Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar

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Arkansas Payment Improvement Initiative (APII)

Tonsillectomy Episode

Statewide Webinar

August 12, 2013

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Contents

▪ Lee Clark, Medicaid Health Innovation Unit Episodes Manager - Overview of the Healthcare Payment Improvement Initiative

▪ Paula Miller – HP APII Analyst - Episode Reports

▪ Shelley Tounzen, Medicaid Health Innovation Unit Public Information Coordinator – Initiative Update

▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care

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Today, we face major health care challenges in Arkansas

▪ The health status of Arkansans is poor: the state is ranked at or near the bottom of all states on national health indicators, such as heart disease and diabetes

▪ The health care system is hard for patients to navigate, and it does not reward providers who work as a team to coordinate care for patients

▪ Health care spending is growing unsustainably:

– Insurance premiums doubled for employers and families in past 10 years (adding to uninsured population)

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Our vision to improve care for Arkansas is a comprehensive, patient-centered delivery system

Episode-based care▪ Acute, post-acute, or

select chronic conditions

How care is deliveredHow care is delivered

Population-based care▪ Medical homes ▪ Health homes

ObjectivesObjectives

▪ Improve the health of the population

▪ Enhance the patient experience of care

▪ Enable patients to take an active role in their care

Four aspects of broader program

Four aspects of broader program

▪ Results-based payment and reporting

▪ Health care workforce development

▪ Health information technology (HIT) adoption

▪ Consumer engagement and personal responsibility

For patientsFor patients

For providersFor providers

Focus today

▪ Reward providers for high quality, efficient care

▪ Reduce or control the cost of care

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Medicaid and private insurers believe paying for results, not just individual services, is the best option to improve quality and control costs

Transition to a payment system that rewards value and patient health outcomes by aligning financial incentivesTransition to a payment system that rewards value and patient health outcomes by aligning financial incentives

Eliminate coverage of expensive services or eligibilityEliminate coverage of expensive services or eligibility

Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)

Pass growing costs on to consumers through higher premiums, deductibles and co-pays (private payers), or higher taxes (Medicaid)

Intensify payer intervention in decisions though managed care or elimination of expensive services (e.g. through prior authorizations) based on restrictive guidelines

Intensify payer intervention in decisions though managed care or elimination of expensive services (e.g. through prior authorizations) based on restrictive guidelines

Reduce payment levels for all providers regardlessof their quality of care or efficiency in managing costsReduce payment levels for all providers regardlessof their quality of care or efficiency in managing costs

This initiative aims to…

This initiative DOES NOT aim to

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Principles of payment design for Arkansas

Patient-centeredPatient-centered

Focus on improving quality, patient experience and cost efficiency

Clinically appropriateClinically appropriate

Design based on evidence, with close input from Arkansas patients and providers

PracticalPractical Consider scope and complexity of implementation

Data-basedData-based Make design decisions based on facts and data

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Contents


▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports


▪ Dr. William Golden, Medicaid Medical Director –Tonsillectomy Episode of Care

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Contents


▪ Paula Miller – HP APII Analyst - Episode Descriptions & Reports


▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Providers, Patients & Quality

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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE

Tonsillectomy: key facts

▪ Surgical removal of the tonsils

▪ Commonly performed on children due to repeated infections of the tonsils

▪ Typically done as a same day surgery

Goals of episode

▪ Reduce multiple pre-op visits

▪ Drive appropriate post-surgery observation period

▪ Reduce inappropriate sleep study, antibiotic and pathology usage

▪ Reduce readmissions

▪ Create a model for ENTs to share practices and design even more effective care

What is a tonsillectomy?

