Primary Care Practice Reports Commercially insured adult and pediatric population Claims incurred January December 2012, with 3 months run-out January 2014 © Maine Health Management Coalition Foundation. All Rights Reserved.

Report Background Inclusions & Exclusions Risk Adjustment & HealthPartners® Cost and Resource Use Key Concepts Report Organization Detailed Content Review Glossary Questions Agenda © Maine Health Management Coalition Foundation. All Rights Reserved.

Overview & Background

© Maine Health Management Coalition Foundation. All Rights Reserved. Maine Health Management Coalition Foundation The Maine Health Management Coalition Foundation (MHMC-F) is a charitable organization whose mission is to bring the people who get care, pay for care, and provide care together in order to measure and improve the quality of health care services in Maine. In February 2013, the State of Maine received one of six State Innovation Model (SIM) awards from the Centers for Medicare and Medicaid Innovation (CMMI). The award includes four primary objectives aimed at achieving the Triple Aim by To accomplish these goals, the State of Maine has enlisted the help of the Maine Health Management Coalition Foundation, Maine Quality Counts, and HealthInfoNet. Each organization will assist the State in carrying out specific aspects of the award, such as quality improvement at the practice level, public reporting, and the creation of provider portals. To support quality improvement at the practice level, the Maine Health Management Coalition Foundation will be distributing Primary Care Practice Reports to primary care practices statewide.

© Maine Health Management Coalition Foundation. All Rights Reserved. History of the Report The Primary Care Practice Reports were designed and developed by the Maine Health Management Coalition Foundation, with support from MaineCare, and with guidance from Maine’s Primary Care Medical Home Pilot Conveners, the Primary Care Medical Home Working Group, Pathways to Excellence Steering Committees and other stakeholders. Maine’s Primary Care Medical Home Pilot practices have received these reports on earlier measurement periods.

© Maine Health Management Coalition Foundation. All Rights Reserved. Purpose of the Reports The goal of the Primary Care Practice Report is to demonstrate practice pattern variation in cost and quality compared to state benchmarks. – How does the cost and quality of all healthcare services received by my practice’s patients compare to the cost and quality of all healthcare service received by other primary care practices’ patients? A wide variety of measures are included to give each practice a detailed understanding of how the care their patients receives differs from the average. – This enables practices to create action plans targeted at improving specific aspects of their patients’ care. The measures are calculated from the best available data. For this version of the reports, only healthcare claims from commercial payers have been collected and meet the necessary quality requirements. – Future versions of reports will be issued for Medicare and MaineCare patients.

© Maine Health Management Coalition Foundation. All Rights Reserved. Public Reporting Although the Primary Care Practice Reports are the property of each primary care practice, key components of these reports may be used to produce cost and quality rankings for hospitals and primary care physicians. These rankings would be available to the public on the website. For additional information on these measures and the process guiding public reporting for physicians and systems, please contact or visit the Pathways to Excellence resource on MHMC’s website (

Patient Panel Inclusions & Exclusions

InclusionExclusion Patient Eligibility Patients must have at least 9 months of eligibility within the reporting period and within the specific practice-age population. The member is attributed to the Primary Care Practice seen the most for evaluation and management visits over a 12 month period. Patient Eligibility Patients with total annual costs above $100,000 are excluded from all sections of the report (with the exception of the High Cost Claimant summaries) Data Sources Commercial Data Reflects the claims data submitted to the MHDO by all commercial payers who offer full medical coverage. Data Sources Commercial Commercial data sources with less than full medical coverage (vision, behavioral health, Medicare supplement, etc.) for members with no other medical coverage are excluded. Medicare & Medicaid These data sources will be incorporated into reports in Patient Age Separate reports are produced for Pediatric Patients and Adult (Non-Medicare) Patients Pediatric: Age <18 Adult: Age Reporting Period: Calendar Year January December 2012 © Maine Health Management Coalition Foundation. All Rights Reserved.

Panel Size & Understanding Practice Patterns If the panel size for your report is below 200, the measure results may not reflect your true practice pattern. Scores based on smaller subpopulations, such as patients with chronic conditions, can fluctuate even more. We have decided to release all reports, regardless of panel size, so that practices can get familiar with the layout and take part in conversations with other practices about the measurement process. Results for reports with small panels can be used as indicative of potential practice characteristics.

Risk Adjustment & HealthPartners® Cost and Utilization Tools

Risk Adjustment & HealthPartners® Tools Risk Adjustment: OptumInsight™ Symmetry® Retrospective Risk – Retrospective risk evaluates disease burden within a population over a 12-month period to provide a relative measure of expected cost for that period. Total Cost Index: HealthPartners® – The TCI is the ratio of the PMPM reimbursement for the care provided to the practice's panel during the reporting period to the PMPM reimbursement of the total analyzed population (the benchmark). Resource Use Index: HealthPartners® – Reflects the amount of healthcare delivered to the practice's panel during the reporting period relative to the benchmark. – Based on standardized cost for each service across treating providers. © Maine Health Management Coalition Foundation. All Rights Reserved.

