How do commercial insurers evaluate physician quality?

Often, this is done with claims-based measures and beneficiary surveys. Today, I take a more detailed look at the UnitedHealth Premium physician designation program. The program evalutates physicians based on established quality measures and–for those who meet the minimum quality requirement–a measure of efficiency (i.e., low cost). A more detailed description is available here. Without further ado…

Quality Measures

The measures used in the Premium program include National Quality Forum (NQF) Endorsed standards for claims-based measures. Non-claims measures include “National Committee for Quality Assurance (NCQA) recognition programs, Bridges to Excellence (BTE) programs, and American Board of Internal Medicine (ABIM) Practice Improvement Modules.” The UnitedHealth program also includes measures form the AQA Alliance (formerly the Ambulatory Care Quality Alliance)

Attributing Patients to Physicians

For quality measures that evaluate adherence, these measures are mapped to evidence-based practices for specific specialties. For example, asthma is mapped to allergists and primary care physicians

For cost measures, each episode is assigned (attributed) to the one physician who generated the highest percentage of services in an episode, subject to having a minimum of 30% of charges. Radiologists, pathologists, anesthesiologists, and other specialties that are not included in the Premium program are not recognized as the responsible physician.

For quality measures, multiple attribution is possible if more than one physician provides care to a patient based on the relevant attribution rules. For instance, because it defines a preventive measure, the “Cervical Cancer Screening” measure could be attributed to both an internal medicine physician and an obstetrician gynecologist. There is no multiple-attribution for cost efficiency measures.

PCP Attribution

  • Medical PCP: Physician with an allowed specialty (Internal Medicine (IM), Family Practice (FP), Pediatrics (PD) and who performed the largest number of evaluation and management type visits. The most recent” visit breaks any ties.
  • Gynecological PCP. Physician with Obstetrics and Gynecology specialty and who performed the largest number of prenatal, postpartum, or antepartum visits, or routine obstetrical care services (the most recent service breaks any ties).

Physician Eligibility

Sufficient data for the quality assessment requires a minimum of five unique patients and 20 quality measure opportunities across all conditions or procedures. “Opportunities” are the number of times a measurement criterion could have been met.

For cost efficiency, a minimum of 10 medical cases (episodes of care) or 10 procedure or surgical cases (procedure episodes) is required.

To receive high-quality designation, the physician must also be board certified. Physicians who are being tracked for potential fraud or abuse are not eligible for the program.

Episode Groupers

Episode groupers are used to aggregate claims into episode of care. Using these episodes, UnitedHealthcare evaluates physician quality and cost relative to other physicians who care for patients within the same episode type. Physicians within the same geographic region (i.e., MSA) and specialty are compared against one another. The episode groupers UnitedHealthcare employs includes:

  • Symmetry EBMConnect. EBM Connect is an Optum tool that assesses quality measures related to preventive care and medical conditions. Each instance of an EBM Connect quality measure, applied to a patient, is referred to hereafter as an EBM measure.
  • Symmetry EpisodeTreatment Groups® (ETG®). ETG is an Optum tool that creates condition-oriented episodes of care, referred to hereafter as ETG episodes.
    Symmetry Procedure Episode Group® (PEG®). PEG is an Optum tool that creates procedure-based episodes. Additional software then creates quality measures related to sequencing of care around procedures, their complications, and repeat studies or related repeat surgery/procedures. Each instance of a procedural episode-based quality measure, applied to a patient, is referred to as a PEG measure. The major procedure performed during the episode is referred to hereafter as the anchor procedure. Related interventions are the targets. If more than one major procedure occurs in a PEG episode, clinical logic determines the anchor.
  • 3M® All Patient Refined Diagnosis Related Groups (APR DRG). APR DRG software from 3M creates severity of illness levels for risk adjusting inpatient PEG quality measures and inpatient PEG episode costs.

Identifying Excellence

Physicians must perform at a level that meets or exceeds the equivalent of the 75th percentile performance for all physicians measured in order to meet the quality criteria…The 75th percentile performance rate is based on the 50th percentile expected rate that is raised to a 75th percentile rate by adding a factor based on the standard deviation of the physician’s expected compliance rate. The standard deviation (SD) is described by the following formula:

  • SD = √ [n x (p) x (1-p)]

where n is the number of opportunities and p is the physician’s expected result rate.

For cost efficiency, uses a rank-based approach. UnitedHealth removes outlier episodes (those with cost of less than $30 or with costs below the 5th percentile. To dampen the effect of having a few high cost outliers, episodes are ranked by percentile. The program then uses the Wilcoxon rank-sum test to determine if the physician’s episode ranks are statistically different from the median.

Primary Care Specialty Areas

  • Family Medicine
  • Internal Medicine
  • Obstetrics and Gynecology
  • Pediatrics

Other Specialty Areas

  • Allergy
  • Cardiology
  • Cardiology – Electrophysiology
  • Cardiology – Interventional
  • Endocrinology
  • Infectious Disease
  • Nephrology
  • Neurology
  • Neurosurgery – Spine
  • Orthopaedics – General
  • Orthopaedics – Hand
  • Orthopaedics – Foot/Ankle
  • Orthopaedics – Hip/Knee
  • Orthopaedics – Shoulder/Elbow
  • Orthopaedics – Spine
  • Pulmonology
  • Rheumatology



Leave a Reply

Your email address will not be published. Required fields are marked *