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Patient journey for tonsillectomy/adenoidectomy

1 Conditions for inpatient observation include Down syndrome, congenital heart defects, coagulopathies, platelet storage deficiency, or coagulation defects2 Complications resulting in return to operating room include excessive bleeding, severe vomiting, or low oxygen saturation3 Major causes for post-procedure admission include dehydration and excessive bleeding

SOURCE: American Academy of Otorhinolaryngology, Expert interviews

post-procedure admission

Post-procedure – 30 daysPre-procedure – (up to 90 days)

Follow-up careFollow-up careSame-day recovery unitSame-day recovery unit

Operating room2

Operating room2

Inpatient Care and Recovery Unit

Inpatient Care and Recovery Unit

Inpatient care and recovery unit1

Inpatient care and recovery unit1 Follow-up careFollow-up care

Presents to ENT specialistPresents to ENT specialist

ProcedureProcedure

Tonsillectomy/adenoidec-tomy performed

Pre-procedural work-up in hospital/outpatient setting

Post-procedure admission3

Post-procedure admission3

This episode excludes cases that present through inpatient/emergency department setting

This episode excludes cases that present through inpatient/emergency department setting

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Episode summary: Number of adenoidectomy, tonsillectomy, and adeno-tonsillectomy in Arkansas

SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010Arkansas Blue Cross Blue Shield claims for patients with tonsillectomy/adenoidectomy between July 1, 2011 – June 30, 2012

BCBS

Total number of proceduresTotal number of procedures 1,311

TonsillectomyTonsillectomy 361

AdenoidectomyAdenoidectomy 176

Number of performing providersNumber of performing providers 74

Adeno-tonsillectomyAdeno-tonsillectomy 774

Medicaid

Total number of proceduresTotal number of procedures 3,498

Adenoidectomy Adenoidectomy 569

TonsillectomyTonsillectomy

2,660

Number of performing providersNumber of performing providers 61

Adeno-tonsillectomyAdeno-tonsillectomy

269

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Tonsillectomy/adenoidectomy episode design (1/2)▪ Episode is triggered by select types of tonsillectomy/adenoidectomy procedures, including:

– All outpatient tonsillectomy, adenoidectomy, and adeno-tonsillectomy procedures (i.e. ED and inpatient tonsillectomies/adenoidectomies are excluded)

– Primary or second diagnosis (Dx1 and Dx2) indicating conditions that require tonsillectomy/adenoidectomy (e.g. chronic tonsillitis, chronic adenoiditis, chronic pharyngitis, hypertrophy of tonsils and adenoids, obstructive sleep apnea, insomnia, peritonsillar abscess)

▪ Episode time frame:– Related services (including sleep studies, head and neck x-rays, laryngoscopy) within 90

days prior to procedure after and including initial consult with performing provider– Related services within 30 days after procedure (i.e., inpatient and outpatient facility

services, professional services, related medications, treatment for post-procedure complications)

– Post-procedure admissions within 30 days after procedure1

Episode definition/ scope

of services

Episode definition/ scope

of services

▪ Certain patients are excluded from this episode design, patients with:– Select co-morbid conditions (e.g., Down syndrome, cancer, severe asthma, cerebral

palsy, muscular dystrophy, myopathies) – Uvulopalatopharyngoplasty (UPPP) on date of procedure – Patients with BMI>502 – Age younger than 3 or older than 21– Dual enrollment in Medicare/Medicaid (i.e., dual eligibles)– Inconsistent enrollment (i.e., not continuously enrolled) during the episode– Death in hospital during episode– Patient status of “left against medical advice” during episode

Patient/ episode exclusionsPatient/ episode exclusions

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1 Excludes post procedure admissions that are not related to the episode as determined by Bundled Payment for Care Improvement (BPCI). Covers entire length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be included in episode)

2 Reported through provider portal

Parameters and codes may vary across different payers; the following algorithm and associated codes sheet applies to Medicaid

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Tonsillectomy/adenoidectomy episode design (2/2)

▪ Episode cost is adjusted based on:

– Risk factors (e.g. COPD, asthma)

– Episode types: (1) adenoidectomy (2) tonsillectomy/adeno-tonsillectomy

▪ Only providers with at least 5 episodes per year are eligible for gain sharing/risk sharing

Episode adjustmentsEpisode adjustments33

▪ Quality metrics required for gain sharing payment:– Percent of episodes with administration of intra-operative steroids1

▪ Metrics for reporting only:– Quality: Post-operative primary bleed rate (i.e., post-procedure

admissions or unplanned return to OR due to bleeding within 24 hours of surgery)

