Download Provider Portal & Certification - Health Care Payment Improvement

Arkansas Payment Improvement Initiative (APII)
ADHD Certification and Reports
Statewide Webinar
May 20, 2013
0
Contents
▪ Dawn Zekis, Medicaid Health Innovation Unit Director Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit
Communications Coordinator – Initiative Update

Patricia Gann, TITLE– Value Options - Provider Portal &
certification
▪ Paula Miller – HP APII Analyst - Reports
Overview
Arkansas aims to create a sustainable patient-centered health system
Objective
Care
delivery
strategies
Enabling
initiatives
Focus of
presentation
Accountability for the Triple Aim
▪ Improving the health of the population
▪ Enhancing the patient experience of care
▪ Reducing or controlling the cost of care
Population-based care delivery
▪ Risk stratified, tailored care delivery
▪ Enhanced access
▪ Evidence-based, shared decision
making
▪ Team-based care coordination
▪ Performance transparency
Episode-based care delivery
▪ Common definition of the
patient journey
▪ Evidence-based, shared
decision making
▪ Team-based care coordination
▪ Performance transparency
Payment improvement initiative
Health care workforce development
Consumer engagement and personal responsibility
Health information technology adoption
SOURCE: State Innovation Plan
Key Design Elements
We have worked closely with providers and patients across Arkansas to
shape an approach and set of initiatives to achieve this goal
▪
Providers, patients, family members, and other
stakeholders who helped shape the new model in public
workgroups
▪
Public workgroup meetings connected to 6-8 sites
across the state through videoconference
▪
Months of research, data analysis, expert interviews
and infrastructure development to design and launch
episode-based payments
▪
Updates with many Arkansas provider associations
(e.g., AHA, AMS, Arkansas Waiver Association,
Developmental Disabilities Provider Association)
1,000+
29
26
Monthly
Episodes Update
For Medicaid, work has occurred on 15 Episodes, with 5 having gone live
Reporting Period
Start Date
Wave 1a
1
Upper Respiratory Infection
Spring 2012
July 2012
2
Attention Deficit Hyperactivity Disorder (ADHD)
Spring 2012
July 2012
3
Perinatal
Spring 2012
July 2012
Wave
1b
Seeking clinical input
Legislative
Review
4
Congestive Heart Failure
November 2012
December 2012
5
Total Joint Replacement (Hip & Knee)
November 2012
December 2012
6
Colonoscopy
May 2013
Q2 CY 2013
7
Cholecystectomy (Gallbladder Removal)
May 2013
Q2 CY 2013
8
Tonsillectomy
May 2013
Q2 CY 2013
9
Oppositional Defiance Disorder (ODD)
May 2013
Q2 CY 2013
10
Coronary Artery Bypass Grafting (CABG)
July 2013
Q3 CY 2013
11
Percutaneous Coronary Intervention (PCI)
12
Asthma
July 2013
Q3 CY 2013
13
Chronic Obstructive Pulmonary Disease (COPD)
14
ADHD/ODD Comorbidity
July 2013
Q3 CY 2013
15
Neonatal
Q3 CY 2013
H2 CY 2013
…
Undecided
Q1 2014
…
…
Undecided
Q1 2014
…
…
Undecided
Q1 2014
…
…
Undecided
Q1 2014
…
Wave 2b
Wave 2c
(not started)
Wave 2
Live
Episode
Wave 2a
Wave 1
In Development
1 Participation includes development and rollout of episode
Pending legislative
review
Multipayer
Participation1
Contents
▪ Dawn Zekis, Medicaid Health Innovation Unit Director Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update

Patricia Gann, TITLE– Value Options - Provider Portal &
certification
▪ Paula Miller – HP APII Analyst - Reports
Upcoming Workgroup Meetings
•
May 22nd 4pm-6pm: Neonatal #2 Public Workgroup
•
May 28th 3:30pm-5:30pm: Long Term Services and Supports Public
Workgroup
Contents
▪ Dawn Zekis, Medicaid Health Innovation Unit Director Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update

Patricia Gann, TITLE– Value Options - Provider Portal &
Certification
▪ Paula Miller – HP APII Analyst - Reports
The provider portal is a multi-payer tool that allows providers to enter quality metrics for
certain episodes and access their PAP reports
Details on the provider portal
Login to portal from payment
initiative website
▪ Accessible to all PAPs
– Login with existing username/ password
– New users follow enrollment process detailed online
▪ Key components of the portal are to provide a way for
providers to
– Enter additional quality metrics for select episodes
(Hip, Knee, CHF and ADHD with potential for other
episodes in the future)
– Access current and past performance reports for all
payers where designated the PAP
NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.
