Coming in 2011 - The New BlueCompare Physician Designation Program
Continued escalation of health care costs has driven pr...
Measured Specialties and Eligibility
The new BlueCompare Physician Designation Program will apply to the Working Specialti...
of members who were provided services satisfying the EBM criteria (numerator). A minimum
of thirty denominator events must...
BlueCompare Physician Cost Assessment (PCA)
Consistent with national guidelines (NCQA PHQ), BCBSTX will first assess a phy...
Episodes of Care
An Episode of Care will be built by linking sets of health care services provided to a patient
over time ...
   are attributed to members with fewer than nine member months for the time period of the
    episode
   belong to a ME...
In the example below, the PCA is 1.16 with a confidence interval from .92 to 1.41. Because
  the lower bound of the confid...
BlueCompare Designations
Results of the BlueCompare Physician Designation Program will be displayed by using the
online Pr...
The Review Process

Affected physicians who are dissatisfied with their BlueCompare results have the right to
request a re...
Appendix A - National Guidelines

   1. NCQA Standards and Guidelines for the Certification of Physician and Hospital Qual...
Appendix B - Evidence Based Measures

    The following Evidence Based Measures will be used in the BlueCompare quality re...
Evidence                                                                                                Strength of      S...
Evidence                                                                                                    Strength of   ...
Evidence                                                                                                       Strength of...
Evidence                                                                                                  Strength of     ...
Appendix C – Details on Calculating EBM Scores

For each relevant EBM indicator category, a physician p-score is calculate...
Definitions

Actual Allowed Cost: This is the allowed cost (physician payment and patient liability) for all
services prov...
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Detailed explanation of the 2011 BlueCompare Physician ....doc

  1. 1. Coming in 2011 - The New BlueCompare Physician Designation Program Continued escalation of health care costs has driven premiums and medical expenses to higher and higher levels each year. This, in turn, has motivated employers and consumers to search for information about the value (quality and cost) they receive for their health care dollars. These stakeholders are asking Blue Cross and Blue Shield of Texas (BCBSTX) to support their purchasing decisions by identifying the providers who offer the best value (quality and cost). BCBSTX must pay attention to the needs of its employers and members. BCBSTX understands the complexities of measuring provider quality and cost performance, both historical and current. Fortunately, we now have available both state and national published guidelines and requirements for provider transparency methodologies and programs. We have taken care to incorporate these guidelines and requirements into a redesigned BlueCompare Physician Designation program as we strive to meet the demand for information on provider performance. See Appendix A for more information on national guidelines. Our redesigned BlueCompare Physician Designation program will measure physicians on both quality related performance and cost efficiency: • The quality related assessment will utilize Evidence Based Measures (EBMs) from nationally recognized entities such as the National Quality Forum (NQF), the Ambulatory Care Quality Alliance (AQA), and the National Committee for Quality Assurance (NCQA). • We have implemented a Bridges to Excellence® program to recognize and reward health care providers who demonstrate implementation of sound management of complex patients and deliver safe, timely, effective and efficient patient-centered care. Therefore, physicians in the BlueCompare measured Working Specialties that are currently recognized by the Bridges to Excellence® organization in their Diabetes Care Link or Cardiac Care Link programs will be recognized and display a BlueCompare Blue Ribbon. • The cost efficiency assessment will be based on an ‘Episodes of Care’ methodology. • Both the quality related and cost efficiency performance measurement will utilize two years of BCBSTX PPO incurred claims data. • The BlueCompare program will adhere to nationally recognized transparency methodology and program standards and guidelines (NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality) and will comply with Texas Insurance Code Chapter 1460. This document contains detailed descriptions of the BCBSTX methodologies for assessment of both quality related performance on EBMs and cost efficiency. Page 1 of 17 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