– Quality: Post-operative secondary bleed rate– Utilization: Rate of antibiotic prescription post-surgery2

Quality/ utilization metrics

Quality/ utilization metrics

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▪ For Medicaid, the Principal Accountable Provider (PAP) will be the primary provider performing the tonsillectomy/adenoidectomy. Other payers independently determine the PAP by considering the following factors:

– Decision making responsibilities

– Influence over other providers

– Portion of episode cost

Principal Accountable Provider

Principal Accountable Provider

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1 Reported through provider portal as an aggregate percentage across all of a PAP’s episode for a specific payor2 American Academy of Otolaryngology – Head and Neck Surgery Tonsillectomy Guidelines for 2011 recommend against prescription of antibiotics

post-procedure

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Design rationale: Episode definition / scope of services (1/4)

30 days post-procedure

90 days pre- procedure

Tonsillectomy/adenoidec-tomy procedure

The episode includes the following services

MedicationMedication

Preparatory visits (office/clinic, or specialist consultation)Preparatory visits (office/clinic, or specialist consultation)

Professional claimfor procedureProfessional claimfor procedure

Labs, imaging, and diagnostic testsLabs, imaging, and diagnostic tests

Inpatient or outpatient facility careInpatient or outpatient facility care

Episode ends

30-day post-procedure admission130-day post-procedure admission1 ▪ Inpatient admission within 30 day post-procedure window as defined by Bundled Payment for Care Improvement (BPCI)

▪ All claims within 90 days prior to procedure with a diagnosis related to adenoidectomy/tonsillectomy

– Claims must occur after initial consult with performing provider (initial consult is included)

▪ All claims on day of procedure or within 30 days post-procedure window with a diagnosis related to tonsillectomy/adenoidectomy

▪ Complications are included in the 30 day post-procedure window

▪ All antibiotics, anti-emetics, narcotics, and steroids prescribed in the 30 day post-procedure window

Episode definition:

▪ All related services up to 90 days prior to (after and including initial consult) and 30 days after tonsillectomy/ad-enoidectomy procedure, including inpatient and outpatient facility services, professional services, and related medications

▪ Complications that occur after the procedure

TriggerEpisode begins

1

1 Covers entire length of readmission if it occurs within 30 days after trigger (i.e. entire 3-day stay admitted on the 29th day post discharge would be included in episode)

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Design rationale: Episode definition / scope of services (2/4)

Episode design decisions Rationale

▪ Tonsillectomies/adenoidectomies which occur in the ER or inpatient often have high variability in patient conditions, outcomes, and episode costs (i.e., variability beyond the control of the PAP), and are therefore excluded

▪ A list of CPT and ICD-9 Px codes for tonsillectomy, adenoidectomy, and adeno-tonsillectomy are identified as triggers for an episode

▪ An appropriate ICD-9 diagnosis code (Dx fields 1 and 2) must also accompany a procedure code for the procedure to be considered a valid trigger for an episode

▪ Trigger identification:

– Only outpatient tonsillectomies/adenoidectomies can be potential triggers (i.e., tonsillectomies/adenoidectomies which occur in the ER or inpatient are automatically excluded as potential triggers)

– Episode is triggered by tonsillectomy/adenoidectomy procedure and appropriate primary or secondary diagnosis

▪ Pre-procedure window is a maximum of 90 days prior to the procedure to allow for capture of the first ENT consult with patient

▪ ER/Inpatient and medication costs are not captured in pre-procedure window since the tonsillectomy/adenoidectomy procedure is often scheduled based on patient convenience, therefore giving some PAPs a greater risk for higher ER/inpatient and medication cost that is beyond PAP’s control

▪ Pre-procedure window:

– Episode begins the day of the first PAP visit within a 90-day window prior to procedure

▫ Any ER/Inpatient cost in pre-procedure window will be excluded

▫ Any medications in pre-procedure window will be excluded

▪ Post procedure admissions due to complications, etc. are included in episode cost calculations since reducing complications and treating them effectively and efficiently is an identified value driver