Provider Portal
Provider Portal
Provider Portal
Provider Portal
To obtain access to the AHIN provider portal
On the login screen of the AHIN portal the provider can click the link Click here to enroll for APII access if not a current AHIN user or
contact Customer Support (501) 378-2336 or
email [email protected]
Provider Portal
Provider Portal
To obtain access to the AHIN provider portal
On the login screen of the AHIN portal the provider can click the link Click here to enroll for APII access if not a current AHIN user or
contact Customer Support (501) 378-2336 or
email [email protected]
Provider Portal
DMS-IV Guidelines
Provider Portal
DMS-IV Guidelines
Certification would be required at the key points in care: entry into system,
episode recurrence, and increase in severity
Completion details
For which patients?
▪
A
‘Quality
Assessment’
certification
▪
B
‘Continuing
care’
certification
▪
C
‘Severity’
certification
All patients new to
treatment and
entering episode
model
All recurring ADHD
patients within
episode model
All patients
escalated to level 2
care, whether firsttime or recurring
▪
Completed after
assessment, to initiate
treatment
▪
Completed by provider
who will deliver care
▪
Completed at episode
recurrence (every 12
months)
▪
Completed by provider
who will continue care
▪
Completed at initial
escalation and every
level two episode
recurrence
▪
Completed by provider
who will deliver level two
care
Description
▪
Requires providers to certify completion of
several guideline-concordant components of
assessment
▪
Encourages thoughtful and high-quality
assessment and diagnosis
▪
Encourages appropriate diagnosis of
comorbid conditions
Requires providers to certify adherence to
basic quality of care measures and guideline
concordant care
▪
▪
Encourages regular re-evaluation of patient
and management at physician level
▪
Requires providers to certify severity for
patients placed into level two care
▪
Completed by physician providing level two
care
Contents
▪ Dawn Zekis, Medicaid Health Innovation Unit Director Overview of the Healthcare Payment Improvement Initiative
▪ Shelley Tounzen, Medicaid Health Innovation Unit Public
Information Coordinator – Initiative Update

Patricia Gann, TITLE– Value Options - Provider Portal &
Certification
▪ Paula Miller – HP APII Analyst - Reports
Version 1.0 design elements specific to ADHD
▪ Any ADHD treatment (defined by primary diagnosis ICD-9 code), with exception of
1
Episode definition/ scope
of services
▪
▪
2
Principal accountable
provider(s)
assessment CPT codes, is included in the episode
Start of episode
– For new patients, episode begins on date of treatment initiation
– For recurring patients, new episode starts on date of first treatment after
previous episode ends (e.g. office visit or Rx filled)
The episode will have a duration of 12 months
▪ PCP, psychiatrist or licensed clinical psychologist eligible to be the PAP
– For Version 1.0, RSPMI provider organization will be official PAP when listed as
billing provider, but reporting will be provided at performing provider level where
available
▪ If licensed clinical psychologist treats patient, a co-PAP is required and providers share
gain / risk sharing
3
Patient severity levels and
exclusions
▪ Includes all ADHD patients aged 6 – 17 without behavioral health comorbid conditions1
▪ Two patient severity levels will be included
– Patients with positive response to medication management, requiring only
▪
1.
