risk-sharing will be determined at the end of the performance period and any applicable payments will be calculated at that time.
Reporting period covering episodes that ended between January 1, 2016 to June 30, 2016
Metrics for information only
Median 0%
You 0%Smoking cessation
% of episodes where smoking cessation counseling is provided during the episode
Median 58%
You 72%
You 18%
You 0%
Chest X-ray % of episodes where a chest x-ray is performed during the trigger window
Median 13%
You 4%Follow-up visit within 7 days
% of episodes where the patient receives an office or home consultation or preventative counseling within 7 days after the trigger acute exacerbation
Follow-up visit% of episodes where the patient receives an office or home consultation or preventative counseling with a physician during the post-trigger window
Asthma controller medication
% of episodes where the patient receives an appropriate medication determined by a filled prescription for an asthma controller medication during the episode window or within 30 days before the episode
Repeat acute exacerbations
% of episodes with a repeat acute exacerbation
Inpatient treatment
% of episodes where the trigger acute exacerbation is treated in an inpatient setting
Metrics linked to gain sharing
Quality and utilization metrics comparison to threshold and other providers
Median 17%
You 10%
Median 12%
Median 6%
Median 29%
You 30%
Threshold 26%
Threshold 28%
Metrics for information only
Median 47%
You 45%
Gestational diabetes screening
% of valid episodes where the patient receives a screening for gestational diabetes during the pre-trigger window
Median 50%
You 40%Chlamydia screening
% of valid episodes where the patient receives a screening for chlamydia during the pre-trigger window
Median 44%
You 40%Hepatitis B screening
% of valid episodes where the patient receives a screening for hepatitis B specific antigen during the pre-trigger window
Median 1.83
Ultrasound rate Average # of ultrasounds given by a PAP in the pre-trigger window of valid episodes
HIV screening % of valid episodes where the patient receives a screening for HIV during the pre-trigger window
GBS screening% of valid vaginal delivery episodes where the patient receives a screening for Group B streptococcus (GBS) during the pre-trigger window
C-section % of valid episodes where the patient receives a C-section during the episode window
Follow-up visit within 60 days
% of valid episodes where the patient receives a follow-up visit during the post-trigger window 1 or post-trigger window 2
You 1.80
Metrics linked to gain sharing
Quality and utilization metrics comparison to threshold and other providers
Median 63%
Median 65%
You 60%
You 70%
Median 29%
Median 40%
You 30%
Threshold 50%
Threshold 50%
Threshold 45%
Threshold 50%
You 30%
Reporting period covering episodes that ended between January 1, 2016 to June 30, 2016
PERINATAL Q1 + Q2 2015
EPISODE of CARE PROVIDER REPORT
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports are neither intended nor suitable for other uses, including the selection of a health care provider. The figures in these reports are preliminary and are subject to revision. For more information, please visit http://medicaid.ohio.gov/Providers/PaymentInnovation.aspx.
PAYER: Ohio - Medicaid FFS PROVIDER: ABC Womens Health CenterPROVIDER ID: 0000000000
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Episode spend breakdown by claim type (non risk adj.)
# of episodeswith spend in claim type % of episodes with spend in claim typeClaim type
Avg. spend per episode when claim type utilized
Episodes included: 28
Average $3,427
$2,262
Average 100%
100%Inpatient 28
$0
Average 0% Average $0
0%Long term care 0
Average $1,119
$650
Average 80%
82%Outpatient 23
Average $104
$100
Average 56%
71%Pharmacy 20
Average $1,536Average 100%
Professional 28 100% $1,775
Reporting period covering episodes that ended between January 1, 2016 to June 30, 2016
PERINATAL Q1 + Q2 2015
PAYER: Ohio - Medicaid FFS PROVIDER: ABC Womens Health CenterPROVIDER ID: 0000000000
EPISODE of CARE PROVIDER REPORT
DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports are neither intended nor suitable for other uses, including the selection of a health care provider. The figures in these reports are preliminary and are subject to revision. For more information, please visit http://medicaid.ohio.gov/Providers/PaymentInnovation.aspx.
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<episode algorithm version #>
State of Tennessee Health Care Innovation
Initiative
Illustrative Provider Report
Payer Name (TennCare/Commercial)Provider NameProvider Code
Preliminary draft of the provider report template for State of TN (for discussion only)All content/ numbers included in this report are purely illustrative
[Report Date][Report Period: Start/end dates of period]
$2,000
$4,000
$6,000
$8,000
$10,000
9. Total gain / risk share$81,783 Net proceeds to you above claims already paid
Not acceptable cost zone
[1. Perinatal] Overall Performance Summary
Episode of careQualitymetrics
ShareValue ($)
Gain/risk share eligibility
Perinatal[Start/end dates of period]
$81,7831.