  2. 2. Measured Specialties and Eligibility The new BlueCompare Physician Designation Program will apply to the Working Specialties for which both quality related performance and cost efficiency can be measured. Physicians must practice in one of the measurable Working Specialties and be a contracted physician in good standing with the BCBSTX BlueChoice® provider network to be eligible for participation in the BlueCompare Physician Designation Program. There are a select number of available EBMs for quality related measurement that meet nationally recognized standards (e.g. NQF, AQA and NCQA), and methodology adherence for quality measurement. BCBSTX will only measure cost efficiency on those Working Specialties where it can also measure quality related performance. Thus, BCBSTX will apply quality related measurement, and in turn the cost efficiency assessment, to the following fourteen Working Specialties: Allergy-Immunology Nephrology Cardiovascular Disease-Non-Interventional Neurology Cardiovascular Disease-Interventional Obstetrics-Gynecology Endocrinology Pediatric Allergy-Immunology Family Practice Pediatric Pulmonary Disease Geriatric Medicine Pediatrics Internal Medicine Pulmonary Disease BlueCompare EBM Assessment BCBSTX will use claims and enrollment data to assess a physician’s adherence to nationally recognized EBMs when treating his/her qualifying patients. These measures cover significant areas of preventive care such as diabetes, cardiovascular disease, and other health care services. A complete list of the EBMs used in the evaluation, along with the clinical intent and sponsoring organizations, is contained in Appendix B of this document. Physicians will be evaluated using only the EBMs that are considered relevant to their Working Specialty and relative to their specialty peers in Texas. All physicians within a common Practice Evaluation ID (typically the Tax Identification Number) and Working Specialty will be evaluated together, regardless of the level of individual physician contribution, and will be given the same BlueCompare EBM designation. For example, a group of physicians practicing under a common Tax Identification Number that is comprised of Internal Medicine, Family Practice, and Obstetrics-Gynecology specialties would receive three distinct evaluations and BlueCompare designations. A physician who practices under multiple Tax Identification Numbers can achieve different EBM evaluation results for each group and Working Specialty in which the physician is evaluated. EBM performance will be attributed to physicians based upon their involvement in treating the BCBSTX PPO members who qualify for the measures, according to HEDIS standards. The number of members who qualify for the EBMs (denominator) will be compared to the number Page 2 of 17
  3. 3. of members who were provided services satisfying the EBM criteria (numerator). A minimum of thirty denominator events must be attributed to the physician or specialty group to qualify for an evaluation. Although two calendar years of PPO claims data will be commonly used, some EBMs will use five years of claims data. The methods for determining the specific denominators and numerators differ by measure. These details are available at www.bcbstx.com/provider/ebi_2010.htm EBM Performance Scoring Details A physician group's performance score is derived from the following factors: •A count of qualifying events, which defines a denominator. An example is the continuously enrolled diabetic patients for whom a specified test or other service is expected. •A count of the clinical responses to the qualifying events, which defines the numerator. An example is the number of diabetic patients in the denominator who receive the expected test or service. •The weighting associated with the applicable indicator. This is determined by the statistical reliability of a measure, as determined by its variance. The composite performance score for a physician group is derived by applying and aggregating the above factors. This score is used to assess the group’s performance relative to its peers. The composite score will be considered valid only if a physician group has a minimum of thirty denominator events across all indicators. Performance will be aggregated across all relevant EBMs. Each EBM will be weighted by the inverse of the variance of the measure, resulting in a weighted average that reflects both the total number of denominator events and the variability of performance by peers. This methodology decreases the impact of differences in the number of denominators that occur from practice to practice, and summarizes performance on individual measures into a single EBM score. The practice EBM scores are distributed for a specialty wide comparison of performance. A system based on statistical methods is used to identify a performance threshold within this distribution. Practices with scores that are at or above the performance threshold will be recognized. Practices with a score more than two standard deviations from the mean, compared to the peer average, are considered outliers. An external statistician, with extensive experience in biostatistics, reviewed and validated the EBM scoring methodology for appropriateness. A more detailed explanation of the scoring methodology can be found in Appendix C of this document. Where there are no measures present for a specialty, insufficient data is available, or threshold performance on the EBMs is not met, an appropriate designation will be assigned to the physician. For more information on designations, see BlueCompare Designation section contained later in this document. This EBM measurement is the quality related component of the BlueCompare Physician Designation Program. It must be satisfied for a physician to be eligible for the cost efficiency evaluation. Page 3 of 17
