Knee and Hip Replacement and Spine Surgery

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Selection Criteria and Program Documentation: Knee and Hip Replacement and Spine Surgery

Released October 2015

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Capabilities Survey®

About This Document ...... 1 About This Document

About the Blue Distinction This Selection Criteria and Program Documentation outlines the Selection Criteria and Specialty Care Program ...... 1 evaluation process used to determine eligibility for the Blue Distinction Centers for Knee and Hip Replacement and Blue Distinction Centers for Spine Surgery programs (the Understanding the Evaluation Program[s]). Process ...... 2 The document is organized into three sections. The first section describes the overall evaluation process and data sources applicable for both the Knee and Hip Replacement Knee and Hip Replacement and Spine Surgery programs. The next section describes the Knee and Hip Replacement Quality Selection program’s quality, business, and cost Selection Criteria. The last section describes the Criteria ...... 4 quality, business, and cost Selection Criteria for the Spine Surgery program.

Knee and Hip Replacement Business Selection About the Blue Distinction Specialty Care Program Criteria ...... 8 Blue Distinction Specialty Care is a national designation program recognizing healthcare facilities that demonstrate expertise in delivering quality specialty care — safely, effectively, Knee and Hip Replacement and cost efficiently. The goal of the program is to help consumers find both quality and Cost of Care Selection value for their specialty care needs, while encouraging healthcare professionals to improve Criteria ...... 9 the overall quality and delivery of healthcare nationwide, and providing a credible foundation for local Blue Cross and/or Blue Shield Plans (Blue Plans) to design benefits Spine Surgery Quality 1 tailored to meet employers’ quality and cost objectives . The Blue Distinction Specialty Selection Criteria ...... 12 Care Program includes two levels of designation:

Spine Surgery Business  Blue Distinction Centers (BDC): Healthcare facilities recognized for their expertise Selection Criteria ...... 15 in delivering specialty care.  Blue Distinction Centers+ (BDC+): Healthcare facilities recognized for their Spine Surgery Cost of Care expertise and cost-efficiency in delivering specialty care. Selection Criteria ...... 16

Quality is key: only those facilities that first meet nationally established, objective quality Questions ...... 19 measures for BDC will be considered for designation as a BDC+.

Facilities are evaluated on objective, transparent Selection Criteria with quality, business, and cost of care components. These Programs focus on total knee replacement, total hip replacement, cervical and lumbar fusion, cervical laminectomy, and lumbar laminectomy/ discectomy procedures. Facilities considered for these Programs are defined as comprehensive, acute care, inpatient facilities. Early in 2015, local Blue Plans invited facilities to be considered for the BDC or BDC+ designations. Of the 2,700 facilities invited across the country, over 1,400 facilities applied for the Knee and Hip Replacement and/or the Spine Surgery designation(s).

1 Benefit design is determined independently by the local Blue Plan and is not a feature of any Blue Distinction program.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 1 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Understanding the Evaluation Process About This Document ...... 1 Selection Process About the Blue Distinction Specialty Care Program ...... 1 The selection process balances quality, cost, and access considerations to offer consumers meaningful differentiation in value for specialty care facilities that are designated as BDC and BDC+. Guiding principles for the selection process include: Understanding the Evaluation Process ...... 2 Quality

Knee and Hip Replacement  Nationally consistent approach to evaluating quality and safety was used, Quality Selection incorporating quality measures with meaningful impact, including delivery system Criteria ...... 4 features and specific quality outcomes to which all can aspire.

Knee and Hip Replacement Cost Business Selection  Nationally consistent and objective approach for selecting BDC+ was used to Criteria ...... 8 address market and consumer demand for cost savings and affordable healthcare.

Knee and Hip Replacement Access Cost of Care Selection Criteria ...... 9  Blue members’ access to Blue Distinction Centers was considered, as needed, to achieve the program’s overall goal of providing differentiated performance on quality and, for the BDC+ designation, cost of care. Spine Surgery Quality Selection Criteria ...... 12

Spine Surgery Business Selection Criteria ...... 15

Spine Surgery Cost of Care Selection Criteria ...... 16

Questions ...... 19

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 2 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Evaluation Components: Data Sources About This Document ...... 1 Objective data from a detailed Provider Survey, publicly available quality data, Blue Plan About the Blue Distinction healthcare claims data, and Plan Survey information were used to evaluate and identify Specialty Care Program ...... 1 facilities that meet the Program’s Selection Criteria. A facility must meet the Program’s specific Selection Criteria, defined by the following evaluation components (Table 1), to be eligible for the BDC or BDC+ designation: Understanding the Evaluation Process ...... 2 Table 1: Evaluation Components

Knee and Hip Replacement BLUE BLUE Quality Selection EVALUATION DISTINCTION DISTINCTION DATA SOURCE Criteria...... 4 COMPONENT CENTERS CENTERS+ (BDC) (BDC+)