Payer Name (TennCare/Commercial) | Provider Name | Provider Code
Period<current>
Period <current – 1>
Period <current – 2>
Period<current – 3>
Met 4,298 Gain SharingCommendable
Avg
. ris
k ad
j.
ep
iso
de
co
st (
$)
1
Average risk adj. episode cost ($)
5,334
6,5146,611
4,2985,000
7,443
Your cost performance over prior reporting periods
Commendable cost zone
Acceptable cost zone
Your cost performance
Preliminary draft of the provider report template for State of TN (for discussion only) | All content/ numbers included in this report are purely illustrative
Description of gain / risk sharing You Description
5. Avg. episode cost (risk adj.) $4,298Commendable
Adjusted cost per episode; Equals line (3) divided by line (4)
2. Total # of included episodes 233 Net of episodes excluded for clinical or operational considerations
3. Avg. episode cost (non adj.) $5,244 Raw claims average ; Equals line (1) divided by line (2)
4. Risk adjustment factor* (avg.) 1.22 Average adjustment to raw claims to account for clinical variability
1. Total cost across episodes $1,221,749 Total of all associated claims submitted and paid during this cycle
6. Versus: commendable cost $5,000 Commendable threshold
7. Total upside generated** $163,566
Total difference in adjusted cost vs. commendable cost; Equals difference between line (5) and line (6), then multiplied by total included episodes i.e. line (2)
8. Risk sharing factor 50% Portion of total upside to be shared with you
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
*Risk adjustment factor calculated for select provider's patient base and rounded to the nearest hundredth** If the average episode cost (risk-adjusted) is below the gain sharing limit, then the gain sharing limit is substituted for the amount from line (5).
5. Avg. episode cost (risk adj.)
You are eligible for gain sharing
Episode cost summary
Overview
Cost of care (avg. adj. episode cost) comparison
1
2
3
[1. Perinatal] A. Episode Summary
182122
4337
64
28
$5500-$5999
$5000-$5499
$4500-$4999
$4000-$4499
Below$4000
80
60
40
20
Above $6500
$6000-$6499
Distribution of provider average episode cost (risk adj.)
Your episode cost distribution (risk adj.)
Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Your average episode cost is commendable
YOUR GAIN/ RISK SHARE
# o
f e
pis
od
es
Avg
. ad
j. e
pis
od
e
cost
($
‘00
0)
Commendable Not acceptableAcceptable
> $4000
Tennessee providers
10
8
6
4
Not acceptableAcceptableCommendableYou
Less than $5,000 More than $7,443$5,000 to $7,443
Parameters YouProvider
base average
Episode quality and utilization summary4
You achieved selected quality metrics
1. HIV screening
2. Group B Strep screening
3. C-section rate
Quality metrics linked to gain sharing
YouGain share
standard
97%
90%
20%
+ $81,783Number of episodes
Sharefactor
Your avg. cost: $4,298 Providers’ base avg. cost: $5,444233 50%
Commendable cost ($)
Your avg. cost ($)
5,000 4,298
– x x
$4,298Commendable
$5,444Acceptable
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
2
1. Gestational DM screening
2. Bacteriuria screening
3. Hepatitis B screening
YouProvider
base averageQuality metrics not linked to gain sharing
56% 50%
90% 62%
58% 55%
1. Total cost across episodes
2. Total # of included episodes
3. Avg. episode cost (non adj.)
233 235
$5,244 $6,152
4. Risk adjustment factor* (avg.) 1.22 1.13
$1,221,749 $1,445,654
* Risk adjustment factor calculated for select provider’s patient base
Metstandard
Preliminary draft of the provider report template for State of TN (for discussion only) | All content/ numbers included in this report are purely illustrative
4. Tdap vaccination rate 90% 62%
85%
85%
41%
Top 5 Prescribed Drugs, by spend
1. Prenatal Plus Tablet
2. Ibuprofen Tablet
3. Hydrocodone-Acetaminophen Tablet
4. Ferrous Sulfate Tablet
5. Zofran Tablet
$2,485
$1,259
$1,099
$1,039
$997
[1. Perinatal] B. Episode quality and utilization details
5025
Percentile (Quartile) of Providers
Quality metrics linked to gain sharing
HIV screening rate
0 10075
Your performance Minimum standard for gain sharing
Quality and utilization (metrics) comparison with provider base5
3
Percent of patients for whom HIV screening was conducted
Provider-base screening rate
Group B strep screening rate
C-section rate
Percent of patients for whom Group B strep screening was conducted
Percent of patients for whom C-Section was conducted
50% 99%
Quality metrics not linked to gain sharing