  4. 4. BlueCompare Physician Cost Assessment (PCA) Consistent with national guidelines (NCQA PHQ), BCBSTX will first assess a physician for performance on quality related measures. Pending that outcome, BCBSTX will review the physician for cost efficiency. A cost-efficiency assessment will only be performed if the specialty-specific quality related criteria are met. BCBSTX engaged physicians currently in clinical practice to assist us in building this new PCA methodology as described below. To assess a physician’s cost efficiency, BCBSTX will analyze claims based on the Episodes of Care that are attributable to the physician. Thompson Reuters MEG (Medical Episode Grouper) software will be utilized for the Episode of Care analysis. PCAs will be performed using two incurred years of outlier trimmed claims data. Similar to the BlueCompare quality related assessment, the PCA will be performed at the Practice Evaluation ID/Working Specialty level. PCA Peer Comparisons will also take into account the disparate costs in the geographic area in which the physician practices. BCBSTX has twenty- two different Peer Comparison areas for which physician cost efficiency can be assessed as depicted below. Page 4 of 17
  5. 5. Episodes of Care An Episode of Care will be built by linking sets of health care services provided to a patient over time to treat a specific disease or health status, and can be composed of one or more encounters or visits, procedures or inpatient admissions. The episode continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status. Episode Grouping Logic example: The example above demonstrates how a complete episode ranges in time between the lab test and the final office visit. A lab or X-ray cannot initiate an episode; however, the look-back period can incorporate such services. Physician Episode of Care Attribution Only one physician per episode will be considered to be the “responsible physician.” The responsible physician is assigned as follows:  Physician who performs procedures with the highest total RVUs billed; if none, then  Physician with the greatest number of E&M services billed; if none, then  Physician with the highest allowed dollars. This logic helps to ensure that primary care physicians are not inappropriately attributed high cost cases for which they are not primarily responsible. The responsible physician will be determined without regard to the physician’s contract status with BCBSTX. Episodes attributed to non-contracted physicians will be removed from the analysis during the data trimming process. Episode of Care Data Trims A trim is an exclusion to the data set done prior to calculation of the PCA. BCBSTX will make several data trims to the base episode of care data to help ensure that the results are not influenced by patient Severity, case mix or burden of illness. BCBSTX will use only complete episodes of care that are risk and Severity adjusted. Listed below are the trims that will be made to the data before the PCA calculation is performed. Episodes will be removed if they:  are incomplete  are high or low cost outliers Page 5 of 17
  6. 6.  are attributed to members with fewer than nine member months for the time period of the episode  belong to a MEG/Sub stage with low volume  represent an episode where the responsible physician has less than 80% of the RVUs driving utilization  contain Emergency Room revenue codes or place of service  are for preventive care  are in MEG categories not typically provided by a particular Working Specialty After these data trims are done, the result is a set of qualified episodes. Only qualified episodes will be used in calculating the PCA. Physician Cost Assessment Calculation The PCA will be calculated based on the average cost of qualified episodes partitioned by:  episode group  Severity of illness for the episode  relative risk of the patient  time period of the episode  Working Specialty of the physician  geographic area of the physician The PCA will be calculated by comparing the Actual Allowed Cost of the physician’s Episodes of Care to an Expected Allowed Cost for the physician’s episodes of care in their Working Specialty. Determination of Physician Cost Efficiency Performance Level Consistent with national guidelines, BCBSTX will use a Confidence Interval methodology to determine if physicians meet cost efficiency performance thresholds for a Working Specialty within a geographic market. Specifically:  PCA results will be cited at the physician/practice, Working Specialty level in conjunction with a 90% Confidence Interval relative to 1.00.  If the lower bound of the Confidence Interval is higher than 1.00, then the physician/practice will be determined to have costs that are higher than their peers and will therefore not have met the cost efficiency designation performance threshold.  If a physician/practice’s Confidence Interval contains 1.00, then the physician/practice will not be determined to have costs that are either higher or lower than their peers. Therefore, costs are similar to their peers and the physician will have met the cost efficiency designation performance threshold. Page 6 of 17