▪ Post-procedure window:

– Related services within 30 days after procedure (i.e., inpatient and outpatient facility services, professional services, related medications, treatment for post-procedure complications)

– Inpatient post-procedure admission within 30 days after procedure as defined by Bundled Payment for Care Improvement (BPCI)

Detailed in following pages

▪ Bundled Payment for Care Improvement (BPCI) provides a list of procedure codes which are not relevant to tonsillectomy/adenoidectomy and these procedures would not be included in episode costs (i.e., if a patient is treated for a condition that is not a complication or relevant to the tonsillectomy/adenoidectomy procedure within 30 days after the procedure, it will not be included in the episode cost calculations)

1

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Design rationale: Patient exclusions (1/5)

Patient exclusion design decision Rationale

▪ Patients with certain co-morbidities which may unfairly increase a PAP’s average episode cost due to their inherent medical condition(s) within a year prior to procedure or during the episode are excluded (i.e., co-morbidities are factors beyond the PAP’s control/influence)

▪ Select co-morbid conditions within 365 days prior to procedure or during episode

▪ Tonsillectomies/adenoidectomies performed on women who are known to be pregnant during an episode window are excluded due to their potentially complex condition

▪ Pregnant during episode

▪ Patients under 3 and older than 21 tend to be more complicated procedures and are therefore excluded

▪ Age younger than 3 or older than 21

▪ In order to reduce the possibility that costs within an episode are not accurately and fully captured (i.e., costs partially covered by another program), patients who have dual enrollment are excluded

▪ Dual enrollment in Medicare/Medicaid (i.e., dual eligibles)

▪ Consistent enrollment ensures that all costs associated with an episode are accurately and fully captured

▪ Inconsistent enrollment with payer during episode

Detailed in following pages2

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Patient exclusion design decision Rationale

▪ Patients with UPPP on date of procedure have a different clinical pathology than relevant tonsillectomy/adeno-tonsillectomy

▪ As a result, the severity of care and episode cost is extremely different and variable as compared to relevant episodes

▪ Uvulopalatopharyngoplasty (UPPP) on date of procedure

▪ Patients with BMI over 50 are higher risk and more complicated to operate on

▪ The PAP cannot control this risk or the variability in outcomes due to this patient condition

▪ Patients with BMI>50

▪ Patients with death in hospital are clinical outliers▪ Death in hospital during episode

▪ A PAP cannot be held responsible for outcomes and resulting cost of care if patient leaves AMA

▪ Patient status of “left against medical advice” during episode

2

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Younger than 3 Older than 21

ED tonsillectomy/

adenoidectomy Inpatient

tonsillectomy/ adenoidectomy

Age on date of procedureAge on date of procedure Care setting1Care setting1

Sickle cell disease

Cystic fibrosis

Coagulopathies

Severe asthma

Down syndrome

Congenital defects of the circulatory system

Post obstructive pulmonary edema

Muscular dystrophy

Myopathies

Degenerative diseases of CNS

Severe mental retardation

Severe/chronic diseases and procedures(Exclusion period: 365 days pre-procedure and during episode window)

Severe/chronic diseases and procedures(Exclusion period: 365 days pre-procedure and during episode window)

Blood disorders

Congenital anomalies

Malignant hypothermia

ESRD (end-stage renal disease)

Uvulopalatopharyngoplasty (UPPP)2

1 Setting where patient presented with symptoms and received treatment2 Exclusion applies only if performed on date of procedure

2

LIST OF EXCLUSION CO-MORBIDITIES


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Other(during episode window)

Other(during episode window) Pneumonia

Fetal disturbances

Forceps or vacuum extractor delivery

Malposition

Other perinatal diagnosis

Umbilical cord complications

Spontaneous abortion

Suicide and intentional self-inflicted injury

Bone cancer

Brain cancer

Bronchial/lung cancer

Colon cancer

Esophageal cancer

GI/peritoneum cancer

Liver cancer

Malignant neoplasm

Neoplasm unspecified

Female genital cancer

Male genital cancer

Cancers(Exclusion period: 365 days pre-procedure and during episode window)