Asymptomatic bacteriuriascreening rate
Hepatitis Bscreening rate
Percent of patients for whom Asymptomatic bacteriuria screening was conducted
Percent of patients for whom Hepatitis B screening was conducted
Gestational diabetesscreening rate
Percent of patients for whom Gestational diabetes screening was conducted
62%43% 73%
55%41% 69%
50%42% 65%
You achieved selected quality metrics linked to gain sharing
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
(first) (second) (third) (fourth)
5025
Percentile (Quartile) of Providers
0 10075(first) (second) (third) (fourth)
66%
97%
56%
–
–
+
+
+90%–
58%– +
Preliminary draft of the provider report template for State of TN (for discussion only) | All content/ numbers included in this report are purely illustrative
Tdap vaccination rate
Percent of patients for whom Tdapvaccination was given
83%60% 93%
33%41% 21%
90%
–
–
–
+
+
+
+
+20%
–
–
85%
90%
85%
41%
55%41% 85%
– +90%
Your performance Provider base average
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
Pharmacy
Emergency department or observation
Preliminary draft of the provider report template for State of TN (for discussion only) | All content/ numbers included in this report are purely illustrative
[1. Perinatal] C. Episode cost details
4
Outpatient lab
Outpatientradiology/ procedures
Inpatient professional
Inpatient facility
Outpatientfacility
Other
Total episodes included: 233
Outpatient Professional
5025
Percentile (Quartile) of Providers
0 10075(first) (second) (third) (fourth)
% of episodes with claims in care category
Avg. adj. cost per episode when care category utilized# of episodes with claims in care category
195
11
90
220
215
220
233
0
210
< $125< $100 < $150
$120
$120
84%
82%
< $45< $25 < $65
5%
< $230< $200 < $260
$235
$230
39%
30%
< $195< $145 < $245
$190
$200
96%
84%
< $325< $275 < $375
$320
$330
94%
88%
< $1,000< $950 < $1,200
$960
$1,000
96%
91%
< $1,300< $1,200 < $1,650
$1,255
$1,315
100%
99%
$0$0 $0
0%
0%
< $190< $165 < $210
$170
$180
90%
88%
5%
0%
0%
$50
$50
Care category
Episode cost breakdown by care category (risk adj.)6
The Excel document contains detailed information for each patient
included in your episode results, such as:
- Provider
- Episode ID
- Patient Identifier
- Episode risk factor
- Cost information
- Quality metrics
5
Payer Name (TennCare/ Commercial) Provider Name Provider Code Report Date: July 2013
[1. Perinatal] D. List of included episodes with cost and quality information
LINK TO LIST OF INCLUDED EPISODES
[1. Perinatal] E. List of excluded episodes
The Excel document contains detailed information for each
patient excluded from your episode results, such as:
- Episode ID
- Provider
- Patient Identifier
- Non-risk adjusted cost
- Reason for exclusion
LINK TO LIST OF EXCLUDED EPISODES
New York’s Delivery System Reform Incentive Payment (DSRIP) Program
New York’s DSRIP Public Facing Dashboards Webpage: https://dsripdashboards.health.ny.gov/ Tutorial: https://dsripdashboards.health.ny.gov/hopscotch.html
Guide for Interpreting Arkansas’ Episode of Care Report
Visit us online to login to the portal and access resources
Our website www.paymentinitiative.org has details on:
� Initiative background and leadership.
� Episode details, methodology, and links to resources.
� Where to direct your questions and how to share feedback.
� Upcoming events/additional resources, such as Town Halls and WebEx informational sessions.
The website also has a link to the online portal. Use a secure username and password to:
� View your full report.
� Submit additional data as required for your episodes.
The Arkansas Health Care Payment Improvement Initiative is a multi-payer collaboration between Arkansas Medicaid, Arkansas Blue Cross Blue Shield, and QualChoice of Arkansas. The initiative rewards providers for high-quality care to drive system-wide quality and efficien-cy. Periodically, each payer will provide a performance report with details on quality, cost, and utilization for episodes where you are designated as Principal Accountable Provider (PAP).
This brief guide explains how to read your report using an illustrative example and may help you
� Understand the cost and quality of care given to patients where you are the PAP. � Identify where there is potential for practice changes, care coordination, and documenting
best practices.
The guide assumes knowledge of the design of payment episodes. To find out more, please go to: www.paymentinitiative.org.
