UnitedHealth Premium Program Attribution Methods

Transcription

1 UnitedHealth Premium Program Attribution Methods Resources u Phone: u Website: UHCprovider.com/Premium u Mail: UnitedHealthcare - UnitedHealth Premium Program MN017-W Health Lane Minnetonka, MN This document should be used with the UnitedHealth Premium Program Methodology at UHCprovider.com/Premium. It is important to review the entire document to understand the Premium program methodology. Overview Attribution methods based on health plan claims data determine which physicians are responsible for care given to patients. Different attribution methods are used for each of the following measure types used in the Premium methodology: Quality Measures Preventive Chronic Disease Acute Condition Pregnancy Global Surgical Cost Efficiency Measures Patient Total Cost Patient Episode Cost Quality Measure Attribution The Premium program applies the following general principles for attributing quality measures to physicians: Quality measures are attributed to physicians in applicable specialties. Quality measures are attributed to physicians with significant involvement in the care of the patient. The determination of significant involvement varies by the physician s role and the quality measure as noted in the Quality Measure Attribution Methods table on the following page.

2 Quality Measure Attribution Methods The following table provides an example of the type of condition/procedure to which each method applies, whether the method allows for attribution to a single physician only or to multiple physicians, the physician role(s) eligible for attribution and the specific criteria for each method. Multiple attribution applies when more than one physician provides care to a patient. This aligns with patient-centered health care models and physicians are expected to coordinate patient care. Attribution Method Condition or Procedure Example Single or Multiple Attribution Applicable Physician Role(s) Attribute the measure to: Preventive Breast Cancer Screening Multiple Identified PCP The identified PCP if they had one or more visits with the patient in the most recent 12 months used Chronic Disease Identified OB-GYN Diabetes Multiple Identified PCP Identified OB-GYN including other PCPs, OB-GYNs and/or Other Specialists The identified OB-GYN if they had one or more visits with the patient in the most recent 12 months used The identified PCP and/or OB-GYN if either or both had one or more visits with the patient in the most recent 12 months used All physicians in applicable specialties with two or more visits with the patient for the condition in the most recent 12 months used Exception: Hypertension and hyperlipidemia only require one visit in the most recent 12 months used. Acute Condition Acute Bronchitis Single including PCPs, OB-GYNs and Other Specialists The physician who saw the patient for the condition when only one physician was involved in the care Pregnancy Pregnancy Multiple Identified OB-GYN The identified OB-GYN if they had one or more pregnancy related visits and performed one or more pregnancy related procedures Family Medicine and Endocrinology physicians and other OB-GYNs All Family Medicine, Endocrinology and other OB-GYN physicians with two or more pregnancy-related visits and one or more pregnancy related procedures Global Medication Safety Monitoring (not specific to a condition) Multiple Identified PCP including other PCPs, OB- GYNs and/or Other Specialists The identified PCP All physicians in applicable specialties with one or more visits with the patient for any condition in the most recent 12 months used Surgical Knee Replacement Surgery Single The physician who performed the primary procedure associated with the quality measure 2

3 Identified PCP or OB-GYN The Identified PCP and/or OB-GYN is determined using the following process to select the most probable primary care giver. 1. Identify the PCP and/or OB-GYN who performed the most recent physical examination or assessment. The largest number of s breaks any ties. 2. Identify the PCP and/or OB-GYN who performed the largest number of evaluation and management type visits. The most recent visit breaks any ties. 3. Identify the PCP who performed the largest number of prenatal, postpartum, or antepartum visits, or routine obstetrical care s. The most recent breaks any ties. This step is limited to physicians in internal medicine, family medicine and pediatrics to account for patients who receive obstetrics and gynecology s from PCPs in specialties other than obstetrics and gynecology. The attribution process for PCPs and OB-GYNs stops as soon as one of the physicians meets the attribution criteria. If this process does not yield an attributed physician in the specialty category, the patient is not attributed to a physician in that specialty category. Type of Service Identified PCP 1 Identified OB-GYN 2 1. Physical Exam or Assessment 2. Evaluation and Preventive Service or physical exam OR Ambulatory visit + medical exam diagnosis Tiebreaker = Largest number of s Preventive or physical exam OR Ambulatory visit + medical exam diagnosis Tiebreaker = Largest number of s 3. Obstetric Visits Obstetric codes are included in exam or assessment step above 1 PCP includes Internal Medicine, Family Medicine, and Pediatrics 2 OB-GYN includes Obstetrics and Gynecology Cost Efficiency Measures Patient Total Cost - Patient Attribution For patient total cost measurement, attribution is based on a hierarchy of s to select the most probable physician(s) responsible for the patient s care within each specialty category. Specialty categories are PCP, OB-GYN, Allergy, Cardiology, Endocrinology, Nephrology, Neurology, Pulmonology and Rheumatology. A patient may be attributed to one eligible physician within each specialty category for each calendar year measured through patient total cost attribution. Multiple attribution applies when more than one physician provides care to a patient. This aligns with patient-centered health care models and physicians are expected to coordinate patient care. Surgical Specialty Eligibility OB-GYNs and cardiologists who perform surgical procedures are not eligible for patient total cost measurement if their surgical cases account for more than 30 percent of their total cases. The percentage is determined by comparing the physician s ratio of surgical episodes to total surgical and medical episodes. 3