Cancers(Exclusion period: 365 days pre-procedure and during episode window)

Ovarian cancer

Pancreas cancer

Rectum/anus cancer

Kidney/renal cancer

Stomach cancer

Urinary organ cancer

Gallbladder cancer

Secondary malignancy

Other respiratory cancer

Other primary cancer

2

LIST OF EXCLUSION CO-MORBIDITIES


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Congenital hydrocephalus

Spina bifida with hydrocephalus, unspecified region

Severe mental retardation

Neoplasm of uncertain behavior of skin

Sickle-cell trait

Acute bronchospasm

Bacterial pneumonia, unspecified

Neoplasm of unspecified nature of bone, soft tissue

Other specified anomalies of pharynx

Ostium secundum type atrial septal defect

Extrinsic asthma with (acute) exacerbation

Multiple congenital anomalies

Ventricular septal defect

Down's syndrome

Lymphadenitis, unspecified, except mesenteric

Asthma, unspecified type, with (acute) exacerbation

Pneumonia, organism unspecified

Description

486

493.92

289.3

758.0

745.4

759.7

493.02

745.5

750.29

239.2

482.9

519.11

282.5

2382

3181

74100

7423

ICD9-Dx

Infantile cerebral palsy, unspecified343.9

Obstructive hydrocephalus331.4

Thrombocytopenia, unspecified2875

SOURCE: Arkansas Medicaid claims for patients with tonsillectomy/adenoidectomy between January 1, 2010 – December 31, 2010

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TOP-20 EXCLUSION CO-MORBIDITIES FROM 2010

Design rationale: Patient exclusions (5/5) INDIVIDUAL PATIENT MAY HAVEMORE THAN ONE CO-MORBIDITY

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Design rationale: Quality metrics

Quality metrics design decision Rationale

▪ To qualify for gain sharing, providers or their staff must report quality metrics through an online provider portal since some quality metrics cannot be extracted from claims data

▪ Providers must meet minimum quality standards agreed upon by a clinical advisory board

– Example:

▫ Average rate of intra-operative steroid administration

▪ Quality metrics required for gain sharing payment:

– Rate of administration of inta-operative steroids

▪ A bleed within 24-hours post-surgery (primary bleed) is related to surgeon technical skill and can drive post-procedure admissions as well as unplanned return to the operation room

▪ A bleed within 2-14 days post-procedure is less related to physician efficiency but should still be monitored as it can drive post-procedure admissions

▪ The Academy of Otolaryngology has recommended against post procedure antibiotic prescription in the revised tonsillectomy guidelines from 2011

▪ Quality/utilization metrics for reporting only:

– Post-operative primary bleed rate (i.e., post-procedure admissions or unplanned return to OR due to bleeding within 24 hours of surgery)

– Post-operative secondary bleed rate

– Utilization: Rate of antibiotic prescription post-surgery

AA

BB

4

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Design rationale: Principal Accountable Provider (PAP)

PAP design decision Rationale

▪ Medicaid has publicly announced that the Principal Accountable Provider (PAP) will be the primary provider performing the tonsillectomy/adenoidectomy since they are in the position to influence the most decisions and costs

▪ Payers independently determine the PAP by considering the following factors:

– Decision making responsibilities

– Influence over other providers

– Portion of episode cost

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Medicaid’s PAP will be the provider performing the tonsillectomy/adenoidectomy

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Contents


▪ Paula Miller –HP APII Analyst - Episode Descriptions & Reports


▪ Dr. William Golden, Medicaid Medical Director – Tonsillectomy Episode of Care

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Arkansas Health Care Payment Improvement InitiativeProvider Report

MedicaidReport date: April 2013

Historical performance: January 1, 2012 – December 31, 2012

Medicaid Little Rock Clinic 123456789 April 2013

DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. The figures in this report are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org

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Division of Medical ServicesP.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437

501-683-4120 · Fax: 501-683-4124

Dear Medicaid provider,

This is an update on the Arkansas Health Care Payment Improvement Initiative (APII) – a payment system developed with input from hundreds of health care providers, patients and family members. Our goal is to support and reward providers who consistently deliver high-quality, coordinated, and cost-effective care.