Knee and Hip Replacement 1. Information obtained from a Business Selection facility in the Provider Survey. Criteria...... 8 2. Publicly available data from Quality: Hospital Compare’s December Knee and Hip Knee and Hip Replacement 2014 release.   Replacement Cost of Care Selection www.hospitalcompare.hhs.gov Criteria...... 9 3. Blue Plan healthcare claims data Spine Surgery Quality Quality: 1. Information obtained from a Selection Criteria ...... 12 Spine facility in the Provider Survey.   Surgery

Spine Surgery Business 1. Information obtained from the Selection Criteria ...... 15 local Blue Plan, for facilities within its Service Area, on: Spine Surgery Cost of Care  Facility and Surgeons’ Selection Criteria ...... 16 Participation Status in the Business: local Blue Plan’s BlueCard® Knee and Hip Preferred Provider Questions ...... 19 Replacement Organization (PPO)   AND Network. Spine  Local Blue Plan Criteria, if Surgery applicable. 2. Information obtained by BCBSA on whether the facility meets BCBSA criteria for avoiding conflicts with BCBSA logos and trademarks. Cost of Care: 1. Blue Plan healthcare claims Knee and Hip data. Replacement AND  Spine Surgery

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 3 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Measurement Framework About This Document ...... 1 The Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery programs established a nationally consistent approach to evaluating quality and safety by About the Blue Distinction Specialty Care Program ...... 1 incorporating quality measures with meaningful impact, with criteria that will evolve over time through future evaluation cycles, consistent with medical advances and measurement in this specialty area. Measurement framework for this and other Blue Distinction value- Understanding the Evaluation based initiatives were developed using the following guiding principles: Process ...... 2

1. Utilize a credible process and produce credible results with meaningful Knee and Hip Replacement differentiated outcomes. Quality Selection Criteria...... 4 2. Align with other national efforts using established measures, where appropriate and feasible.

Knee and Hip Replacement 3. Simplify and streamline measures and reporting processes. Business Selection Criteria...... 8 4. Enhance transparency and ease of explaining program methods.

5. Utilize existing resources effectively to minimize costs and redundancies. Knee and Hip Replacement Cost of Care Selection 6. Meet existing and future demands from Blue Plans, national accounts, and Blue Criteria...... 9 Members.

Spine Surgery Quality Knee and Hip Replacement Quality Selection Criteria Selection Criteria ...... 12 Facilities were evaluated on quality metrics developed through a process that included: Spine Surgery Business input from the medical community and quality measurement experts; review of medical Selection Criteria ...... 15 literature, together with national quality and safety initiatives; and a thorough analysis of meaningful quality measures from objective, publicly available sources. The quality Spine Surgery Cost of Care evaluation for facilities was based on objective, publicly available quality metrics obtained Selection Criteria ...... 16 from Hospital Compare, nationally established metrics calculated from Blue Plan healthcare claims data, and facility responses to the Provider Survey. Questions ...... 19 The quality Selection Criteria includes general facility structure metrics and knee and hip replacement specific outcome metrics. Additionally, the quality Selection Criteria utilized two outcome measures:  Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA).  Hospital-level 30-day, all-cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). These measures were created by the Yale/New Haven Center for Outcomes Research and Evaluation (CORE) under contract by Centers for Medicare and Medicaid Services (CMS). The measures are NQF-endorsed for use in the 65 and older population. More information about these measures can be found at https://www.medicare.gov/hospitalcompare/Data/RCD-Overview.html.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 4 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Separate quality Selection Criteria was established for these outcome measures for each About This Document ...... 1 data source. The first uses Hospital Compare Data released by CMS in December 2014 using the population of 65 and older covered under Medicare. The second uses Blue Plans About the Blue Distinction healthcare claims data for the 18 to 64 aged population. Specialty Care Program ...... 1 For use in Blue Plans healthcare claims data, the measure specifications were modified as follows: Understanding the Evaluation Process ...... 2  Calculated the measures for the 18 to 64 aged population with inpatient dates of service from July 1, 2011 through June 30, 2013 for the trigger procedure. Knee and Hip Replacement  Required one year of data with continuous Blue Plan enrollment following the Quality Selection trigger procedure. Criteria...... 4  Included Members from all commercial products (i.e. PPO, HMO). Medicare and

Knee and Hip Replacement Medicaid claims were excluded. Business Selection Measurement results from each of the data sources (Hospital Compare and Blue Plan Criteria...... 8 healthcare claims data) were calculated separately and are included in the quality Selection Criteria. Knee and Hip Replacement Table 2 below identifies all of the domains used in the quality evaluation for Knee and Hip Cost of Care Selection Criteria...... 9 Replacement. A facility must meet all requirements in Table 2 to meet the Quality evaluation of the overall eligibility decision for the Blue Distinction Centers for Knee and Hip Replacement designation. Spine Surgery Quality Selection Criteria ...... 12

Spine Surgery Business Selection Criteria ...... 15

Spine Surgery Cost of Care Selection Criteria ...... 16

Questions ...... 19

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 5 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Table 2: Knee and Hip Replacement Quality Selection Criteria About This Document ...... 1 ALL SELECTION CRITERIA MUST BE MET FOR ELIGIBILITY CONSIDERATION About the Blue Distinction Specialty Care Program ...... 1 DOMAIN SOURCE QUALITY SELECTION CRITERIA