2.
medication and parent / teacher administered support
– Patients for whom response to medication management is inadequate and
therefore psychosocial interventions are medically indicated
Severity will be determined by a provider certification
4 – 5 year olds will continue to be paid fee-for-service in version 1.0 because of limited evidence-based treatment guidelines and consensus
Level II episodes will not be available in July due to lack of data from the provider portal. Level II episodes started on October 2012
ADHD algorithm summary (1/2)
Medicaid ADHD episode v1.0
Triggers
Level I subtype episodes are triggered by either two medical claims with a primary diagnosis of ADHD or a medical claim with a primary
diagnosis of ADHD as well as a pharmacy claim for medication used to treat ADHD. Level II subtype episodes are triggered by a completed
Severity Certification followed by either two medical claims with a primary diagnosis of ADHD or a medical claim with a primary diagnosis of
ADHD as well as a pharmacy claim for medication used to treat ADHD.
PAP
assignment
Determination of the Principal Accountable Provider (PAP) is based upon which provider is responsible for the largest number of claims within
the episode.
If the provider responsible for the largest number of claims is a physician or an RSPMI provider organization, that provider is designated the
PAP. In instances in which two providers are responsible for an equal number of claims within the episode, the provider whose claims
accounted for a greater proportion of total reimbursement will be designated PAP.
If the provider responsible for the largest number of claims is a licensed clinical psychologist operating outside of an RSPMI provider
organization, that provider is a co-PAP with the physician or RSPMI provider providing the next largest number of claims within the episode. In
instances in which two providers are responsible for an equal number of claims within the episode, the provider whose claims accounted for a
greater proportion of total reimbursement will be designated co-PAP.
Where there are co-PAPs for an episode, the positive or negative supplemental payments are divided equally between the co-PAPs.
Exclusions
Episodes meeting one or more of the following criteria will be excluded:
A. Duration of less than 4 months
B. Small number of medical and/or pharmacy claims during the episode
C. Beneficiaries with any behavioral health comorbid condition
D. Beneficiaries age 5 or younger and beneficiaries age 18 or older at the time of the initial claim
Episode time
window
The standard episode duration is a 12-month period beginning at the time of the first trigger claim. A Level I episode will conclude at the
initiation of a new Level II episode if a Severity Certification is completed during the 12-month period.
Claims
included
All claims with a primary diagnosis of ADHD as well as all medications indicated for ADHD or used in the treatment of ADHD.
Quality
measures
Quality measures “to pass”:
1. Percentage of episodes with completion of either Continuing Care or Quality Assessment certification – must meet minimum threshold of
90% of episodes
Quality measures “to track”:
1. In order to track and evaluate selected quality measures, providers are asked to complete a “Quality Assessment” certification (for
beneficiaries new to the provider) and a “Continuing Care” certification (for beneficiaries previously receiving services from the provider)
2. Percentage of episodes classified as Level II
3. Average number of physician visits/episode
4. Percentage of episodes with medication
5. Percentage of episodes certified as non-guideline concordant
6. Percentage of episodes certified as non-guideline concordant with no rationale
Adjustments
Total reimbursement attributable to the PAP for episodes with a duration of less than 12 months will be scaled linearly to determine a
reimbursement per 12-months for the purpose of calculating the PAP’s performance.
ADHD algorithm summary (1/2)
Medicaid ADHD episode v1.0
Trigger
codes
Diagnosis or medication that would trigger the episode
ICD-9 codes (on Professional claim): 314.xx
HIC3: H7Y, H8M, H2V, J5B
CPT codes for assessment: 90801, 96101, 96118, T1023
Exclusion
codes
The following ICD-9 diagnoses exclude an episode. The same diagnosis must appear at least twice within the year to qualify for
exclusion.