  7. 7. In the example below, the PCA is 1.16 with a confidence interval from .92 to 1.41. Because the lower bound of the confidence interval is below 1.00, the physician in this example would meet the cost efficiency performance threshold. PCA = 1.16 Lower bound of 90% PCA Upper bound of 90% PCA confidence interval: 0.92 confidence interval: 1.41 PCA 90% Confidence Interval 5% 5% 0.5 1.0 1.5 Page 7 of 17
  8. 8. BlueCompare Designations Results of the BlueCompare Physician Designation Program will be displayed by using the online Provider Finder® tool at bcbstx.com. When members search for providers in the BlueChoice network, search results will include one of the following symbols/designations next to the physician’s name: Meets or exceeds expected quality related performance compared to other doctors. Meets or exceeds expected quality related and cost efficiency performance compared to other doctors. Performance measures are not available for this specialty. There is not enough data to measure performance or this doctor is new to the network. Re-evaluations are conducted periodically. Meets or exceeds expected quality related performance compared to other doctors, but there is not enough BCBSTX claims data to measure cost efficiency performance. This doctor requested to not participate in the BlueCompare program. Physicians that are in a measured Working Specialty but do not meet the required quality related and cost efficiency recognition threshold will not have a symbol in Provider Finder. The BlueCompare tool is provided for informational purposes only. Physician selection is a personal choice, and consumers are informed that they should not base decisions solely on information displayed in BlueCompare. BlueCompare designations are based on claims from BCBSTX PPO membership records and may not be indicative of the physician’s overall practice. Page 8 of 17
  9. 9. The Review Process Affected physicians who are dissatisfied with their BlueCompare results have the right to request a review in writing. In addition to the written fair review reconsideration process, BCBSTX also provides a fair reconsideration proceeding as described below: • When a physician requests a review, BCBSTX will provide a fair reconsideration proceeding. This proceeding will be conducted by teleconference or in person, at the physician’s option. • A physician requesting a review has the right to provide information, to have a representative participate, and to submit a written statement at the conclusion of the reconsideration proceeding. • BCBSTX will communicate the outcome of the reconsideration proceeding in writing, including the specific reason(s) for the final determination. Page 9 of 17
  10. 10. Appendix A - National Guidelines 1. NCQA Standards and Guidelines for the Certification of Physician and Hospital Quality: http://www.ncqa.org/tabid/740/Default.aspx 2. Ambulatory Care Quality Alliance http://www.aqaalliance.org/performancewg.htm 3. National Quality Forum http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.aspx 4. Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs: Ensuring Transparency, Fairness and Independent Review http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf Page 10 of 17
  11. 11. Appendix B - Evidence Based Measures The following Evidence Based Measures will be used in the BlueCompare quality related assessment. Evidence Strength of Specialty Based Measure Clinical Intent Guideline Sponsoring Organization(s) Evidence1 Attribution Cervical Cancer To ensure that U.S. Preventive Services United States Preventive Services A Family Practice, Screening all women ages Task Force (USPSTF), Task Force (USPSTF), American Internal 21-64 receive a Screening for Cervical Cancer Society, American Medicine, cervical cancer Cancer, 2003 Academy of Family Physicians Obstetrics- screening test http://www.ahrq.gov/clinic/us (AAFP), American College of Gynecology during the pstf/uspscerv.htm Obstetricians and Gynecologists measurement (ACOG), American College of year or the 2 Preventive Medicine, American years prior. Medical Assn. (AMA), Canadian Task Force on Preventive Health Care, American Academy of Pediatrics, NCQA (HEDIS 2009 Technical Specification), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Colorectal To ensure that ASGE Guideline: Colorectal NCQA (HEDIS 2009 Technical A Family Practice, Cancer members 50–80 Cancer Screening and Specification), United States Geriatric Screening years of age Surveillance. 2006 Preventive Services Task Force Medicine, received http://www.guideline.gov/su (USPSTF), American Cancer Internal appropriate mmary/summary.aspx? Society, American College of Medicine, screening for ss=15&doc_id=10162&nbr=5 Obstetricians and Gynecologists Obstetrics- colorectal 347#s24 (ACOG), American Academy of Gynecology cancer. Family Physicians (AAFP), American Gastroenterological Association, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Page 11 of 17