Look inside to learn more about:
Arkansas Health Care Payment Improvement InitiativeProvider Report
MedicaidReport date: July 2012
Historical performance: January 1, 2011 – December 31, 2011
Medicaid Little Rock Clinic 123456789 July 2012
Guide to Reading Your Report
Summary Quality detail Cost detailPerformance
summary Episode detail
Building a healthier future for all Arkansans
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Medicaid Little Rock Clinic 123456789 July 2012
$$
$$
$$
$$
Phar
mac
yC
ost
# cl
aim
s
Patie
nt
nam
eEp
isod
e ID
Mar
k S
mith
4578
61
Ali
Cru
ss65
722
Fran
kC
ole
4902
12
Mar
k S
mith
8219
20
Jude
Pau
l84
4563
Cra
ig
Han
sen
1244
45
Bill
W
ilson
1002
35
Mol
ly
Sm
ith83
2011
Jerr
y Fr
ank
3245
77
Tim
W
esto
n11
5320
Rah
ulP
awar
1124
47
Eile
en
Sim
ms
4500
21
Bill
W
ilson
7879
99
Will
Bra
dley
9002
91
Mat
t Ja
ckso
n66
6587
Non
-ad
just
ed
cost
Cos
t
Epis
ode
star
t da
teEp
isod
een
d da
te
Inpa
tient
fa
cilit
yC
ost
# cl
aim
s
Ente
red
clin
ical
in
put
$$
01/1
3/13
02/0
1/13
Y
$$
01/1
5/13
02/0
4/13
Y
$$
02/1
9/13
03/0
9/13
Y
$$
04/1
3/13
05/0
2/13
Y
$$
04/2
1/13
05/1
1/13
Y
$$
51/1
4/13
06/0
3/13
Y
$$
05/1
4/13
06/0
3/13
Y
$$
06/0
2/13
6/22
/13
N
$$
06/0
3/13
06/2
3/13
Y
$$
06/0
7/13
06/2
7/13
Y
$$
06/0
7/13
06/2
7/13
Y
$$
06/0
7/13
06/2
7/13
Y
$$
06/0
9/13
06/2
9/13
Y
$$
06/1
0/13
06/3
0/13
N
$$
06/1
0/13
06/3
0/13
Y
Car
e ca
tego
ries
with
cos
ts
Det
aile
d ep
isod
e co
st in
form
atio
n fo
r D
r. Jo
e Sm
ith
Inpa
tient
pr
ofes
sion
alC
ost
# cl
aim
s
Out
patie
nt
prof
essi
onal
Cos
t#
clai
ms
Out
patie
nt
surg
ery
Cos
t#
clai
ms
Out
patie
nt
radi
olog
y /
proc
edur
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ost
# cl
aim
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Out
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ost
# cl
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Emer
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y de
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ost
# cl
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Oth
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ost
# cl
aim
s
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
#$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ # #$ #
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 – Perinatal
Carecategory
All providersYou
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 July 2012
Total episodes included = 233
Inpatientprofessional
Inpatientfacility
Outpatientprofessional
Pharmacy
Outpatientlab
Outpatientradiology / procedures
Emergencydepartment
Outpatientsurgery
Other
233
230
221
184
21
16
12
1
7
# and % of episodes with claims in care category
Total cost in care category, $
Average cost per episode when care category utilized, $
Quality and utilization detail – Perinatal
5025Percentile
Metric
HIV screening rate
Group B strep screening rate
Chlamydia screening rate
You met the minimum quality requirements
Metric
C-section rate
% episodes with an ultrasound
5025
Percentile
Gestational diabetes screening rate
Asymptomatic bacteriuria screening rate
Hepatitis B screening rate
You
97%
87%
90%
56%
90%
58%
25th
50%
60%
63%
42%
43%
41%
50th
66%
83%
84%
50%
62%
55%
75th
99%
93%
87%
65%
73%
69%
Percentile
Percentile
Avg number of ED visits per episode
25th
23%
71%
1.7
50th
30%
75%
2.1
You
17%
78%
1.3
75th
40%
81%
5.1
Medicaid Little Rock Clinic 123456789 July 2012
0
0
100
100
75
75
Metric with a minimum quality requirementYou Minimum quality requirement
Quality metrics: Performance compared to provider distribution
Utilization metrics: Performance compared to provider distribution
-
-
-
-
--
Upper Respiratory Infection – PharyngitisQuality of service requirements: Not met
Upper Respiratory Infection – Sinusitis
Average episode cost: Commendable
Quality of service requirements: N/A
You are not eligible for gain sharing
Your gain/risk shareYou will receive gain sharing
Your gain/risk share
Upper Respiratory Infection – Non-specific URI
Average episode cost: Not acceptable
Quality of service requirements: N/A
You are subject to risk sharing
Your gain/risk share
Perinatal
Average episode cost: Acceptable
Quality of service requirements: Met
You will not receivegain or risk sharing
Your gain/risk share
Average episode cost: Acceptable
Attention Deficit/ Hyperactivity Disorder (ADHD)
Average episode cost: Acceptable
Quality of service requirements: N/A
You will not receive gain or risk sharing
Your gain/risk share
$0
$x $0
$0
$x
Medicaid Little Rock Clinic 123456789 July 2012
Performance summary (Informational)
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Summary and Results: Example, Perinatal
Summary
1
2
3 4
1Overview
The overview indicates the total number of episodes you treated, and how many were included and excluded in your results.
� These are episodes completed during the period for which you are considered the PAP.
� Throughout the report, unless otherwise indicated, all results are based on the “total episodes included” number.
� An episode could be excluded for a number of reasons (e.g., extreme cost outlier or high risk patient).
Total episodes:262
Total episodes included:233
Total episodes excluded:29
2Average cost of care compared to other providers
The bar above shows the cost ranges for commendable, acceptable, and not acceptable costs.
� If your costs are considered not acceptable, you are subject to risk sharing.
� If you are in the acceptable range there is no gain or risk sharing.
� If your costs are within the commendable range, you are eligible for gain sharing as long as you meet required quality metrics.
How ranges/thresholds are set.
