MN DEPARTMENT OF HEALTH
PROVIDER PEER GROUPING (PPG)
ADVISORY GROUP


INFORMATION NEEDS FOR DIFFERENT AUDIENCES
PHASE II RECOMMENDATIONS FOR PROVIDER PEER
GROUPING
ANN ROBINOW
MEETING 8: SEPTEMBER 11, 2009
PPG Advisory Meeting Schedule
MEETING
DATE
TOPIC
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
f/u Quality Measures for Conditions
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
AUGUST RECESS (Draft Report distributed August 19)
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues:
Information Needs by Audience
Phase II of PPG
Meeting 9
Wednesday, September 30
Final Review
Introduction

Comments and changes to meeting summary?

Review of questions or comments since last meeting.

Report Technical Panel responses since last meeting.

MN Community Measure request for Diabetes Condition
Specific to follow D5. Not concerned that Total Care will
not follow D5.
Review: Quality Weighting
Condition Specific
Quality
65%
35%
Total Care
Quality
Hospital Total Care Composite
Measure (combined
weighting)
Measures of post
discharge
complications
20%
Prevention measures
15%
Composite process
measure
Composite of
process measures
10%
Minor acute care
20%
Composite
ER/Readmit outcome
measure
10%
Chronic disease
processes
30%
Composite hospital
mortality measure
25%
Chronic disease
outcomes
20%
Composite inpatient
complication score
35%
Hospital avoidance
15%
Patient experience
Review: Total Care Quality Weighting
Review: Total Care Quality Weighting
Review: Total Care Quality Weighting
Review: Condition Quality Weighting
Condition
Measure
Pneumonia
Rate of hospital re-admission for bacterial pneumonia
Pneumonia
Rate of hospital ER visits for pneumonia post discharge
Pneumonia
Process Measure (none)
Weighting
Guidelines
65%
35%
Asthma
Asthma
Asthma
Asthma
Rate of hospital admissions for asthma
Rate of hospital re-admissions for asthma
65%
Rate of hospital ER visits for asthma
% asthma patients, ages 5-56, who were prescribed appropriate medication
35%
Review: Condition Quality Weighting
Condition
Measure
Diabetes
Rate of hospital admissions for short-term complications
Diabetes
Rate of hospital admissions for uncontrolled
Diabetes
Diabetes
Rate of hospital ER visits for diabetes
% of diabetes patients, ages 18-75, who lower LDL or "bad" cholesterol to less
than 100 mg/dl
Diabetes
% of diabetes patients, ages 18-75, who control blood sugar so that A1c level is
less than 7%
Diabetes
% of diabetes patients, ages 18-75, who don't smoke
Diabetes
% of diabetes patients, ages 18-75 ,who take an aspirin daily, for those ages 40
and older
Diabetes
Diabetes
Weighting
Guidelines
65%
% asthma patients, ages 5-56, who were prescribed appropriate medication
35%
Process Measure (none)
Condition Specific Quality : Summary
Condition
CAD
Measure
CAD
CAD
Rate of hospital admissions for CAD
% of vascular disease patients, ages 18-75, who maintain blood pressure less
than 130/80
% of vascular disease patients, ages 18-75, who lower LDL or "bad"
cholesterol to less than 100 mg/dl
% of vascular disease patients, ages 18-75, who don't smoke
CAD
Process Measure (none)
Heart Failure
Rate of hospital admissions for congestive heart failure
Heart Failure
Rate of hospital ER visits for heart failure
Heart Failure
30-day mortality after hospital discharge
Heart Failure
Process Measure (none)
Total Knee
Review ER and readmission measures, as well as other potential measures
CAD
Weighting
Guidelines
65%