Retrospective Risk Adjustment Example Retrospective Risk Score Interpretation PracticeBenchmark Practice has an 11% higher disease burden than does the benchmark. Adjusted PMPM costs for this practice will be lower than the practice’s raw PMPM values. This is due to adjusting the practice’s population to a lower disease burden that is comparable to the benchmark’s disease burden Practice has a 6% lower disease burden than does the benchmark. Adjusted PMPM costs for this practice will be higher than the practice’s raw PMPM values. This is due to adjusting the practice’s population to a higher disease burden that is comparable to the benchmark’s disease burden. © Maine Health Management Coalition Foundation. All Rights Reserved.

Key Concepts

Primary Care Practice Reports currently incorporate Medical Claims data. – Content from practice EMRs and patient-reported content is not included. – NCQA quality measures are limited to claims data and may not align with internal practice reports. – Feasibility of incorporating alternative data sources for future Practice Reports is being evaluated. Benchmarking – Almost all rates reported throughout the Primary Care Practice Reports provide reference to a “Peer Benchmark” – This benchmark can be used as a reference to understand how your specific practice is performing relative to the other Adult or Pediatric practices in the state of Maine Different benchmarks are used for Adult and Pediatric reports – The benchmark is the entire panel of all the patients attributed to practices in the state Key Concepts © Maine Health Management Coalition Foundation. All Rights Reserved.

Report Organization

Demographics & Annual Trends Inpatient Overview Outpatient & Professional Overview Physician Specialties & Pharmacy Overview Condition Overview & High Cost Claimants Best Practice in Quality Page 1Page 2 Page 4 Page 5 Page 3 Page 6 © Maine Health Management Coalition Foundation. All Rights Reserved.

Patient Demographics & Annual Practice Trends Demographics & Annual Trends Page 1

Patient Demographics & Annual Practice Trends Patient Demographics – General demographic information and prevalence rates within the panel’s population. Annual Per-Member, Per-Month Cost reported over 3-years compared to the Benchmark – Does it cost more or less than the Benchmark to manage your patient population? © Maine Health Management Coalition Foundation. All Rights Reserved.

Patient Demographics & Annual Practice Trends PMPM costs across various service categories – Includes total cost and resource use indexes in addition to both raw and adjusted practice PMPM – If the practice’s adjusted PMPM is higher in a given service category, the indexes may provide insight into why. Increased cost of services or a higher rate of services? TCI of 1.03 indicates practice is 3% more cost-intensive than the benchmark. RUI of 0.87 indicates practice is 13% less resource intensive than the benchmark. © Maine Health Management Coalition Foundation. All Rights Reserved.

Inpatient Overview Page 2

Inpatient PMPM by Detailed Service Category – Is your practice’s inpatient PMPM higher than the benchmark? – This section will highlight which types of admissions are most influencing inpatient PMPM. Total count of admissions by quarter over 3-year period – Are there any seasonal trends in admissions? Is the admission rate declining as new interventions are being put in place? Inpatient Overview © Maine Health Management Coalition Foundation. All Rights Reserved.

Inpatient Utilization – Overall admission and NCQA all-cause readmission rates – AHRQ PQI Ambulatory Care Sensitive admission and all-cause readmission rates “Prevention Quality Indicators (PQIs) are a set of measures that can be used with hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." These are conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.” 1 Most-Frequent Diagnosis-Related Groups (DRG) – Highlights the most common DRGs within the panel and provides insight into the admission rate for those DRGs within the benchmark. Is panel particularly high in mental health and substance abuse related admissions? Is panel particularly high in joint replacement admissions? Is panel particularly high in maternity admissions? – Of these – are there any admissions that may be preventable? 1 Inpatient Overview © Maine Health Management Coalition Foundation. All Rights Reserved.

Outpatient and Professional Utilization and Cost Outpatient & Professional Overview Page 3

Outpatient & Professional Overview Variation in utilization and cost across professional and outpatient claims was found based on provider location within the State. – Southern Maine, specifically Cumberland County, tends to have much higher professional utilization and cost (but much lower outpatient facility utilization and cost) as compared with the rest of the state. – Variation appears to be linked to claims filing and billing practices rather than practice pattern variation. To account for this variation, outpatient and professional services are combined within this report. © Maine Health Management Coalition Foundation. All Rights Reserved.