ICD-9: 290.xx, 291.xx, 292.xx, 293.xx, 294.xx, 295.xx, 296.xx, 297.xx, 298.xx, 299.xx¹, 300.xx, 301.xx, 302.xx, 303.xx, 304.xx,
305.xx, 306.xx, 307.xx, 308.xx, 309.xx, 310.xx, 311.xx, 312.xx, 313.xx, 315.xx¹, 317.xx¹, 318.xx¹, 319.xx¹
These codes represent the set of business and clinical exclusions described previously
Included
claim
codes
Any claim with a primary diagnosis of ADHD – defined by the following ICD-9 codes – is included.
ICD-9-CM code: 314.xx
Further, all pharmacy claims for medications with the following HIC3 classification are included.
HIC3 code: A4B, H2E, H2G, H2M, H2S, H2U, H2V, H2W, H2X, H7B, H7C, H7D, H7E, H7J, H7O, H7P, H7R, H7S, H7T, H7U, H7X,
H7Y, H7Z, H8H, H8I, H8J, H8M, H8O, H8P, J5B
List of CPT codes for psychosocial therapy claims within the episode
'OFFICE' codes: 01, 02, 03, 04
Psychosocial visits: 90846, 90847, 90849, 90853, 97110, 97150, 97530, 97532, 97535, H0004, H0046, H2011, H2015, H2017,
H2012
1 Please note that DD comorbid exclusions (ICD-9 299.xx, 315.xx, 317.xx, 318.xx, 319.xx) will not be applied until July 2013 release
PAPs will be provided tools to help measure and improve patient care
Example of provider reports
▪ Overview of quality across a PAP’s
episodes
▪ Overview of cost effectiveness (how a
PAP is doing relative to cost thresholds
and relative to other providers)
▪ Overview of utilization and drivers of a
PAP’s average episode cost
Medicaid
Little Rock Clinic
123456789
July 2012
Performance summary (Informational)
Upper Respiratory Infection –
Pharyngitis
Upper Respiratory Infection –
Sinusitis
Quality of service
requirements: Not met
Quality of service
requirements: N/A
Average episode cost:
Acceptable
Average episode cost:
Commendable
Your gain/risk share
You are not eligible
for gain sharing
Your gain/risk share
Medicaid
$0
Little Rock Clinic
$x
Overview
Upper Respiratory Infection –
Perinatal
Total episodes: 262
Non-specific URI
Quality of service
requirements: N/A
July 2012
Total episodes included: 233
Total episodes excluded: 29
Gain/Risk share
Cost of care
compared
to other providers
Quality
of service
requirements: Met
Commendable
Average episode cost:
Not acceptable
< $70
Your gain/risk share
You are subject to
risk sharing
123456789
You will receive gain
sharing
Summary – Pharyngitis
Acceptable
Not acceptable
Average$70
episode
to $100 cost:
Acceptable
> $100
Your gain/risk share
$x Quality summary
You will not receive
gain or risk sharing
$0
$0
You
All provider
average
You are not eligible for gain sharing
 Quality requirements: Not met
 Average episode cost: Acceptable
Medicaid
Cost summary
Little Rock Clinic
You
Quality metrics – linked to gain sharing
Attention Deficit/
Hyperactivity Disorder (ADHD) % episodes with
strep test when
antibiotic filled
Quality of service
requirements: N/A
July 2012
Your total cost overview, $
Quality metrics – not linked to gain sharing
$0
% episodes with
at least one
antibiotic filled
% episodes with 6%
multiple courses
of antibiotics filled
Average cost overview, $
Metric
Percentile
You 25th 50th 75th
You (nonYou
% of episodes
that had a
strep
adjusted)
(adjusted)
30%
Your episode
cost distribution
% of episodes
with at least
one
64% 44% 60%
antibiotic filled
80
100
75%
$40
58%
10%
$40$55
5%
45
29
6%
$55–
$70
23
3%
$70–
$85
0
All providers
99%
50 with15
23
% of episodes
multiple
courses of antibiotics filled
64%
You
81%
test when an anti-biotic was filled
Your gain/risk share
Metric with a minimum quality requirement
Minimum quality requirement
25,480 Performance compared
Quality metrics:
to provider
distribution
84
81
20,150
48%
66%
Average episode cost:
Acceptable
You will not receive
gain or risk sharing
123456789
Quality and utilization
– Pharyngitis
Your average cost is detail
acceptable
You did not meet the minimum quality requirements
# episodes
Reports provide performance
information for PAP’s episode(s):
75
100
-
18
10%
$85$100
Percentile
50
25
-
Medicaid
-
20%
Little Rock Clinic
123456789
July 2012