National Accreditation* Provider The facility is fully accredited by at least one of Understanding the Evaluation Survey the following national accreditation Process ...... 2 Q#3 organizations:*  The Joint Commission (TJC) (without Knee and Hip Replacement provision or condition) in the Hospital Quality Selection Accreditation Program. Criteria ...... 4  Healthcare Facilities Accreditation Program (HFAP) of the American Knee and Hip Replacement Osteopathic Information Association Business Selection (AOIA) as an acute care hospital. Criteria ...... 8  National Integrated Accreditation Program (NIAHOSM)—Acute Care of DNV GL Healthcare. Knee and Hip Replacement Cost of Care Selection  Center for Improvement in Healthcare Criteria ...... 9 Quality (CIHQ) in the Hospital Accreditation Program. *NOTE: To enhance quality while improving Blue Spine Surgery Quality Members' access to qualified providers, alternate local Selection Criteria ...... 12 Accreditations that are at least as stringent as any National Accreditations, above, may be offered under the local Blue Plan Criteria; for details, contact the facility's local Blue Plan. Spine Surgery Business Selection Criteria ...... 15 Comprehensive Facility Provider The facility is a comprehensive acute care Survey facility that offers all of the following services on Spine Surgery Cost of Care Q#4 site: Selection Criteria ...... 16  Intensive care unit;  Emergency Room or Emergency Questions ...... 19 Services that include plans or systems for onsite emergency admission of post- operative patients with 24/7 availability of onsite medical response teams;  24/7 availability of in-house emergency physician coverage;  Diagnostic radiology, including MRI and CT;  24/7 availability of inpatient pharmacy services (may include alternative night- time access when pharmacy is closed);  Blood bank or 24/7 access to blood bank services; AND  24/7 availability of Clinical Laboratory Improvement Amendments (CLIA) accredited laboratory services.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 6 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

About This Document ...... 1 ALL SELECTION CRITERIA MUST BE MET FOR ELIGIBILITY CONSIDERATION

DOMAIN SOURCE QUALITY SELECTION CRITERIA About the Blue Distinction Specialty Care Program ...... 1 Total Facility Case Provider The total facility case volume, which includes Volume Survey both primary and revision total hip arthroplasty Understanding the Evaluation Q#13 (THA) and/or total knee arthroplasty (TKA), is Process ...... 2 greater than zero for the requested timeframe. Complication Rate Hospital Hospital-level risk-standardized complication Knee and Hip Replacement Compare rate (RSCR) following elective primary total hip Quality Selection arthroplasty (THA) and/or total knee Criteria ...... 4 arthroplasty (TKA) is reported as “better than” or “no different than” the U.S. National Rate. Knee and Hip Replacement Complication Rate Blue Claims Hospital-level risk-standardized complication Business Selection rate (RSCR) following elective primary total hip Criteria ...... 8 arthroplasty (THA) and/or total knee arthroplasty (TKA) is “better than” or “no Knee and Hip Replacement different than” the Blue National Rate. Cost of Care Selection Criteria ...... 9 Blue Volume for Blue Claims Analytic volume for complication outcomes is at Complication Outcome least 25 primary total hip arthroplasty (THA) Analysis and/or total knee arthroplasty (TKA) for Blue Spine Surgery Quality Claims data. Selection Criteria ...... 12 Blue Volume for Blue Claims Analytic volume for readmission outcomes is at Readmission Outcome least 25 primary total hip arthroplasty (THA) Spine Surgery Business Analysis and/or total knee arthroplasty (TKA) for Blue Selection Criteria ...... 15 Claims data. 30 Day All-Cause Hospital Hospital-level 30-day, all-cause risk- Spine Surgery Cost of Care Readmission Rate Compare standardized readmission rate (RSRR) Selection Criteria ...... 16 following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) is Questions ...... 19 reported as “better than” or “no different than” the U.S. National Rate. 30 Day All-Cause Blue Claims Hospital-level 30-day, all-cause risk- Readmission Rate standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) is “better than” or “no different than” the Blue National Rate.