As a reminder, a core component of this multi-payer initiative is episodes of care. An episode is the collection of care provided to treat a particular condition over a given length of time. Since July of 2012, Arkansas Medicaid has introduced new episodes, including Upper Respiratory Infection (URI), Perinatal (colloquially, called “pregnancy”), Attention Deficit/Hyperactivity Disorder (ADHD), and more. To see the most up to date list of episodes visit the APII website at www.paymentinitiative.org.

For each episode, the provider that holds the main responsibility for ensuring that care is delivered at appropriate cost and quality will be designated as the Principal Accountable Provider (PAPs). For some episodes in the period covered in the attached report, you were identified as the PAP. After appropriate risk-adjustments and exclusions, your average quality and cost was compared with previously announced thresholds. This determines any potential sharing of savings or excess cost indicated in the report. Note that all information described throughout your report is based on claims already submitted and all providers should continue to submit and receive reimbursement for claims as they do today.

This report contains episodes currently in the ‘preparatory phase’ and so the data and analyses for these reports are historical only (i.e. they are not data from the time period that you will be measured against). To see “performance” reports (i.e., containing episodes eligible for gain or risk sharing) for episodes launched earlier, log onto the provider portal at www.paymentinitiative.org to download a separate report.

To aid you in your role as a PAP for future episodes, we have been working hard with providers and other payers to design a set of reports that give you detailed data about the quality and cost of your care as well as how this compares with previously announced thresholds and the range of performance of other providers. As each payer will send a report covering their patients, you may receive similar reports from Arkansas Blue Cross Blue Shield and / or QualChoice.

We encourage you to log onto the provider portal to access your current and previous ‘preparatory period’ and ‘performance period’ reports. As a PAP for select episodes, you should begin using this portal to enter selected quality metrics for each patient with an episode of care starting. To see which episodes have quality metrics linked to gain sharing visit the APII website.

We have been working diligently to solicit feedback from the provider community and will continue in our efforts to respond to all questions, comments and concerns raised in a timely and consistent manner. For answers to frequently asked questions regarding the initiative and episodes, please refer to the payment initiative website (www.paymentinitiative.org) You can also call us at 1-866-322-4696 or locally at 501-301-8311 with questions or email [email protected]. Additionally, be sure to check the website regularly for updates on upcoming informational WebEx sessions, other resources, or to sign up for alerts.

Sincerely,

Andy Allison, PhDMedicaid Director

DISCLAIMER: The information contained in these reports is intended solely for use in the administration of the Medicaid program. The data in the reports is neither intended nor suitable for other uses, including the selection of a health care provider. These figures are preliminary and are subject to revision. For more information, please visit www.paymentinitiative.org.

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Table of contents

Performance summary

Upper Respiratory Infection – Pharyngitis

Upper Respiratory Infection – Sinusitis

Upper Respiratory Infection – Non-specific URI

Perinatal

Attention Deficit/Hyperactivity Disorder (ADHD) – Level I

Total Joint Replacement

Congestive Heart Failure

Glossary

Appendix: Episode level detail

Colonoscopy

Oppositional Defiance Disorder

Cholecystectomy

Attention Deficit/Hyperactivity Disorder (ADHD) – Level II


Tonsillectomy

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Performance summary

Episode of CareQuality of Service

Share Amount

Average Episode Cost Your Gain/Risk Share

Upper Respiratory Infection – Pharyngitis

Not met $0.00Acceptable Not eligible for gain sharing

Upper Respiratory Infection – Sinusitis N/A Commendable Will receive gain sharing $349.50