4 Attribution Process The following table shows the hierarchical process to attribute each patient to one eligible physician within the PCP and OB-GYN categories and one physician in each specialty within the Other Specialist category. Attribution is based on code sets specific to the specialty category and identified s. PCP and OB-GYN attribution is determined based on claims from the same calendar year used for measurement. If no qualifying s are found, the previous calendar year is used. OB-GYN patients are attributed only if they are females and at least 12 years old. Other Specialist attribution is determined based on claims from the same calendar year used for measurement. For PCP and OB-GYN attribution, the process stops as soon as one of the physicians meets the attribution criteria. If this process does not yield an attributed physician in the specialty category, the patient is not attributed to a physician in that specialty category. For Other Specialist attribution, the process identifies an attributed physician for each specialty included in the Other Specialist category. If this process does not yield an attributed physician in the specialty, then the patient is not attributed to a physician in that specialty. Type of Service Identified PCP 3 Identified OB-GYN 4 Other Specialist 5 1. Physical Exam or Assessment Preventive Service or physical exam OR Ambulatory visit + medical exam diagnosis Preventive or physical exam OR Ambulatory visit + medical exam diagnosis Tiebreaker = Largest number of s Tiebreaker = Largest number of s 2. Evaluation and 3. Obstetric Visits Obstetric codes are included in exam or assessment step above 3 PCP includes internal medicine, family medicine, and pediatrics 4 OB-GYN includes obstetrics and gynecology 5 This method applies separately to Allergy, Cardiology, Endocrinology, Surgery, Nephrology, Neurology, Pulmonology and Rheumatology Patient Episode Cost - Patient Attribution The Premium program applies the following general principles for attributing episodes to physicians: Episodes are only attributed to physicians in applicable specialties. Episodes are only attributed to physicians with significant involvement in the care of the patient. The determination of significant involvement varies between medical and surgical episodes as follows. 4

5 Medical Episode Attribution Each medical episode is attributed to the physician who was responsible for generating the highest percentage of s, based on cost, in the episode. The attributed physician must be in a specialty that typically manages the care of patients for the medical condition. To make sure there was significant involvement, the attributed physician must be responsible for at least 30 percent of the total cost of the episode. About 80 percent of medical episodes attributed for patient episode cost measurement are managed by one physician. We do not attribute episodes to radiologists, pathologists and anesthesiologists. Surgical Episode Attribution Surgical episodes are attributed to the physician who performed the primary surgical procedure. Performing the surgical procedure constitutes significant involvement and therefore no cost percentage threshold is applied. Important notes about the UnitedHealth Premium Physician Program The information from the UnitedHealth Premium program is not an endorsement of a particular physician or health care professional s suitability for the health care needs of any particular member. UnitedHealthcare does not practice medicine nor provide health care s. Physicians are solely responsible for medical judgments and treatments supplied. A Premium Physician or Quality Physician designation does not guarantee the quality of health care s members will receive from a physician and does not guarantee the outcome of any health care s members will receive. Likewise, the fact that a physician has a Not Evaluated for Premium or a Does Not Meet Premium Quality Criteria designation does not mean that the physician does not provide quality health care s. All physicians in the UnitedHealthcare network have met certain minimum credentialing requirements. Regardless of whether a physician has received a Premium Physician designation, members have access to all physicians in the UnitedHealthcare network, as further described under the member s benefit plan. The designation of Not Evaluated for Premium is given when a physician does not practice in a specialty that is evaluated by the Premium program, or when a physician s evaluation is in process. It is also given when a physician does not have enough health plan claims data to be evaluated, but it is not an indicator of the total number of patients treated by the physician or the number of procedures performed by the physician. Rather, it reflects the statistical requirements of the Premium program, which includes only health plan claims associated with specific Premium program measures and relevant to the physician s specialty. In some cases, there may not be enough data to complete the analytic process from a statistical standpoint. UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error. There is a risk of error in the claims data used in the evaluation, the calculations used in the evaluation, and the way the Premium program determined that an individual physician was responsible for the treatment of the patient s condition. Physicians have the opportunity to review this data and submit a reconsideration request. UnitedHealthcare uses statistical testing to compare a physician s results to expected or normative results. There is a risk of error in statistical tests when applied to the data and a result based on statistical testing is not a guarantee of correct inference or classification. We inform members that it is important that they consider many factors and information when selecting a physician. We also inform our members that they may wish to discuss designations with a physician before choosing him or her, or confer with their current physician for advice on selecting other physicians. The information contained in this Attribution Methods document is subject to change. Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, or their affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative s provided by United Health Services, Inc., OptumRx, OptumHealth Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. D /18 Doc#: PCA _ United Health Services, Inc.