THE FOLLOWING CRITERION IS PROVIDED AS INFORMATIONAL FEEDBACK ONLY

DOMAIN SOURCE QUALITY SELECTION CRITERIA

Functional Assessments Provider Percentage of knee or hip replacement patients Survey that have undergone both pre-and post- operative functional assessment at least 6 Q#16 months after surgery.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 7 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Knee and Hip Replacement Business Selection Criteria About This Document ...... 1 The Business Selection Criteria (Table 3) consists of four components: Facility About the Blue Distinction Participation; Surgeons Participation; Blue Brands Criteria; and Local Blue Plan Criteria (if Specialty Care Program ...... 1 applicable). A facility must meet all requirements in Table 3 to meet the Business evaluation of the overall eligibility decision for the Blue Distinction Centers for Knee and Understanding the Evaluation Hip Replacement designation. About This Process ...... 2 Table 3 – Knee and Hip Replacement Business Selection Criteria Document...... 1 Knee and Hip Replacement BUSINESS SELECTION CRITERIA Quality Selection Criteria ...... 4 Facility All facilities are required to participate in the local Blue Plan’s BlueCard About the Blue Distinction Participation Preferred Provider Organization (PPO) Network. Centers for Specialty Care® Knee and Hip Replacement Program ...... 1 Business Selection All surgeons (identified in the Provider Survey as those who perform Criteria ...... 8 Surgeons Participation the Knee and Hip Replacement procedures at that facility) are required to participate in the local Blue Plan’s BlueCard PPO Network.2 Knee and Hip Replacement Cost of Care Selection Facility meets BCBSA criteria for avoiding conflicts with BCBSA logos Understand the Evaluation Blue Brands Criteria ...... 9 Criteria and trademarks. Process ...... 2

Spine Surgery Quality An individual Blue Plan, at its own independent discretion, may Local Blue Selection Criteria ...... 12 establish and apply local business requirements as additional Selection Plan Criteria (if applicable) Criteria for eligibility in a Blue Distinction Centers program, for facilities Quality Selection Spine Surgery Business located within its Service Area. Criteria ...... 4 Selection Criteria ...... 15

Spine Surgery Cost of Care Selection Criteria ...... 16 Business Selection Criteria ...... 8 Questions ...... 19

Cost of Care Selection Criteria ...... 8

Summary of Report – Feedback Report…………………….11

2 De Minimis Rule may be applied, at the local Blue Plan’s discretion.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 8 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Knee and Hip Replacement Cost of Care Selection Criteria About This Document ...... 1 Cost of care measures were designed to address market and consumer demand for cost About the Blue Distinction savings and affordable healthcare. The cost of care Selection Criteria were used to provide Specialty Care Program ...... 1 a consistent and objective approach to identify BDC+. Quality is key: only those facilities that first meet nationally established, objective quality Understanding the Evaluation measures for BDC will be considered for designation as a BDC+. Process ...... 2 Cost Data Sources and Defining the Episodes Knee and Hip Replacement Quality Selection Cost of Care evaluation was based on a nationally consistent claims analysis of Blue Plan Criteria ...... 4 claims data. The scope of this analysis included:  Claims were evaluated, using adjusted allowed amounts derived from Blue Plan Knee and Hip Replacement claims data from July 1, 2010 through June 30, 2014, and paid through August 31, Business Selection 2014 for Knee and Hip Replacement trigger procedures (defined below) occurring Criteria ...... 8 between April 1, 2012 and March 31, 2014.

Knee and Hip Replacement  Knee and Hip Replacement episodes were identified through a trigger procedure (or Cost of Care Selection index event) for each clinical category through the assigned Medicare Severity Criteria ...... 9 Diagnosis Related Groups (MS-DRGs) and only those episodes categorized using the following MS-DRGs were included in further analysis:

Spine Surgery Quality  MS-DRG 469 (Major Joint Replacement or Reattachment of Lower Extremity Selection Criteria ...... 12 w/ MCC)  MS-DRG 470 (Major Joint Replacement or Reattachment of Lower Extremity Spine Surgery Business w/o MCC) Selection Criteria ...... 15  Episodes with commonly used and clinically comparable primary diagnoses and most typical MS-DRGs were included. The remaining atypical episodes were Spine Surgery Cost of Care excluded, as were bilateral or multiple replacements. Episodes were also excluded Selection Criteria ...... 16 from analysis if either professional costs or procedure/facility costs were not included in the claims data. Questions ...... 19  Adjusted allowed amounts for professional and in-network facility claims were included, using specific Knee Replacement and Hip Replacement clinical categories

for actively enrolled commercial Blue members. Members under 18 or over 64 years were excluded from the cost analysis.  Medicare/Medicaid and secondary claims were excluded.  The episode window begins 30 days prior to the date of the index admission (look- back period) and ends 90 days following discharge from the index admission (look- forward period) for both Knee and Hip Replacement clinical categories. The episode window includes services from facility, physician, other professional, and ancillary providers.  The look-back period includes relevant services (a service presumed related to the episode, regardless of diagnosis) and relevant diagnoses (other conditions and symptoms directly relevant to the episode).

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2013 Benefit Design Plan Capabilities Survey