� Each payer sets thresholds independently using claims data for PAPs in that episode .
� The diamond represents your average cost; the triangle represents the overall average.
5
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Quality summary
The quality of service section gives you a more detailed picture of the quality metrics that go into your quality outcomes, and how you are performing relative to other PAPs in this episode.
� The metrics on the left side are numerically linked to gain sharing. The metrics on the right are currently informational.
� If the bars are blue, it indicates that you exceeded the minimum quality requirement. If the bars are red it indicates you did not meet the requirement
� The metrics are widely accepted clinical guidelines and are evidence based best practices.
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
3
Upper Respiratory Infection – PharyngitisQuality of service requirements: Not met
Upper Respiratory Infection – Sinusitis
Average episode cost: Commendable
Quality of service requirements: N/A
You are not eligible for gain sharing
Your gain/risk shareYou will receive gain sharing
Your gain/risk share
Upper Respiratory Infection – Non-specific URI
Average episode cost: Not acceptable
Quality of service requirements: N/A
You are subject to risk sharing
Your gain/risk share
Perinatal
Average episode cost: Acceptable
Quality of service requirements: Met
You will not receivegain or risk sharing
Your gain/risk share
Average episode cost: Acceptable
Attention Deficit/ Hyperactivity Disorder (ADHD)
Average episode cost: Acceptable
Quality of service requirements: N/A
You will not receive gain or risk sharing
Your gain/risk share
$0
$x $0
$0
$x
Medicaid Little Rock Clinic 123456789 July 2012
Performance summary (Informational)
5Key utilization statistics
The utilization statistics show you how many times you have performed certain activities and procedures relative to other PAPs.
� This may help you see where improvements could be made. It may also encourage you to identify other providers to see how they may have achieved better rates.
4Cost summaryThis section shows a breakdown of your cost performance. There will be a summary page for each episode for which you are the PAP.
� The blue bars on the top left show total costs for all included episodes compared to total costs for all included episodes after risk adjustments have been made.
� The blue bars on the top right show your average individual episode costs compared to all PAPs.
� The middle section shows how much the episodes you treated cost, on a range of low to high, and how many episodes were completed at that cost.
– This information may be helpful to you in trying to understand the source of the high costs.
– It may also help you identify the practices that led to lower cost episodes.
Your performance summary page includes data for all epi-sodes for which you are considered the PAP. In this exam-ple, the PAP has results for five different episode types.The results show whether you will receive gain sharing, no change to payment, or are subject to risk sharing.
Performance summary
Gain sharing: (Green) If your quality of service is above the minimum standard, and costs are lower than the commendable threshold (indicated with check marks) you are eligible for gain sharing.
No impact on payment: (Gray) If your costs are between commendable and acceptable, there is no gain or risk sharing.
Risk sharing: (Red) If your costs are higher than the acceptable threshold (regardless of whether the quality standard is met), you are subject to risk sharing.
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Summary – Perinatal
Quality summary
71268825
41
20
>$4500$3906-$4500
$3735-$3906
$3565-$3735
$3394-$3565
$3000$3394
$3000
6040
347,889
You (non- adjusted)
473,934
You(adjusted)
All providers
3,600
You
3,196
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Chlamydia screening rate 90%
Group B strepscreening rate 87%
HIV screening rate 97%
Quality metrics – linked to gain sharing
Minimum quality requirement
All providers
11%17% 21
Key utilization metricsC-section rate Avg number of ED visits per episode
OverviewTotal episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You met the minimum quality requirements Your average cost is commendable
Allproviders
You
Gain/Risk share
You are not eligible for gain sharing Quality requirements: Met Average episode cost: Acceptable
# ep
isod
esC
ost,
$
You All providers
Commendable Not acceptableAcceptable
> $4000$0
Hepatitis Bscreening rate 58%
Asymptomatic bacter-iuria screening rage 90%
Gestational diabetesscreening rate 56%
Quality metrics – not linked to gain sharing
Medicaid Little Rock Clinic 123456789 July 2012
84%
83%
66%
50%
62%
55%
Average cost of care compared to other providers
Not acceptableAcceptableCommendableYou
< $3000 > $4000$3000 to $4000
01000200030004000500060007000
Percentiles
Medicaid Little R