$100- >$115
$115
Cost detail – Pharyngitis
You did not meet the minimum acceptable quality requirements
Distribution of provider average episode cost
Total episodes included = 233
You
80
All providers
Cost, $
Utilization metrics: Performance compared to provider distribution
Metric
60 3
Percentile
You
40
25th Care
50th 75th
Does not meet minimum quality requirements
Minimum quality requirement
All providers
category
Average number of visits per
episode
You
Commendable
1.7
Key utilization metrics
Avg number of visits per episode
1.7
1.1
% episodes with antibiotics
64%
1.1
Acceptable
You
1.3
# and % of episodes
Percentile
in care
0 with claims
25
50
category
75
Average cost per
episode
100 when care
category utilized, $
Total cost in care
category, $
2.3
Percentile
89
Not acceptable
Outpatient
professional
All providers
500
51%
600
10,625
9,492
48%
77
Emergency
department
49%
3,000
52%
2,500
3,865
3,409
30%
221
Pharmacy
4
Outpatient
radiology /
procedures
184
Outpatient
lab
21
Outpatient
surgery
16
95%
59
1,237
97%
51
1,307
79%
81
1,321
77%
81
944
9%
194
11%
179
7%
2,260
1,251
1,400
5%
1,062
1,400
1,062
5
Other
12
5%
62
433
3%
69
643
6
NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.
Medicaid
Little Rock Clinic
123456789
April 2013
Arkansas Health Care Payment Improvement Initiative
Provider Report
Medicaid
Report date: April 2013
Historical performance: January 1, 2012 – December 31, 2012
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
Division of Medical Services
P.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 501-3018311 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, PhD
Medicaid Director
Medicaid
Little Rock Clinic
123456789
Table of contents
Performance summary
Attention Deficit/Hyperactivity Disorder (ADHD) – Level I
Attention Deficit/Hyperactivity Disorder (ADHD) – Level II
Cholecystectomy
Colonoscopy
Congestive Heart Failure
Oppositional Defiant Disorder
Perinatal
Tonsillectomy
Total Joint Replacement
Upper Respiratory Infection – Non-specific URI
Upper Respiratory Infection – Pharyngitis
Upper Respiratory Infection – Sinusitis
Glossary
Appendix: Episode level detail
April 2013
Medicaid
Little Rock Clinic
123456789
April 2013
Performance summary
1
Quality of services and cost summary
Quality
of Service
Average
Episode Cost
Your Gain/Risk Share
Share
Amount
Attention Deficit / Hyperactivity Disorder
(ADHD) – Level I
Met
Acceptable
Not eligible for gain sharing
$0.00
Attention Deficit / Hyperactivity Disorder
(ADHD) – Level II
Met
Acceptable
Not eligible for gain sharing
$0.00
Cholecystectomy
Met
Acceptable
Not eligible for gain sharing
$0.00
Colonoscopy
Met
Acceptable
Not eligible for gain sharing
$0.00
Congestive Heart Failure
Not met
Acceptable
Not eligible for gain sharing
$0.00
Oppositional Defiant Disorder
Met
Acceptable
Not eligible for gain sharing
$0.00
Perinatal
Met
Acceptable
Not eligible for gain sharing
$0.00
Tonsillectomy
Met
Acceptable
Not eligible for gain sharing
$0.00
Total Joint Replacement
N/A
Acceptable
Not eligible for gain sharing
$0.00
N/A
Not acceptable
Subject to risk sharing
-$3,844.50
Not met
Acceptable
Not eligible for gain sharing
$0.00
N/A
Commendable
Will receive gain sharing
$349.50
Episode of Care
Upper Respiratory Infection – Nonspecific URI
Upper Respiratory Infection –
Pharyngitis
Upper Respiratory Infection – Sinusitis
Across these Episodes of Care You are Subject to Risk Sharing:
Stop-loss was applied
-$3,000.00
Medicaid
Little Rock Clinic
123456789
April 2013
Summary – ADHD: Level I closed episodes
1
Overview
Total episodes: 262
2
Total episodes included: 233
Cost of care compared to other providers
Commendable
< $1,547
3
Total episodes excluded: 29
Acceptable
$1,547 to $2,223
Gain/Risk share
Not acceptable
>>$2,223
$4000
Quality summary
50%
There are no quality metrics
0% to gain sharing generated
linked
from claims
quality
Youdata. Selected
Avg
data submitted on the Provider
Portal will generate additional
quality metrics for future reports.