 The index admission includes all costs during the inpatient admission (i.e., facility, About This Document ...... 1 physician/professional, and ancillary costs).  The look-forward period includes relevant services (a service presumed related to About the Blue Distinction the episode, regardless of diagnosis), relevant diagnoses (other conditions and Specialty Care Program ...... 1 symptoms directly relevant to the episode), and complications (identified based on relevant diagnosis). Understanding the Evaluation Process ...... 2  Cost methodology took the sum of all costs incurred during the episode (including facility, physician, other professional, and ancillary costs) for each individual member, including the specified days before and after the trigger for the Knee and Knee and Hip Replacement Quality Selection Hip Replacement episode. Criteria ...... 4  For facilities located in overlapping areas served by more than one local Blue Plan, the same method for cost evaluation was used but the claims data and results were Knee and Hip Replacement evaluated separately for each of those local Blue Plans. Business Selection Criteria ...... 8 Adjusting Episode Costs Facility episode costs were analyzed and adjusted separately for each clinical category, as Knee and Hip Replacement follows: Cost of Care Selection Criteria ...... 9 A geographic adjustment factor was applied to the episode cost, to account for geographic cost variations in delivering care. Episode costs were adjusted using the 2012 CMS Spine Surgery Quality Geographic Adjustment Factors (GAF), resulting in a Geographically Adjusted Facility Selection Criteria ...... 12 Episode Cost. Risk adjustment was used to adjust for variation in cost that may relate to differences in Spine Surgery Business patient severity (with or without comorbidity), as well as case mix, using the following Selection Criteria ...... 15 steps:  Identified patient severity levels, using the MS-DRG risk stratification system. Spine Surgery Cost of Care Selection Criteria ...... 16  Created separate risk bands within Knee Replacement and Hip Replacement clinical category episodes, based on patient severity level and gender. Only one Questions ...... 19 age band, 18-64 years, was used for all patients because there was no meaningful variation in cost based on age subgroups.

 Managed outliers through winsorization within risk bands. Outliers were identified in each risk band as those values for which geographically adjusted costs were the top 2 percent and bottom 2 percent of episode costs. Outlying cost values were truncated to these points, to preserve their considerations in calculating the overall episode cost estimate while moderating their influence.  Calculated a Risk Ratio for each risk band by taking the mean of the episode costs within each risk band and dividing it by the overall mean episode cost for the relevant clinical category.  The Risk Adjustment Factor (which is the inverse of the Risk Ratio) is multiplied by each facility’s geographically adjusted facility episode costs for each clinical category/risk level combination to normalize for risk, resulting in a final episode cost that is both geographically adjusted and risk adjusted.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 10 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Establishing the Cost Measure About This Document ...... 1 Each Knee and Hip Replacement episode was attributed to the facility where the procedure/surgery occurred, based on trigger events that occurred at that facility for each About the Blue Distinction clinical category. Clinical Category Facility Cost (CCFC) was calculated separately for Specialty Care Program ...... 1 Knee Replacement and Hip Replacement, based on the median value of the adjusted episode costs. Understanding the Evaluation Process ...... 2 Confidence intervals (90 percent) were calculated around each Clinical Category Facility Cost measure; the Upper Confidence Limit of the measure was divided by the National Knee and Hip Replacement median episode cost to become the Clinical Category Facility Cost Index (CCFCI). Quality Selection Using each of the Clinical Category Facility Cost Index values, an overall Composite Criteria ...... 4 Facility Cost Index (CFCI) was calculated for the facility. Each Clinical Category Facility Cost Index was weighted by that facility’s own volume and facility costs to calculate a Knee and Hip Replacement composite measure of cost called the Composite Facility Cost Index. The Composite Business Selection Facility Cost Index was then rounded down to the nearest 0.025 for each facility and Criteria ...... 8 compared to the National Cost Selection Criteria. A minimum of 5 episodes was required for each Knee Replacement and Hip Replacement Knee and Hip Replacement Cost of Care Selection clinical category, in order to consider the Clinical Category Facility Cost Index valid. Any Criteria ...... 9 facility that did not meet this episode minimum did not meet the cost of care Selection Criteria.

Spine Surgery Quality Selection Criteria ...... 12 Cost Selection Criteria In addition to meeting the nationally established, objective quality and business measures Spine Surgery Business for BDC, a facility also must meet all of the following cost of care Selection Criteria (Table Selection Criteria ...... 15 4) requirements to be considered eligible for the BDC+ designation for Knee and Hip Replacement. Spine Surgery Cost of Care Table 4 – Knee and Hip Replacement Cost of Care Selection Criteria Selection Criteria ...... 16 COST OF CARE SELECTION CRITERIA Questions ...... 19

Facility must have a minimum of 5 episodes of cost data for each of the 2 clinical categories.

The Composite Facility Cost Index must be below 1.200.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 11 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Spine Surgery Quality Selection Criteria About This Document ...... 1 Facilities were evaluated on quality metrics developed through a process that included: About the Blue Distinction input from the medical community and quality measurement experts; and review of medical Specialty Care Program ...... 1 literature, together with national quality and safety initiatives. The quality evaluation for facilities was based on facility responses to the Provider Survey. Understanding the Evaluation Facility results for outcome metrics were analyzed using a confidence interval (90 percent) Process ...... 2 around the point estimate from the reported numerator and denominator events. “Confidence Interval” is a term used in statistics that measures the probability that a result Knee and Hip Replacement will fall between two set values. Each facility’s lower confidence limit (LCL) result was Quality Selection compared to the national Selection Criteria. When the LCL is above the threshold, the Criteria ...... 4 facility’s result (e.g., complications) is statistically worse than the threshold. Table 5 below identifies all of the domains used in the Quality evaluation for Spine Surgery. Knee and Hip Replacement Facilities were evaluated for quality in the following domains for the Blue Distinction Business Selection Criteria ...... 8 Centers for Spine Surgery program. A facility must meet all requirements in Table 5 to meet the Quality evaluation of the overall eligibility decision for the Blue Distinction Centers for Spine Surgery designation. Knee and Hip Replacement Cost of Care Selection Table 5: Spine Surgery Quality Selection Criteria Criteria ...... 9 ALL METRICS MUST BE MET FOR ELIGIBILITY CONSIDERATION Spine Surgery Quality Selection Criteria ...... 12 DOMAIN SOURCE METRIC DESCRIPTION