ock Clinic 123456789 July 2012
$ $ $ $ $ $ $ $
PharmacyCost# claims
Patient name
Episode ID
Mark Smith
457861
Ali Cruss
65722
FrankCole
490212
Mark Smith
821920
JudePaul
844563
Craig Hansen
124445
Bill Wilson
100235
Molly Smith
832011
Jerry Frank
324577
Tim Weston
115320
RahulPawar
112447
Eileen Simms
450021
Bill Wilson
787999
Will Bradley
900291
Matt Jackson
666587
Non-adjusted cost Cost
Episodestart date
Episodeend date
Inpatient facilityCost# claims
Entered clinical input
$ $01/13/13 02/01/13Y
$ $01/15/13 02/04/13Y
$ $02/19/13 03/09/13Y
$ $04/13/13 05/02/13Y
$ $04/21/13 05/11/13Y
$ $51/14/13 06/03/13Y
$ $05/14/13 06/03/13Y
$ $06/02/13 6/22/13N
$ $06/03/13 06/23/13Y
$ $06/07/13 06/27/13Y
$ $06/07/13 06/27/13Y
$ $06/07/13 06/27/13Y
$ $06/09/13 06/29/13Y
$ $06/10/13 06/30/13N
$ $06/10/13 06/30/13Y
Care categories with costs
Detailed episode cost information for Dr. Joe Smith
Inpatient professionalCost# claims
Outpatient professionalCost# claims
Outpatient surgeryCost# claims
Outpatient radiology / proceduresCost# claims
Outpatient labsCost# claims
Emergency departmentCost# claims
OtherCost# claims
#
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$
#
#
$
#
#
$
#
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 – Perinatal
Carecategory
All providersYou
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 July 2012
Total episodes included = 233
Inpatientprofessional
Inpatientfacility
Outpatientprofessional
Pharmacy
Outpatientlab
Outpatientradiology / procedures
Emergencydepartment
Outpatientsurgery
Other
233
230
221
184
21
16
12
1
7
# and % of episodes with claims in care category
Total cost in care category, $
Average cost per episode when care category utilized, $
Quality and utilization detail – Perinatal
5025Percentile
Metric
HIV screening rate
Group B strep screening rate
Chlamydia screening rate
You met the minimum quality requirements
Metric
C-section rate
% episodes with an ultrasound
5025
Percentile
Gestational diabetes screening rate
Asymptomatic bacteriuria screening rate
Hepatitis B screening rate
You
97%
87%
90%
56%
90%
58%
25th
50%
60%
63%
42%
43%
41%
50th
66%
83%
84%
50%
62%
55%
75th
99%
93%
87%
65%
73%
69%
Percentile
Percentile
Avg number of ED visits per episode
25th
23%
71%
1.7
50th
30%
75%
2.1
You
17%
78%
1.3
75th
40%
81%
5.1
Medicaid Little Rock Clinic 123456789 July 2012
0
0
100
100
75
75
Metric with a minimum quality requirementYou Minimum quality requirement
Quality metrics: Performance compared to provider distribution
Utilization metrics: Performance compared to provider distribution
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-
-
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Guide to Quality, Cost, and Episode Detail pages
Cost detail
Quality detail
Episode detail
Contact our knowledgeable provider support teams with questions and feedback
This page details your performance compared to both other providers and to the threshold required for gain sharing. The spectrum of red-gray-green repre-sents a range of results from lowest to highest quality. The diamond indicates your performance and the black line shows the minimum requirement. This information can help you identify areas for improvement or areas to continue best practices if you achieved high quality results.
� The blue shading indicates metrics required to be eligible for gain sharing; unshaded metrics are informational and may help you evaluate your practice.
Utilization rates do not currently affect eligibility for gain sharing, but may be useful in showing:
� How you are performing compared with other providers. � Where your practice patterns could be changed.
This page provides a detailed look at your costs and average costs of all providers. Care categories list all categories of service that make up an episode.
� The number of episodes refers to how many episodes included costs in this category.
� Average cost per category is shown per PAP and overall. This may indicate that other providers were able to achieve better results, or that your performance was strong and may be valuable to sustain.
� Total category cost shows your cost summary compared to overall costs among all PAPs.
This page has detailed information for each patient included in your results. This may help you understand what occurred for an individual patient’s episode(s) of care.
� The episode ID is a reference number. � The name is the name of the patient from claims data.
� The Y/N column indicates whether appropriate data was entered via the portal. It is n/a if data entry is not required.
� The cost information to the right is a detailed look at how much each component cost for that patient.
� Arkansas Medicaid:1-866-322-4696 (in-state) or 1-501-301-8311 (local and out-of state) or [email protected]. � Arkansas Blue Cross Blue Shield: Provider Line 1-800-827- 4814, direct line to EBI 1-888-800-3283 or
[email protected]. � QualChoice of Arkansas: 1-501-228-7111 or [email protected].