% of vascular disease patients, ages 18-75, who take an aspirin daily
35%
65%
35%
Context For Today’s Discussion
High Level Steps in Peer Grouping
Combining
Cost & Quality
Questions for Today’s Meeting: Peer Grouping
Information Needs by Audience
1.
How can different audiences use the information and
what can’t the information be used for?
2.
What specific types of information are needed by each
user of the peer grouping? (providers, payer/purchaser,
consumer)
3.
What are issues associated with releasing detailed data
to providers & plans?
How can Peer Grouping Data be
Used?
Useful For:
Providers
Payer/Purchasers
Consumers
Contracting
Yes
Yes
-----
Overall understanding of Relative
Quality and Quality relative to
Cost
Yes
Yes
Yes
Overall understanding of
Resource Use
Yes
Yes
Yes
Overall understanding of Relative
Cost
Yes
Yes
Yes
Specific impact of cost to user
No
No
No
Identifying efficient referral
providers
Yes
Yes
-----
Selecting provider for specific
condition
Yes
Yes
Yes
Care Management
No
-----
-----
What Specific Types of Data are
Needed By Audience?
Data from
Recommendations
Needed by
Providers
Needed by
Payer/Purchasers
Needed by
Consumers
Quality
by specific measures
by composite score
Yes
Yes
Yes
Yes
Yes
Yes
Actual Cost
by service category
by composite score
Yes
Yes
Yes
Yes
Yes
Yes
by actual Payer Mix
by Normalized Payer Mix
Yes
Yes
Yes
Yes
Yes
Yes
Repriced Cost
by service category
by composite score
Yes
Yes
Yes
Yes
Yes
Yes
by actual Payer Mix
by Normalized Payer Mix
Yes
Yes
Yes
Yes
Yes
Yes
Report & Data Options for Different
Audiences
Need for Detailed Data for
Providers & Purchasers
 Should MDH provide providers and/or purchasers a
more detailed data set for analytic purposes?
Examples of Potential Data Uses:
 Providers can compare their resource utilization with peer
group on a Total Care basis and on Condition Specific basis.
 Providers can compare cost and utilization of referral
providers and hospitals for their attributed patients.
 Payers can compare provider utilization across entire
population by diagnosis, by service, by region, etc.
Example of Comparison Summary for Clinic ABC
(not inclusive of all fields that can be provided)
TOTAL CARE EXAMPLE
CLINIC ABC
Year: 200X
Actual
Allowed
Description
Member Months
Total Inpatient Hospital
Total Outpatient Hospital
Total Professional (MD)
Total Non-Pharmacy Services
Total Pharmacy
All Peer Group
% Differ
Repriced
Repriced
PMPM
Total member months
for all clinics
PMPM
Repriced
PMPM
PMPM
Total members months attributed
to Clinic ABC
Repriced is a
reflection of
Clinic’s
Actual Allowed is resource use
priced at a
the total amount
owed to provider standardized
unit price.
per plan contract.
All Peer Group
Repriced PMPM is a
reflection of entire
Peer Group’s average
resource use priced at a
standardized unit price.
Total PMPM
Risk Adjustment Factor for
Population
Illness burden of Clinic’s members
as compared to the entire peer group.
Risk Adjusted PMPM
Resource use reflected as a PMPM
and adjusted for expected resource use
of the Clinic’s illness burden.
Percent
difference
in resource
use
between
Clinic and
Peer Group
Example of Comparison Summary for Clinic ABC
(not inclusive of all fields that can be provided)
TOTAL CARE EXAMPLE
CLINIC ABC
Year: 200X
Actual
Description
Allowed
Repriced
All Peer Group
% Differ
Repriced
Repriced
PMPM
PMPM
PMPM
PMPM
Member Months
94,839
94,839
610,991
Total IP Hospital
$51.22
$27.16
$27.87
-2.53%
Total OP Hospital
$35.48
$20.34
