Methodology for DFW Diabetes Care Reports

• Measures and measures specifications
• Data used to construct measured results
• Identifying the eligible patient population
• Assigning patients to physicians
• Constructing physician diabetes care results
• Developing a master physician list
• Validating the results
• Limitations of using administrative claims data
• Physician reporting
• Pilot testing of DFW Diabetes Care Reports

Measures and measures specifications

The Partnership for Peak Healthcare Performance (PPHP) Leadership Team chose measures that are:

• Consistent, clearly defined, standardized and nationally recognized and endorsed
• Could be calculated using the available administrative claims data

The measures are:

• A1c testing
• LDL cholesterol testing
• Nephropathy testing or evidence of treatment (includes ACE inhibitor/ARB therapy)
• Retinal exams (performed by eye care professional)

All four measures, based on calendar year claims data for the measurement year, use the Healthcare Effectiveness Data and Information Set (HEDIS) Technical specifications related to that measurement year. The measurement year is the calendar year identified on the report (calendar year 2008 is the measurement year reported in October, 2010; baseline data for 2007 was reported in May, 2009).

Results for each measure are calculated as a ratio:

# of qualifying patients who received the service, based on claims data

all eligible patients who should have received a particular service

For each physician, health plans determine which patients should be included in the ratio using the HEDIS specifications for eligible diabetes patients. Patient information is aggregated by physician to ensure patient confidentiality and sent by the health plans to Austin Provider Solutions Inc. (APS), a third-party vendor contracted by the DFWBGH to aggregate the data and generate physician reports.

In addition to the four process measurements listed above, health plans capture A1c and LDL lab values when they can be linked to the prescribing physician. Lab values can be linked to physicians for less than a third of the eligible diabetes patients. Although these data are incomplete and cannot be considered reliable, an average of available A1c and LDL values is calculated for each physician as information only. As technology for collecting these values improves, these data will become more valuable to physicians for tracking diabetes care management for their population of patients.

Data used to construct measured results

The PPHP project combines calendar year commercial PPO and POS administrative claims data from five commercial DFW health plans (Aetna, Blue Cross Blue Shield of Texas, CIGNA, Humana and UnitedHealthcare) to generate physician-level diabetes care measures. (Note: Aetna's indemnity claims data was included in the calendar year 2007 data reported May, 2009.) No hybrid data (data including chart reviews) are used. Data used to generate the measures include:

• Eligibility files
• Provider files
• Medical claims files
• Laboratory claims files
• Laboratory results
• Pharmacy claims files

Identifying the eligible patient population

The eligible patient population is comprised of adult diabetes patients with commercial PPO and POS plans administered or offered by the five participating health plans. Eligible patients meet the following criteria:

• Age 18 to 75 years as of Dec. 31 of the measurement year.
• Continuously enrolled with one health plan, with no more than one gap in coverage of up to 45 days during the measurement year.
• Identified as having diabetes through a diabetes diagnosis, or evidence of insulin or oral hypoglycemics/antihyperglycemics use during the measurement year or year prior.

Assigning patients to physicians

The health plans assign patients to the physician who saw the patient the most during the measurement year, so each patient is assigned to just one physician. In the event of a "tie" in the number of visits a patient has with two or more physicians, the patient is assigned to the physician with whom s/he has had the most recent visit.

Only physicians with practice specialties of endocrinology, family practice, general practice and internal medicine are included in the project. Many physicians have multiple specialty designations across the commercial health plans. A single, primary specialty is assigned to each.

The patient is assigned to just one physician because of the Leadership Team's interest in promoting a "medical home" model of patient care in which the physician the patient sees most assumes a lead role in managing overall care.

Constructing physician diabetes care results

After patients are assigned to physicians, patient data is summarized at the physician level and submitted by the health plans to APS for aggregation across the five health plans. This produces a consolidated set of physician-level results for each of the measures.

Developing a master physician list

Part of the work of aggregating data from different health plans involves matching providers across the five plans to identify a single set of unique physicians. Given the absence of a single, commonly used identifier for individual physicians, the health plans provide tax ID numbers with three characters of the provider's last name and two characters of the first name appended. Each plan also provides any other commonly used identifiers (i.e. Unique Physician Identification Number and the new National Provider Identifier or NPI). APS developed software to use all this information to test for a variety of factors in determining physician matches and assigns its own unique provider IDs for this study.

Validating the results

The PPHP calculates and compares the overall physician averages for each of the participating health plans, and compares the overall regional average aggregated results to national benchmarks to check for anomalies that could indicate problems in the collection or aggregation methodology. Comparisons are made to:

• Commercial HEDIS audit means for PPOs (NCQA)
• Commercial HEDIS 90th percentile for PPOs (NCQA)

Overall averages by health plan are also compared to each other to look for outlying data that could indicate problems. Additionally physician members of PPHP committees review their own results for reasonableness.

Limitations of using administrative claims data

PPHP acknowledges the limitations of using administrative claims data for accurately calculating diabetes care measures. For example, vision care services may not be captured because claims were filed through vision care coverage instead of the medical plan. Additionally, the measurements reflect not just physician activity, but also patient adherence, health plan design and claims coding. Still, the measurements from this study will have value for physicians in several ways:

• Aggregating data across five health plans provides a larger sample of patients and a broader, more statistically significant view of the care a physician's diabetes patients receive.
• Consistent measurement criteria and methodology across the five health plans provides meaningful comparisons of individual physician results to the regional average.
• Comparing individual physician results among health plans may show claims coding and processing differences that can be corrected for more accurate data going forward.

Also, the PPHP and the health plans can use these data to identify how different health plan benefit designs may affect access to care, care management, and patient compliance.

Physician reporting

The PPHP project is reporting all aggregated results to physicians to share whatever information is available about their patients. Reports were sent only to those physicians to whom 20 or more eligible diabetes patients were assigned; fewer than 20 patients is too small a sample for reliable reporting.

Pilot testing of DFW Diabetes Care Reports

The PPHP worked closely with physicians to engage them in the review and modification of the Diabetes Care Report that would share results. Physicians served on the committee responsible for design of the report, which was then approved by the Leadership Team. Practicing physicians from all the PPHP committees were asked to review and comment on their own results (including report format, content, and data validity). The PPHP Physician Advisory Council also reviewed report format, summary data results and communications materials accompanying the reports. The final report format and content incorporated feedback from all these groups.

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