You met the minimum quality requirements
Community Health Choice Provider Submitted Quality Data Spreadsheets
Field Group Item # Category Measure set Data Field Format Member 1 Member 2 Member 31 Member ID Alphanumeric2 Member Last Name Alphanumeric3 Delivery Only Indicator Alphanumeric4 Newborn Gestational Age Numeric5 Newborn Weight Numeric
6 Pre-natal care Term and Pre Term Did the patient receive gestational diabetes pre-screening testing 1=YES; 0=NO; N/A7 Pre-natal care Term and Pre Term Date of Gestational Diabetes Screening MM/DD/YYYY
8 Pre-natal care Term and Pre TermDid patient participate in documented shared decision making discussion(s) 1=YES; 0=NO; N/A
9 Pre-natal care Term and Pre Term Date of shared decision making in patient record/patient refusal MM/DD/YYYY10 Pre-natal care Pre Term only Antenatal steroids 1=YES; 0=NO; N/A11 Delivery care Term only Was the delivery an elective delivery 1=YES; 0=NO; N/A12 Delivery care Term only Was the delivery a c-section 1=YES; 0=NO; N/A13 Delivery care Term only Was patient nulliparous 1=YES; 0=NO;14 Delivery care Term and Pre Term Intrapartum antibiotic prophylaxis For GBS 1=YES; 0=NO; N/A15 Delivery care Term and Pre Term Was an episiotomy performed 1=YES; 0=NO; N/A16 Post-Partum Care Term and Pre Term Post-Partum follow up visit 1=YES; 0=NO; 17 Post-Partum Care Term and PreTerm Date of post-partum visit MM/DD/YYYY18 Post-Partum care Term and Pre Term Blood Pressure Monitoring 1=YES; 0=NO; N/A19 Post-Partum care Term and Pre Term Date of Blood Pressure screening MM/DD/YYYY20 Post-Partum care Term and Pre Term Post partum glucose test for patients at risk 1=YES; 0=NO; N/A21 Post-Partum care Term and Pre Term Date of post partum glucose test MM/DD/YYYY22 Post-Partum care Term and Pre Term Depression Screening 1=YES; 0=NO; N/A23 Post-Partum care Term and Pre Term Date of Depression Screening MM/DD/YYYY24 Baby care Term Only Exclusively breast fed during hospital stay 1=YES; 0=NO; N/A25 Baby care Term and Pre Term Babies recceiving Hep B vac prior to discharge 1=YES; 0=NO; N/A26 Baby care Term and Pre Term Date of Hep B vac MM/DD/YYYY27 Baby care Term and Pre Term Baby discharge date MM/DD/YYYY28 Baby care Pre Term only Blood Stream Infection Prior to discharge 1=YES; 0=NO; N/A29 Baby care Pre Term only Baby - late sepsis or meningitis 1=YES; 0=NO; N/A30 Baby care Pre Term only Retinopathy of prematurity - screened 1=YES; 0=NO; N/A
Qua
lity
Scor
ecar
d M
easu
res
Community Health ChoiceExample Maternity Scorecare
Full Term Scores
Measure (244 patients) Domain Numerator DenominatoRatio ThresholdScorecard Points Score Numerator Description Denominator Description Score Calculation
Prenatal gestational diabetes screening Prenatal 5
Patient had a resulted procedure/test between 16-28 weeks gestation
All patients that were not delivery only (as submitted by provider)
Points awarded according to ratio (ratio x points)
Pre-natal shared decision making Prenatal 5Patient had a completed birth plan prior to delivery
All patients that were not delivery only (as submitted by provider)
Points awarded according to ratio (ratio x points)
% Elective deliveries Delivery 0.10 15
Patients with elective induction between 1 day prior to admit and delivery date and/or elective csection (not marked as "medical" reason)
Patients with newborn age >= 37 and < 39 weeks
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 15 points and >10% = 0 points
Primary csection rate Delivery 0.18 13Nulliparous Patients with C-section delivery mode
Nulliparous Patients (those with first time pregnancies)
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 13 points and >18% = 0 points
Patients receiving antibiotic prophylaxis during delivery encounter Delivery 5
Administration of IV antibiotic during the delivery encounter prior to delivery
Vaginal delivery Patients with positive or no result from most recent GBS lab test within 7 weeks prior to delivery
Points awarded according to ratio (ratio x points)
Obstetric trauma with instrument Delivery 0.10 5
Vaginal deliveries with instrument with OB trauma indicated
Vaginal deliveries with instrument
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 5 points and >10% = 0 points
Obstetric trauma without instrument Delivery 0.10 7
Vaginal deliveries without instrument with OB trauma indicated
Vaginal deliveries without instrument
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 7 points and >10% = 0 points
Vaginal deliveries with episiotomy Delivery 5
Patients with episiotomy procedure coded on hospital record
Vaginal deliveries (excluding those with shoulder dystocia coded on record)
Points awarded according to inverse of ratio (1-ratio) x points
Was there a post-partum visit Post-Partum
Patients with a post-partum visit between 1 day after discharge and 8 weeks postpartum All delivery patients
Points awarded according to ratio (ratio x points)
Post-Partum BP Monitoring Post-Partum 10
Outpatient blood pressure was recorded for the patient between 1 day after discharge and 8 weeks postpartum
All delivery patients; Note this may change to a base of patients with a recorded post-partum visit for Year 2
Points awarded according to ratio (ratio x points)
Post-Partum Depression Screening Post-Partum 5
Patients with a recorded score for postpatum screen on an outpatient visit that was recorded between 1 day after discharge and 8 weeks postpartum