$20.87
-2.53%
Total Professional
$106.32
$91.87
$91.37
0.55%
Total Non-Pharmacy Services
$193.02
$139.37
$140.10
-0.52%
Total Pharmacy
$48.75
$48.75
$51.67
-5.65%
Total PMPM
$241.77
$188.12
$191.77
-1.90%
0.9541
0.9541
1.00
-4.59%
$253.40
$197.17
$191.77
2.82%
Risk Adjustment Factor
Risk Adjusted PMPM
Example: Referral Summary for Patients Attributed to Clinic
ABC
(not inclusive of all fields that can be provided)
Attributed
Clinic Name Patients
Allow Reprice
per
Resource Repriced per
Patient Patient
Billed Allowed
Use
$
Clinic
Type
# patients
Clinic
All
attributed
Specialty
providers to Clinic
to
ABC and
where
indicate
the # of
patients
type of
patients
were
services
seen
at
provided
patient
other
care
received
providers
Addt’l
Fields
Other
fields that
may also
be
included
are
diagnosis
codes or
ETG to
allow for
sorting by
diagnosis
or
condition.
Measure
of
Repriced
utilization
=
Resource
Usually
Use x
stated in
Standar
Relative
d Price
Value
Units
TOTAL
NON-RX
CARE
Example: Referral Summary for Patients Attributed to Clinic
ABC
(not inclusive of all fields that can be provided)
Clinic Attributed
Name Patients
Clinic
ABC
624
Allow Reprice
per
Resource Repriced per
Patient Patient
Allowed
Use
$
Clinic
Type
Primary
Care
$320,089 $288,821
5592.93 $250,557
$463
$402
ICD1
$274,226 $242,839
4656.02 $207,049
$427
$364
ICD2
Billed
Addt’l
Fields
Clinic 1
569
Rad
Clinic 2
252
Ortho
$69,734
$38,025
1010.25
$36,826
$151
$146
ICD3
Clinic 3
222
Cardio
$48,181
$44,460
1166.69
$42,476
$200
$191
ICD4
Clinic 4
216
Derm
$950,053 $383,842
Clinic 5
160
Derm
$189,072 $119,172
Hosp 1
89
Hosp
$1,099,505 $502,013
Hosp 2
89
Hosp
$72,418
Hosp 3
TOTAL
NONRX
CARE
80
Hosp
$104,104
624
490.71
$22,347 $1,777
1905.86 $103,202
$745
$103
$645
1200.05
$54,002 $5,641
$607
$34,600
1100.35
$49,516
$556
$88,598
800
$3,127,382 $1,742,370
$389
$36,000 $1,107
17922.9 $801,975 $2,792
$450
$1,285
Example of Detailed Data:
Hospital Only Summary for Clinic ABC
(not inclusive of all fields that can be provided)
Hospital
Name
Hospital
A
Hospital
A
Hospital
A
Hospital
A
Hospital
A
Hospital
B
Hospital
B
Hospital
B
Hospital
B
Hospital
C
Type of
Service Admit Days
Complex
Newborn
1
3
Billed
Allowed Repriced
Allowed /
Admit
Repriced/
Admit
Addt’l Fields
ICD1 - ICD5
$2,968
$1,765
$1,063
$1,765
$1,063
$71,676
$39,989
$19,578
$7,998
$3,916
$290,930 $127,981
$78,733
$1,765
$4,631
$3,526
$2,123
$882
$531
Delivery
5
20
Medical
Normal
Newborn
17
61
4
12
Surgical
15
31
$295,970 $137,388
$76,366
$9,159
$5,091
Delivery
11
30
$118,728
$59,215
$35,654
$5,383
$3,241
Medical
Normal
Newborn
7
12
$49,331
$14,835
$8,933
$2,119
$1,276
11
27
$11,782
$5,529
$3,329
$503
$303
Surgical
12
67
$313,671 $123,477
$76,367
$10,290
$6,364
Medical
3
52
$101,760
$39,627
$21,851
$13,209
$7,892
$65,552
Hosp proc codes
DRG for inpt
hospital
APC for outpt
hospital
Example of Detailed Data:
Patient Level Data Attributed to Clinic ABC
(not inclusive of all fields that can be provided)
Attributed DOS DOS Provider
Member From To
Name
Unique
member
identifier
within data
set but
untraceable
to actual
personal
information
CPT
Type of Code
Billed Allow Resource
Service w/Mod Units
$
$
Use
Type of
services
provided
(E&M,
Lab, Rad,
Surg, etc)
Name of
Clinic/
Group/
Hospital
providing
services
Measure
of
utilization
Repriced Addt’l
$
Fields
ICD1 ICD5
Repriced
=
Usually Resource
Use x
stated in
Relative Standard
Price
Value
Units
Hosp
proc
codes
DRG
for inpt
hosp
APC
for
outpt
hosp
Example of Detailed Data:
Patient Level Data Attributed to Clinic ABC
(not inclusive of all fields that can be provided)
Mbr
DOS
From
001
Mar 30
001
Mar 30
Mar 30
001
DOS
Type of
To Prvd TIN Service
Clinic
Mar 30 ABC
Med
Clinic
Mar 30 ABC
Med
Clinic
Mar 30 ABC
E&M
Clinic
Apr27
Med
ABC
Clinic
Apr27
Med
ABC
CPT
Code
w/Mod Units
Billed
$
90471
1
$ 12.00
Allow Resource Repriced Addt’l
$
Use
$
Fields
ICD1 $11.88
0.49
$12.00 ICD5
90744
1
$ 72.00
$38.88
0.8
$ 36.00
99212
1
$ 55.00
$54.54
1.02
$ 45.90
90471
1
$ 12.00
$11.88
0.49
$ 12.00
90744
1
$ 72.00
$8.88
0.8
$ 36.00
$9.18
0.18
$ 8.10
Hosp
proc
codes
001
Apr27
001
Apr27
001
Jul04
Jul04
Clinic X
Rad
73140
1
$ 17.00
001
Jul04
Jul04
Clinic Y
E&M
99283
1
$ 330.00 $313.50
1.71
DRG
for inpt
$ 76.95 hosp
001
Jul04
Jul04
Clinic Y
Rad
83140
2
$ 143.00 $135.85
0.73
$ 32.85
001
Jul04
Jul04
Clinic Y
Surg
12001
1
$ 282.00 $267.90
3.73
$167.85
001
Jul10
Jul10
Clinic Z
Surg
11760
1
$ 585.00 $585.00
4.4
$198.00
APC
for
outpt
hosp
Example of Detailed Data for Payers:
Similar to Provider data excluding allowed amounts
(not inclusive of all fields that can be provided)
Mbr
DOS
From
DOS
To
001
30MAR
30MAR
001
30MAR
30MAR
001
30MAR
30MAR
001
27APR
27APR
Type of
Prvd TIN Service
Clinic
Med
ABC
Clinic
Med
ABC
Clinic
ABC
E&M
Clinic
Med
ABC
CPT
Code
w/Mod
Units
90471
1
Resource Repriced Addt’l
Use
$
Fields
ICD1 $ 12.00
0.49
$12.00
ICD5
90744
1
$ 72.00
0.8
$ 36.00
99212
1
$ 55.00
1.02
$ 45.90
90471
1
$ 12.00
0.49
$ 12.00
Billed
$
Hosp
proc
codes
001
04JUL
04JUL
Clinic Y
E&M
99283
1
$ 330.00
1.71
DRG for
inpt
$ 76.95 hospital
001
04JUL
04JUL
Clinic Y
Lab
73140
1
$ 143.00
0.73
$ 32.85
001
04JUL
04JUL
Clinic Y
Surg
12001
1
$ 282.00
3.73
001
10JUL
10JUL
Clinic Z
Surg
11760
1
$ 585.00
4.4
$167.85 APC for
outpt
hospital
$198.00
Report & Data Options for Different
Audiences
Level of Detail: Options
Comparison Data: Options
Data Reporting Examples
Total Care Cost Reporting Recommendations
Cost Data Reporting for Total Care
Relativity Only
Aggregate
Components
Dollar Value or Quality Score
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
Condition Specific Cost Reporting Recommendations
Cost Data Reporting for Conditions
Relativity Only
Aggregate
Components
Dollar Value or Quality Score
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
Total Care Quality Reporting Recommendations
Quality Data Reporting for Total Care
Relativity Only
Aggregate
Components
Dollar Value or Quality Score
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
Condition Specific Quality Reporting
Recommendations
Quality Data Reporting for Conditions
Relativity Only
Aggregate
Components
Dollar Value or Quality Score
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
 Providers
 Providers
 Payers/Purchasers
 Payers/Purchasers
 Consumers
 Consumers
Modes of Communication
Phase II of PPG


Additional specific conditions
Data refinement
Problems and feedback from users
 Usefulness and access by audience
 Accuracy and completeness
 Opportunities for improvement

Evolving quality measures
 Other uses for data set
 Process and participants recommendations
 Timing of phase II activities

PPG Advisory Meeting Schedule
MEETING
DATE
TOPIC
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
f/u Quality Measures for Conditions
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
AUGUST RECESS (Draft Report distributed August 19)
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues
Meeting 9
Wednesday, September 30
Final Review