Outpatient & Professional Overview Outpatient Facility & Professional PMPM by Service Category – Is your practice’s PMPM higher than the benchmark in particular service areas? Emergency Department Utilization – Overall ED utilization – AHRQ PQI Ambulatory Care Sensitive ED Visits – Frequent ED Visits – ED Visits by Quarter In this example, the practice has fewer overall ED visits than the Benchmark, BUT of those visits, has more potentially avoidable ED visits. This may indicate a possible opportunity in managing patients going to the ED. © Maine Health Management Coalition Foundation. All Rights Reserved.

Outpatient & Professional Overview Radiology Dashboard – Understand practice trends across various radiology services. – Utilize the TCI and RUI to understand cost and resource use against the benchmark. Multiple Imaging Procedures – Are patients within the panel receiving 3 or more imaging procedures? How does your practice’s rate compare to the benchmark? Are there areas where your patients are receiving more radiology procedures than the benchmark? © Maine Health Management Coalition Foundation. All Rights Reserved.

Physician Utilization & Pharmacy Overview Physician Specialties & Pharmacy Overview Page 4

Specialist Utilization – Provides insight into practice panel’s utilization of common provider specialties against utilization trends within the benchmark population. Specialist Utilization © Maine Health Management Coalition Foundation. All Rights Reserved.

Pharmacy by Detailed Service Category – Breaks overall pharmacy spend down into various medication types and provides insight through use of TCI and RUI into cost and utilization against the benchmark. Pharmacy Utilization – Compares brand and generic rates of pharmacy utilization against the benchmark. Most-Frequent Brand Medications where a Generic Alternative is Available – This table may provide insight into the most common brand medications patients are receiving when there may be a more cost-effective alternative available. Pharmacy Utilization © Maine Health Management Coalition Foundation. All Rights Reserved.

Clinical Condition Overview & High Cost Claimants Page 5

Clinical Condition Overview – Highlights total counts and prevalence rates of various clinical conditions as compared to the benchmark. – Supplies the total adjusted per-patient cost for treating patients with these conditions. – The TCI and RUI can help further understand where and why there is variation in per-patient cost across the conditions. The cost per patient with Depression in this practice is about $1,000 more than the benchmark. RUI indicates that the practice is expending 6% more resources on this clinical population TCI indicates that the practice costs 33% more to treat these patients. This suggests that most of the cost differential is price rather than amount of services. © Maine Health Management Coalition Foundation. All Rights Reserved.

Best Practice Compliance Summary Best Practice Compliance Summary is designed to give practices a quick snapshot of performance on claims-based healthcare quality measures. – Measures included in this summary are populated in further detail on page 6 of the report. Example: Diabetes Indicates 25% of diabetic patients are compliant on ALL diabetes measures. Indicates 70% of diabetic patients are compliant on SOME diabetes measures. Indicates 5% of diabetic patients are compliant on NO diabetes measures. © Maine Health Management Coalition Foundation. All Rights Reserved.

High Cost Claimant Summary Patients with costs greater than $100,000 are excluded throughout the report. This section highlights the actual cost and utilization of these patients. Overview – Identifies total number of high cost patients as well as the average cost per high cost patient. Utilization – Highlights overall utilization trends among the high cost claimants and to what percent they make up the total utilization across service categories for the practice. Leading Diagnoses – Provides insight into the top diagnoses of the high cost patients. © Maine Health Management Coalition Foundation. All Rights Reserved.

Quality Measure Best-Practice Best Practice in Quality Page 6

NCQA HEDIS claims-based quality measures are reported against the Benchmark across the following areas: – Behavioral Health – Cardiovascular Conditions – Comprehensive Diabetes Care – Medication Management – Musculoskeletal Conditions – Pediatric/Well-Care Visits – Prevention & Screening – Respiratory Conditions Results displayed as hash lines rather than solid fill indicate that the measure is not statistically reliable because there were fewer than 30 patients in the denominator. Quality Measure Best-Practice © Maine Health Management Coalition Foundation. All Rights Reserved.

Glossary

A detailed glossary has been provided to define measures and terminology used throughout the report. © Maine Health Management Coalition Foundation. All Rights Reserved.

Questions?

We understand that practices receive numerous reports and would like the opportunity to understand those areas practices are most interested in evaluating and to understand the best avenue for reporting results. – New measures? – What measures should be removed? – What section(s) of the report are confusing? – Changes to report formatting and design? – Other comments/suggestions? Join the Practice Report Advisory Group! © Maine Health Management Coalition Foundation. All Rights Reserved.

Please direct questions concerning report content and/or measure specifications to Becky Dugas & Cindy Waller: – Maine Health Management Coalition Data Program (207) Contact Information © Maine Health Management Coalition Foundation. All Rights Reserved.