National Provider The facility is fully accredited by at least one of the Spine Surgery Business Accreditation* Survey following national accreditation organizations*: Selection Criteria ...... 15 Q#3  The Joint Commission (TJC) (without provision or condition) in the Hospital Accreditation Spine Surgery Cost of Care Program. Selection Criteria ...... 16  Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Information Questions ...... 19 Association (AOIA) as an acute care hospital.  National Integrated Accreditation Program SM (NIAHO )—Acute Care of DNV GL Healthcare.  Center for Improvement in Healthcare Quality (CIHQ) in the Hospital Accreditation Program. *NOTE: To enhance quality while improving Blue Members' access to qualified providers, alternate local Accreditations that are at least as stringent as any National Accreditations, above, may be offered under the local Blue Plan Criteria; for details, contact the facility's local Blue Plan.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 12 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

About This Document ...... 1 ALL METRICS MUST BE MET FOR ELIGIBILITY CONSIDERATION

DOMAIN SOURCE METRIC DESCRIPTION About the Blue Distinction Specialty Care Program ...... 1 Comprehensive Provider The facility is a comprehensive acute care facility that Facility Survey offers all of the following services on site: Understanding the Evaluation Q#4  Intensive care unit; Process ...... 2  Emergency Room or Emergency Services that include plans or systems for onsite emergency Knee and Hip Replacement admission of post-operative patients with 24/7 Quality Selection availability of onsite medical response teams; Criteria ...... 4  24/7 availability of in-house emergency physician coverage; Knee and Hip Replacement  Diagnostic radiology, including MRI and CT; Business Selection  24/7 availability of inpatient pharmacy services Criteria ...... 8 (may include alternative night-time access when pharmacy is closed);

Knee and Hip Replacement  Blood bank or 24/7 access to blood bank services; AND Cost of Care Selection Criteria ...... 9  24/7 availability of Clinical Laboratory Improvement Amendments (CLIA) accredited laboratory services. Spine Surgery Quality Selection Criteria ...... 12 Primary Posterior Provider Analytic volume for outcome measurement is at least Lumbar Fusion Survey 30 spondylolisthesis patients who had a 1 or 2 level Spine Surgery Business Volume for Q#27 primary posterior lumbar fusion +/- decompression. Selection Criteria ...... 15 Outcome Analysis

Primary Posterior Provider 1 or 2 level primary posterior lumbar fusion +/- Spine Surgery Cost of Care Lumbar Fusion Survey decompression for spondylolisthesis reoperation within Selection Criteria ...... 16 Reoperation Q#28 30 days. 90% lower confidence limit is at or below 3.2. Questions ...... 19 Primary Posterior Provider 1 or 2 level primary posterior lumbar fusion +/- Lumbar Fusion Survey decompression for spondylolisthesis unplanned

Readmission Q#29 readmission within 30 days. 90% lower confidence limit is at or below 6.8.

Primary Posterior Provider 1 or 2 level primary posterior lumbar fusion +/- Lumbar Fusion Survey decompression for spondylolisthesis venous Venous Q#30 thromboembolism within 30 days. Thromboembolism 90% lower confidence limit is at or below 1.28.

Primary Posterior Provider 1 or 2 level primary posterior lumbar fusion +/- Lumbar Fusion Survey decompression for spondylolisthesis surgical site Surgical Site Q#31 infection within 30 days. Infection 90% lower confidence limit is at or below 5.4.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 13 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

About This Document ...... 1 ALL METRICS MUST BE MET FOR ELIGIBILITY CONSIDERATION

DOMAIN SOURCE METRIC DESCRIPTION About the Blue Distinction Specialty Care Program ...... 1 Primary Anterior Provider Analytic volume for outcome measurement is at least Cervical Fusion Survey 30 patients who had a single level primary anterior Understanding the Evaluation Volume for Q#32 cervical fusion. Process ...... 2 Outcome Analysis

Primary Anterior Provider Single level primary anterior cervical fusion reoperation Knee and Hip Replacement Cervical Fusion Survey within 30 days. Quality Selection Reoperation Criteria ...... 4 Q#33 90% lower confidence limit is at or below 1.6.