All delivery patients; Note this may change to a base of patients with a recorded post-partum visit for Year 2
Points awarded according to ratio (ratio x points)
Post-Partum fasting glucose testing Post-Partum 5
Patient had a resulted procedure recorded between 1 day after discharge and 8 weeks postpartum
Patients with a diagnosis of gestational diabetes documented between gestational age of 16 weeks and delivery date
Points awarded according to ratio (ratio x points)
Exclusively breastfed Newborn 10
Newborns that had no formula documented and that had breastmilk intake or time recorded
All newborns except with gestional age <37 weeks; stillborns; or multiple liveborn babies; or no flowsheets documented
Points awarded according to ratio (ratio x points)
Babies receiving Hep B Vaccine Newborn 10
Newborns with HEPB vaccine administered between birth date and disharge date
All newborns excluding stillborns
Points awarded according to ratio (ratio x points)
Total Score 100 0.0Total 244 0.0 0.748466258
82 0.251533742326
not collected/scored for Year 1; will add to year 2
Community Health ChoiceExample Maternity Scorecare
Preterm Scores
Measure (82 patients) Domain Numerator DenominatoRatio ThresholdScorecard Points Score Numerator Description Denominator Description Score Calculation
Prenatal gestational diabetes screening Prenatal 15
Patient had a resulted procedure/test between 16-28 weeks gestation
All patients that were not delivery only (as submitted by provider) and not <24 weeks gestional age
Points awarded according to ratio (ratio x points)
Pre-natal shared decision making Prenatal 5Patient had a completed birth plan pror to delivery
All patients that were not delivery only (as submitted by provider)
Points awarded according to ratio (ratio x points)
Antenatal steroids administered for at risk patients Prenatal
Patients with administration of steroids within 10 weeks prior to delivery date
Patients with newborn gestational age between >=24 weeks and <34 weeks
Points awarded according to ratio (ratio x points)
Patients receiving antibiotic prophylaxis during delivery encounter Delivery 20
Administration of IV antibiotic during the delivery encounter prior to delivery
Vaginal delivery Patients with positive or no result from most recent GBS lab test within 7 weeks prior to delivery
Points awarded according to ratio (ratio x points)
Obstetric trauma with instrument Delivery 0.10 10
Vaginal deliveries with instrument with OB trauma indicated
Vaginal deliveries with instrument
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 5 points and >10% = 0 points
Obstetric trauma without instrument Delivery 0.10 5
Vaginal deliveries without instrument with OB trauma indicated
Vaginal deliveries without instrument
Points awarded according to inverse of ratio (1-ratio) x points, on a scale within the threshold of 0% = 7 points and >10% = 0 points
Vaginal deliveries with episiotomy Delivery 5
Patients with episiotomy procedure coded on hospital record
Vaginal deliveries (excluding those with shoulder dystocia coded on record)
Points awarded according to inverse of ratio (1-ratio) x points
Was there a post-partum visit Post-Partum
Patients with a post-partum visit between 1 day after discharge and 8 weeks postpartum All delivery patients
Points awarded according to ratio (ratio x points)
Post-Partum BP Monitoring Post-Partum 10
Outpatient blood pressure was recorded for the patient between 1 day after discharge and 8 weeks postpartum
All delivery patients; Note this may change to a base of patients with a recorded post-partum visit for Year 2
Points awarded according to ratio (ratio x points)
Post-Partum Depression Screening Post-Partum 5
Patients with a recorded score for postpatum depression screen on an outpatient visit that was recorded between 1 day after discharge and 8 weeks postpartum
All delivery patients; Note this may change to a base of patients with a recorded post-partum visit for Year 2
Points awarded according to ratio (ratio x points)
Post-Partum fasting glucose testing Post-Partum 5
Patient had a resulted procedure recorded between 1 day after discharge and 8 weeks postpartum
Patients with a diagnosis of gestational diabetes documented between gestational age of 16 weeks and delivery date
Points awarded according to ratio (ratio x points)
Babies receiving Hep B Vaccine Newborn 5
Newborns with HEPB vaccine administered between birth date and disharge date
All newborns excluding stillborns
Points awarded according to ratio (ratio x points)
Blood stream infection prior to discharge Newborn 5
Newborns with a secondary diagnosis of sepsis or bacteremia
All live newborns with birth weight >=500 and <1500g; LOS >7 days; gestional age >=24 weeks or <=30 weeks; Exclude newborns with primary diagnosis of sepsis or bacteriemia
Points awarded according to inverse of ratio (1-ratio) x points
Newborn sepsis or meningitis Newborn 5Newborns with diagnosis of sepsis, regardless of age
All live newborns with birth weight <=1500g or GA <=29 weeks and LOS > 3 days
Points awarded according to inverse of ratio (1-ratio) x points
Newborns screened for retinopathy of pre Newborn 1.0 5Consult for pediatric ophthalmology ordered
All live newborns with LOS >3 days and gestional age <=29 weeks
Receive all points for ratio of 1 and 0 points for ratio less than 1
Total Score 100 0.0
not collected/scored separately in Year 1--will be added for year 2
not collected/scored for Year 1; will add to year 2