  12. 12. Evidence Strength of Specialty Based Measure Clinical Intent Guideline Sponsoring Organization(s) Evidence1 Attribution Diabetic Retinal To ensure that American Diabetes NCQA (HEDIS 2009 Technical B Endocrinology, Exam (Annual) all diabetic Association, Texas Specifications), American Family Practice, members ages Department of State Health Diabetes Association, American Geriatric 18-75 receive at Services-Minimum Practice Academy of Ophthalmology, Medicine, least 1 retinal or Recommendations for American College of Physicians, Internal dilated eye exam Diabetes. Revised 1/8/09 National Quality Forum (NQF) Medicine, during the http://www.dshs.state.tx.us/d endorsed measure, AMA Nephrology measurement iabetes/hcstand.shtm Physician Consortium for year. The National Quality Performance Improvement (PCPI) Measures Clearinghouse™ endorsed; AQA Alliance endorsed (NQMC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services http://www.qualitymeasures. ahrq.gov/summary/summary .aspx?doc_id=4078 Glycosylated To ensure that American Diabetes American Diabetes Association, B Endocrinology, Hemoglobin all diabetic Association, Texas American Association of Clinical Family Practice, (HbA1c) Test for members ages Department of State Health Endocrinologists, American Geriatric Diabetics 18-75 receive at Services-Minimum Practice College of Endocrinology, Medicine, (Annual) least 1 Recommendations for Centers for Disease Control and Internal glycosylated Diabetes. Revised 1/8/09 Prevention, Veterans Affairs Medicine, hemoglobin test http://www.dshs.state.tx.us/d Administration, NCQA (HEDIS Nephrology during the iabetes/hcstand.shtm 2009 Technical Specifications), measurement National Quality Forum (NQF) year. endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Appropriate To ensure that CDC - Get Smart: Know Centers for Disease Control and B Allergy- Treatment for children, ages 3 When Antibiotics Work Prevention, American College of Immunology, Children with months to 18 http://www.cdc.gov/getsmart/ Physicians, American Society of Family Practice, Upper years old as of specific-groups/healthcare- Internal Medicine, American Pediatrics, Respiratory the end of the providers.html Academy of Family Physicians, Pediatric Allergy Infection (URI) measurement American Academy of Pediatrics, and Immunology year, diagnosed Infectious Diseases Society of with nonspecific America, NCQA (HEDIS 2009 upper respiratory Technical Specifications), infections are National Quality Forum (NQF) not being endorsed measure, AMA inappropriately Physician Consortium for treated with Performance Improvement (PCPI) antibiotics. endorsed; AQA Alliance endorsed Page 12 of 17
  13. 13. Evidence Strength of Specialty Based Measure Clinical Intent Guideline Sponsoring Organization(s) Evidence1 Attribution LDL Monitoring To ensure that American Diabetes American Diabetes Association, B (for most adults Cardiovascular for Diabetes all members age Association, Texas NCEP-ATP-III Guidelines, NCQA with diabetes) Disease - Non- (Annual) 18-75 years old Department of State Health (HEDIS 2009 Technical C (for adults with Interventional, with diabetes Services-Minimum Practice Specifications), National Quality low-risk lipid Cardiovascular receive LDL Recommendations for Forum (NQF) endorsed measure, values [LDL < Disease - monitoring Diabetes. Revised 1/8/09 AMA Physician Consortium for 100mg/dl, HDL > Interventional, during the http://www.dshs.state.tx.us/d Performance Improvement (PCPI) 50mg/dl, and Endocrinology, measurement iabetes/hcstand.shtm endorsed; AQA Alliance endorsed triglycerides < Family Practice, year. 150mg/dl]) Geriatric Medicine, Internal Medicine, Nephrology Mammography To ensure that Screening Mammography for United States Preventive Services A (50 to 69) Family Practice, Screening all eligible Breast Cancer: American Task Force (USPSTF), Canadian B (40 to 49) Geriatric women age College of Preventive Task Force on Preventive Health Medicine, 40-69 receive a Medicine Practice Policy Care, American Academy of Internal mammography Statement, 1996. Family Physicians (AAFP), Medicine, screening test http://www.acpm.org/breast. American College of Preventive Obstetrics- during the htm Medicine, American Medical Gynecology measurement Assn. (AMA), American College year or year of Obstetricians and prior. Gynecologists (ACOG), American College of Radiology, American Cancer Society, NCQA (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Treatment of To ensure that AHA/ACC Guidelines for NCQA (HEDIS 2009 Technical A Cardiovascular Cardiovascular members with Secondary Prevention for Specifications), Third Report of Disease – Non Conditions: cardiovascular Patients With Coronary and the National Cholesterol -Interventional, Monitoring Lipid conditions Other Atherosclerotic Education Program (NCEP) Cardiovascular Levels (Annual) receive lipid Vascular Disease: 2006 Expert Panel on Detection, Disease - level monitoring Update http://guidelines.gov/ Evaluation and Treatment of High Interventional, at a clinically summary/summary.aspx? Blood Cholesterol in Adults (Adult Family Practice, appropriate doc_id=9373 Treatment Panel III, or ATP III), Geriatric frequency. American College of Cardiology, Medicine, American Heart Association, Internal Medicine National Cholesterol Education Program, National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Page 13 of 17