Primary Anterior Provider Single level primary anterior cervical fusion unplanned Knee and Hip Replacement Cervical Fusion Survey readmission within 30 days. Business Selection Readmission 90% lower confidence limit is at or below 4.0. Criteria ...... 8 Q#34 Primary Anterior Provider Single level primary anterior cervical fusion venous Knee and Hip Replacement Cervical Fusion Survey thromboembolism within 30 days. Cost of Care Selection Venous Q#35 90% lower confidence limit is at or below 0.67. Criteria ...... 9 Thromboembolism

Spine Surgery Quality Primary Anterior Provider Single level primary anterior cervical fusion surgical site Selection Criteria ...... 12 Cervical Fusion Survey infection within 30 days. Surgical Site Q#36 90% lower confidence limit is at or below 0.87. Infection Spine Surgery Business Selection Criteria ...... 15 Surgeon Staffing Provider Facility has at least 2 spine surgeons actively Survey performing spine surgeries. Spine Surgery Cost of Care Q#39 Selection Criteria ...... 16 Surgeon Procedure Participation Facility commits to examine spine surgeon procedure Questions ...... 19 Volume Agreement volume with consideration for reviewing evidence linking volume and outcomes and establishing a surgeon level case volume minimum requirement.

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2013 Benefit Design Plan Capabilities Survey

Spine Surgery Business Selection Criteria About This Document ...... 1 The Business Selection Criteria (Table 6) consists of four components: Facility About the Blue Distinction Participation; Surgeons Participation; Blue Brands Criteria; and Local Blue Plan Criteria (if Specialty Care Program ...... 1 applicable). A facility must meet all requirements in Table 6 to meet the Business evaluation of the overall eligibility decision for the Blue Distinction Centers for Spine Understanding the Evaluation Surgery designation. Process ...... 2 Table 6 – Spine Surgery Business Selection Criteria

Knee and Hip Replacement BUSINESS SELECTION CRITERIA Quality Selection Criteria...... 4 Facility All facilities are required to participate in the local Blue Plan’s BlueCard Participation Preferred Provider Organization (PPO) Network. Knee and Hip Replacement Business Selection All surgeons (identified in the Provider Survey as those who perform the Surgeons Criteria...... 8 Spine Surgery procedures at that facility) are required to participate in Participation the local Blue Plan’s BlueCard PPO Network.3 Knee and Hip Replacement Cost of Care Selection Blue Brands Facility meets BCBSA criteria for avoiding conflicts with BCBSA logos Criteria...... 9 Criteria and trademarks.

An individual Blue Plan, at its own independent discretion, may establish Spine Surgery Quality Local Blue Plan and apply local business requirements as additional Selection Criteria Selection Criteria ...... 12 Criteria for eligibility in a Blue Distinction Centers program, for facilities located (if applicable) within its Service Area. Spine Surgery Business Selection Criteria ...... 15

Spine Surgery Cost of Care Selection Criteria ...... 16

Questions ...... 19

3 De Minimis Rule may be applied, at the local Blue Plan’s discretion.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 15 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Spine Surgery Cost of Care Selection Criteria About This Document ...... 1 Cost of care measures were designed to address market and consumer demand for cost About the Blue Distinction savings and affordable healthcare. The cost of care Selection Criteria were used to provide Specialty Care Program ...... 1 a consistent and objective approach to identify BDC+. Quality is key: only those facilities that first meet nationally established, objective quality Understanding the Evaluation measures for BDC will be considered for designation as a BDC+. Process ...... 2 Cost Data Sources and Defining the Episodes Knee and Hip Replacement Cost of Care evaluation was based on a nationally consistent claims analysis of Blue Plan Quality Selection claims data. The scope of this analysis included: Criteria ...... 4  Claims were evaluated, using adjusted allowed amounts derived from Blue Plan Knee and Hip Replacement claims data from July 1, 2010 through June 30, 2014, and paid through August 31, Business Selection 2014 for Spine Surgery trigger procedures (defined below) occurring between Criteria ...... 8 January 1, 2011 and December 31, 2013.  Spine Surgery episodes were identified through a trigger procedure (or index event) Knee and Hip Replacement for each clinical category by CPT, HCPC, or ICD-9 codes, and were placed in one Cost of Care Selection of the four clinical categories: Criteria ...... 9  Lumbar Fusion  Lumbar Laminectomy / Discectomy Spine Surgery Quality Selection Criteria ...... 12  Cervical Fusion  Cervical Laminectomy Spine Surgery Business  A hierarchy was used to place episodes that include multiple trigger procedures into Selection Criteria ...... 15 a single clinical category for analysis, based on the level of the surgical procedure (i.e., Cervical Spine > Thoracic Spine > Lumbar Spine [includes sacral] > Spine – Spine Surgery Cost of Care site not otherwise specified). Selection Criteria ...... 16  Episodes with commonly used and clinically comparable primary diagnoses and most typical procedures are included. The remaining atypical episodes were Questions ...... 19 excluded. Thoracic Spine procedures and revision procedures were excluded. Bilateral or multiple replacements were also excluded. Episodes were also excluded from analysis if either professional costs or procedure/facility costs were not included in the claims data  Adjusted allowed amounts for professional and in-network facility claims were included, using specific Spine Surgery clinical categories for actively enrolled commercial Blue members. Members under 18 or over 64 years were excluded from the cost analysis.  Medicare/Medicaid and secondary claims were excluded.  The episode window for all four Spine Surgery clinical categories begins 30 days prior to the date of the index admission (look-back period). Cervical Laminectomy and Lumbar Laminectomy/Discectomy episodes end 90 days following discharge from the index admission (look-forward period). Cervical Fusion and Lumbar Fusion episodes end 180 days following discharge from the index admission (look-forward period). The episode window includes services from facility, physician, other professional, and ancillary providers.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 16 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