Perinatal Met $0.00Acceptable Not eligible for gain sharing

Attention Deficit / Hyperactivity Disorder (ADHD) – Level II

Met $0.00Acceptable Not eligible for gain sharing

Quality of services and cost summary1

Total Joint Replacement N/A $0.00Acceptable Not eligible for gain sharing

Congestive Heart Failure Not met $0.00Acceptable Not eligible for gain sharing

Upper Respiratory Infection – Non-specific URI

N/A Not acceptable Subject to risk sharing -$3,844.50

Colonoscopy Met $0.00Acceptable Not eligible for gain sharing

Cholecystectomy Met $0.00Acceptable Not eligible for gain sharing

Tonsillectomy Met $0.00Acceptable Not eligible for gain sharing

Attention Deficit / Hyperactivity Disorder (ADHD) – Level I

Not met $0.00Acceptable Not eligible for gain sharing


Oppositional Defiance Disorder Met $0.00Acceptable Not eligible for gain sharing

The figures in this report are preliminary and are subject to revision

Across these Episodes of Care You are Subject to Risk Sharing: -$3,000.00Stop-loss was applied

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Cost summary

Key utilization metrics

Overview

Cost of care compared to other providers

1

2

4

5

Summary – Tonsillectomy

You (non- adjusted)

512,000

You (adjusted)

466,000

All providers

1,750

You

2,000Your total cost overview, $

Distribution of provider average episode cost

Your episode cost distribution

Average cost overview, $

Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29

Your average cost is acceptable

Selected quality metrics: N/A Average episode cost: Acceptable

#

ep

iso

de

sC

os

t,

$

Commendable Not acceptableAcceptable> $4000

You

You will not receive gain or risk sharing

$0

Percentile

Gain/Risk share

All providers

Not acceptableAcceptableCommendableYou

< $974 > $1,003$974 to $1,003

7500

5000

2500

>$1,542

Quality summary3

Linked to gain sharing

Post-procedure primary bleed rate

Post-op Abx Rx rate

100%

50%

0%AvgYou

Intra-op steroid Rx rate

Stan

da

rd

for g

ain

s

harin

g

You achieved selected quality metrics

100%

50%

0%AvgYou

100%

50%

0%Series

AvgYou


Post-procedure secondary bleed

100%

50%

0%AvgYou

182342

84

282315

100

50

$1,003-$1,542

$993-$1003

$984-$993

$974-$984

$899-$974

<$899

There are no quality metrics linked to gain sharing generated

from claims data. Selected quality data submitted on the Provider Portal will generate additional

quality metrics for future reports.

30%17%

Surgical pathology utilization rate You All providers

30

Quality and utilization detail – Tonsillectomy

5025Percentile

Metric You 25th

Metric 25th 50th

50th 75th

You 75th 5025Percentile

Percentile

Percentile

0

0

100

100

75

75

Metric linked to gain sharingYou Minimum standard for gain sharing

Quality metrics: Performance compared to provider distribution

Utilization metrics: Performance compared to provider distribution

1

2

1% 0%1% 2%Post-procedure primary bleed rate

0% 1%2% 4%Post-procedure secondary bleed

25% 20% 30% 40%Post-procedure Abx Rx

You achieved selected quality metrics


---

-

31

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 – Tonsillectomy

Care category

All provider averageYou

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


Total episodes included = 233

233

230

221

184

21

16

12

1

7

# and % of episodes with claims in care category

Total vs. expected cost in care category, $

Average cost per episode when care category utilized, $

Outpatient professional

Pharmacy

Emergency department

Inpatient professional

Inpatient facility

Outpatientsurgery

Other

Outpatient lab

Outpatientradiology / procedures

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Questions

33

For more information talk with provider support representatives…

▪ More information on the Payment Improvement Initiative can be found at www.paymentinitiative.org

– Further detail on the initiative, PAP and portal

– Printable flyers for bulletin boards, staff offices, etc.

– Specific details on all episodes

– Contact information for each payer’s support staff

– All previous workgroup materials

Online

Phone/ email▪ Medicaid: 1-866-322-4696 (in-state) or 1-501-301-8311 (local

and out-of state) or [email protected]

▪ Blue Cross Blue Shield: Providers 1-800-827- 4814, direct to EBI 1-888-800-3283, [email protected]

▪ QualChoice: 1-501-228-7111, [email protected]

Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar

Documents

Transcript of Arkansas Payment Improvement Initiative (APII) Tonsillectomy Episode Statewide Webinar