  14. 14. Evidence Strength of Specialty Based Measure Clinical Intent Guideline Sponsoring Organization(s) Evidence1 Attribution Appropriate Use To ensure that National Committee for Agency for Healthcare Research A Family Practice, of Imaging in all members Quality Assurance (NCQA). and Quality, Institute for Clinical Geriatric Low Back Pain diagnosed with HEDIS 2009 American Systems Improvement, American Medicine, Assessment lower back pain College of Radiology (ACR) Academy of Family Physicians, Internal did not receive a http://www.guideline.gov/su American College of Physicians, Medicine, clinically mmary/summary.aspx? American College of Radiology, Neurology inappropriate view_id=1&doc_id=13671 American Pain Society, NCQA imaging study. (HEDIS 2009 Technical Specifications), National Quality Forum (NQF) endorsed measure, AMA Physician Consortium for Performance Improvement (PCPI) endorsed; AQA Alliance endorsed Follow-up After To ensure that NCCN National American Society of Clinical B Family Practice, Initial Diagnosis all eligible Comprehensive Cancer Oncology, National Geriatric and Treatment members with Network, Clinical Practice Comprehensive Cancer Network Medicine, of Colorectal colorectal cancer Guidelines in Oncology - Internal Cancer: CEA who are status Colon Cancer, 2007 Medicine, post colon http://www.nccn.org/professi resection receive onals/physician_gls/PDF/col follow up CEA on.pdf test at least every 6 months to monitor for cancer reoccurrence. X-ray Prior to To ensure that American College of Agency for Healthcare Policy and B Family Practice, MRI/CAT Scan an x-ray is Physicians, American Pain Research, American Academy of Internal in the conducted prior Society Family Physicians, American Medicine, Evaluation of to an MRI for http://www.annals.org/cgi/rep Academy of Neurology, American Geriatric Lower Back eligible members rint/147/7/478.pdf College of Physicians, American Medicine, Pain diagnosed with Pain Society, Institute for Clinical Neurology lower back pain. Systems Improvement. Use of Long- To ensure that National Heart, Blood and The National Asthma Education A (inhaled Allergy – Term Control members with Lung Institute, National and Prevention Program, The corticosteroid or Immunology, Drugs for persistent Asthma Education and Joint Council of Allergy, Asthma inhaled Family Practice, Persistent asthma receive Prevention Program, Expert and Immunology, National Heart, corticosteroid Geriatric Asthma medication Panel Report 3 (EPR 3): Lung and Blood Institute, NCQA combos) Medicine, appropriate for Guidelines for the Diagnosis (HEDIS 2009 Technical B (other classes of Internal long term control and Management of Asthma, Specifications), National Quality medication [i.e., Medicine, of asthma. Section 3 & 4, 2007 Forum (NQF) endorsed measure, mast cell Pediatrics, http://www.nhlbi.nih.gov/guid AMA Physician Consortium for stabilizers, Pediatric Allergy elines/asthma/asthgdln.htm Performance Improvement (PCPI) leukotriene and endorsed; AQA Alliance endorsed modifiers, Immunology, methylxanthines]) Pediatric Pulmonary Disease, Pulmonary Disease Page 14 of 17
  15. 15. Evidence Strength of Specialty Based Measure Clinical Intent Guideline Sponsoring Organization(s) Evidence1 Attribution Chlamydia To ensure that U.S. Preventive Services American Academy of Family A (for women 24 Educational: Screening for sexually active Task Force (USPSTF), Physicians, Centers for Disease years and Family Practice, Women women 16-25 Screening for Chlamydia, Control and Prevention and U.S. younger) Internal years of age had 2007 Preventive Services Task Force C (for women 25 Medicine, at least one http://www.ahrq.gov/clinic/us (USPSTF), NCQA (HEDIS 2009 years) Obstetrics- screening test pstf/uspschlm.htm Technical Specification), National Gynecology for chlamydia Quality Forum (NQF) endorsed during the measure measurement year. Monitoring for To ensure American Diabetes American Diabetes Association, B Educational: Diabetic diabetic Association, Texas NCQA (HEDIS 2009 Technical Endocrinology, Nephropathy members ages Department of State Health Specifications), National Quality Family Practice, 18-75 receive a Services-Minimum Practice Forum (NQF) endorsed measure, Geriatric diabetic Recommendations for AMA Physician Consortium for Medicine, nephropathy Diabetes. Revised 1/8/09 Performance Improvement (PCPI) Internal Medicine screening test http://www.dshs.state.tx.us/d endorsed during the iabetes/hcstand.shtm measurement year. 1 Strength of Evidence Definitions: A. Recommendation based on consistent and good-quality patient-oriented evidence. B. Recommendation based on inconsistent or limited-quality patient-oriented evidence. C. Recommendation based on consensus, usual practice, disease-oriented evidence, case series for studies of treatment or screening, and/or opinion. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the Medical Literature http://www.aafp.org/afp/20040201/548.html Page 15 of 17