You will not receive gain or risk sharing
 Selected quality metrics: N/A
 Average episode cost: Acceptable
Cost summary
Your average cost is acceptable
Your total cost overview, $
512,000
466,000
Episodes with medication
100%
You (nonadjusted)
50%
0%
Average cost overview, $
2,000
1,750
You
(adjusted)
You
100
50
50%
0%
84
15
23
<$700
$700$1547
42
28
$1547$1772
$1772$1998
$1998-$2223
23
$2223$10157
Cost,
$
5000
2500
0
You
You
Avg
Commendable
Acceptable
Percentile
Not acceptable
Key utilization metrics
4.1
3.9
>$10157
7500
10
Average number of visits per episode
18
Distribution of provider average episode cost
You
Avg
Avg. # of physician visits
20
5
All providers
Your episode cost distribution
You
Avg
% Level I episodes
100%
#
episodes
Standard
for gain
sharing
% Completed certification
100%
All providers
4
You achieved selected quality metrics
Linked to gain sharing
$0
You
Average number of psychosocial visits per episode
62
38
You
All providers
Medicaid
Little Rock Clinic
123456789
April 2013
Quality and utilization detail – ADHD: Level I closed
You
1
Metric linked to gain sharing
Minimum standard for gain sharing
Quality metrics: Performance compared to provider distribution
Metric
You
25th
Percentile
50th
75th
% with completed certification
92%
50%
75%
85%
% of episodes with medication
48%
40%
52%
67%
% of episodes that are Level I
25%
20%
30%
40%
4.1
2.3
3.9
4.3
% non-guideline concordant
28%
10%
30%
50%
% non-guideline no rationale
15%
5%
15%
25%
Avg. physician visits per episode
0
25
Percentile
50
75
100
-
-
You achieved selected quality metrics
2
Utilization metrics: Performance compared to provider distribution
Metric
You
25th
Percentile
50th
75th
Average number of visits per episode
4.1
2.3
3.9
4.3
Average number of psychosocial visits per
episode
62
15
38
74
0
25
Percentile
50
75
100
Medicaid
Little Rock Clinic
123456789
April 2013
Cost detail – ADHD: Level I closed episodes
Total episode included = 233
Care category
Outpatient
professional
Pharmacy
Emergency
department
Outpatient lab
You
# and % of episodes with claims
in care category
233
100%
100%
230
99%
99%
221
95%
97%
79%
77%
184
Average cost per episode
when care category
utilized, $
All provider average
Total vs. expected cost
in care category, $
550
500
128,150
116,500
2,415
2,400
76
76
81
[email protected]
555,450
552,000
16,796
16,796
81
14,904
14,904
Outpatient
radiology /
procedures
21
75%
80%
117
95
2,457
1,995
Inpatient
professional
16
78%
75%
70
75
1,120
1,200
Inpatient facility
Outpatient
surgery
Other
12
5%
3%
69
62
828
744
1
<1%
<1%
97
84
97
84
7
3%
4%
25
27
175
189
Questions
For more information talk with provider support representatives…
▪ More information on the Payment Improvement Initiative
Online
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
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]