  16. 16. Appendix C – Details on Calculating EBM Scores For each relevant EBM indicator category, a physician p-score is calculated as the ratio of the number of occasions on which the indicated service was provided by the physician to the number of eligible patient encounters. The aggregate p-score for a physician is the weighted average over all relevant indicators of the physician’s p-scores. Before summing, each p-score is multiplied by the inverse of its approximate variance. This weighting factor explicitly takes into account the number of eligible patient encounters within each indicator for the physician so that p-scores based on a large number of encounters are more influential in determining the aggregate score than p-scores based on a smaller number of encounters. The statewide p-score for the indicator is the ratio of the total number of occasions in the state on which the indicated service was provided to the total number of eligible patient encounters, all within the indicator category. The same inverse-variance weighting factors are used, so the numbers of eligible patient encounters within each indicator category are again taken into account. The expected p-score for the physician is the weighted sum over all relevant indicators of the statewide p-scores. The physician EBM score is the ratio of the physician’s aggregate p-score to the corresponding statewide p-score, divided by the approximate standard deviation of the ratio. The EBM score may be positive or negative, indicating that the physician’s overall rate of performance of indicated services falls above or below statewide rate. To determine the practice group EBM score, each member physician’s EBM score is weighted by the inverse of its variance, and then aggregated across the relevant indicators. This results in a weighted average that reflects both the total number of patient encounters for each physician and the variability of the EBM score. EBM scores based on many patient encounters are weighted more heavily than those based on fewer encounters. This methodology takes into account differences in the numbers of patient encounters for both individual physicians and for practice groups. The specialty ratio for a practice group is the ratio of the number of occasions on which the indicated service was provided to the number of eligible patient encounters, aggregated over all physicians in the group. A physician group is evaluated using only those indicators which are considered relevant to the specialty. Thirty or more patient encounters across all indicators must be attributed to the physician group to be included in the assessment. A group's performance is assessed relative to other physicians in the same specialty within the BCBSTX network. Page 16 of 17
  17. 17. Definitions Actual Allowed Cost: This is the allowed cost (physician payment and patient liability) for all services provided by all physicians, ancillary providers and facilities related to the episodes of care attributed to the physician. Confidence Interval: The probability at a 90% level of confidence that a PCA lies within a specified range. Expected Allowed Cost: This is based on the average allowed cost of qualified episodes partitioned by MEG, severity, comorbidity group, and time period for a specialty in a geographic region. Episode of Care: An episode of care is composed of one or more encounters or visits, procedures or inpatient admissions. It is built by linking sets of health care services provided to a patient over time to treat a specific disease or health status. It continues as long as there is relatively continuous contact with the health care system for the same basic diagnosis, disease or health status. MEG (Medical Episode Group): The Thomson Reuters Medical Episode Group numeric code identifying a clinically homogenous episode of care. PCA: Total cost of all qualified episodes attributed to the Practice Evaluation ID (for a Working Specialty) divided by the total expected cost for those episodes. Peer Comparison: All comparisons are made to specialty peers in the same geographic area on episodes in the same Medical Episode Group (MEG) at the same level of severity, in the same Comorbidity Group and during the same time period. Practice Evaluation ID: The Tax Identification Number for group providers or other unique identifier for solo providers. Severity: Indicates the level of severity observed in episodes of a specific clinical condition (Medical Episode Group). Subdivisions (x.xx) indicate more precise classification. For some Medical Episode Groups, severity is further classified using age, gender and type of episode. 0 History of a significant predisposing factor for the disease, but no current pathology, e.g. history of carcinoma or neonate born to mother suspected of infection at time of delivery 1 Conditions with no complications or problems with minimal severity 2 Problems limited to a single organ or system; significantly increased risk of complications than Stage 1 3 Multiple site involvement; generalized systemic involvement; poor prognosis Working Specialty: A specialty designation derived by utilizing the physician’s primary, secondary and tertiary specialties on record, practice limitations, physician type, and in certain cases, primary place of service. Page 17 of 17

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