 The look-back period includes relevant services (a service presumed related to the About This Document ...... 1 episode, regardless of diagnosis) and relevant diagnoses (other conditions and symptoms directly relevant to the episode). About the Blue Distinction  The index admission includes all costs during the inpatient admission or outpatient Specialty Care Program ...... 1 stay (i.e., facility, physician, other professional, and ancillary costs).

Understanding the Evaluation  The look-forward period includes relevant services (a service presumed related to Process ...... 2 the episode, regardless of diagnosis), relevant diagnoses (other conditions and symptoms directly relevant to the episode), and complications (identified based on relevant diagnosis). Knee and Hip Replacement Quality Selection  Cost methodology took the sum of all costs incurred during the episode (including Criteria ...... 4 facility, physician, other professional, and ancillary costs) for each individual member, including the specified days before and after the trigger for the Spine Knee and Hip Replacement Surgery episode. Business Selection  For facilities located in overlapping areas served by more than one local Blue Plan, Criteria ...... 8 the same method for cost evaluation was used but the claims data and results were evaluated separately for each of those local Blue Plans. Knee and Hip Replacement Cost of Care Selection Adjusting Episode Costs Criteria ...... 9 Facility episode costs were analyzed and adjusted separately for each clinical category, as follows: Spine Surgery Quality Selection Criteria ...... 12 A geographic adjustment factor was applied to the episode cost, to account for geographic cost variations in delivering care. Episode costs were adjusted using the 2012 CMS Spine Surgery Business Geographic Adjustment Factors (GAF), resulting in a Geographically Adjusted Facility Selection Criteria ...... 15 Episode Cost. Risk adjustment was used to adjust for variation in cost that may relate to differences in Spine Surgery Cost of Care patient severity (with or without comorbidity), as well as case mix, using the following Selection Criteria ...... 16 steps:  Identified patient severity levels, using the MS-DRG risk stratification system. Questions ...... 19  Created separate risk bands, based on patient severity level, case mix, and gender for each clinical category. Only one age band, 18-64 years, was used for all patients because there was no meaningful variation in cost based on age subgroups. Case mix sub-categorization and categorization due to outpatient surgeries were done following these criteria:  Lumbar Fusion and Cervical Fusion procedures were divided into two sub- categories: 1-2 level and 3+ level procedures.  Lumbar Laminectomy/Discectomy, Cervical Fusion, and Cervical Laminectomy clinical categories included inpatient and outpatient procedures, stratified separately.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 17 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

 Managed outliers through winsorization within risk bands. Outliers were identified in About This Document ...... 1 each risk band as those values for which geographically adjusted costs were the top 2 percent and bottom 2 percent of episode costs. Outlying cost values were About the Blue Distinction truncated to these points, to preserve their considerations in calculating the overall Specialty Care Program ...... 1 episode cost estimate, while moderating their influence.  Calculated a Risk Ratio for each risk band by taking the mean of the episode costs Understanding the Evaluation within each risk band and dividing it by the overall mean episode cost for the Process ...... 2 relevant clinical category.  The Risk Adjustment Factor (which is the inverse of the Risk Ratio) is multiplied by Knee and Hip Replacement each facility’s geographically adjusted facility episode costs for each clinical Quality Selection category/risk level combination to normalize for risk, resulting in a final episode cost Criteria ...... 4 that is both geographically adjusted and risk adjusted.

Knee and Hip Replacement Establishing the Cost Measure Business Selection Criteria ...... 8 Each Spine Surgery episode was attributed to the facility where the procedure/surgery occurred, based on trigger events that occurred at that facility for each clinical category. Clinical Category Facility Cost (CCFC) was calculated separately for Lumbar Fusion, Knee and Hip Replacement Cost of Care Selection Lumbar Laminectomy / Discectomy, Cervical Fusion, and Cervical Laminectomy, based on Criteria ...... 9 the median value of the adjusted episode costs. Confidence intervals (90 percent) were calculated around each Clinical Category Facility Spine Surgery Quality Cost measure; the Upper Confidence Limit of the measure was divided by the National Selection Criteria ...... 12 median episode cost to become the Clinical Category Facility Cost Index (CCFCI). Using each of the Clinical Category Facility Cost Index values, an overall Composite Spine Surgery Business Facility Cost Index (CFCI) was calculated for the facility. Each Clinical Category Facility Selection Criteria ...... 15 Cost Index was weighted by that facility’s own volume and facility costs to calculate a composite measure of cost called the Composite Facility Cost Index. The Composite Spine Surgery Cost of Care Facility Cost Index was then rounded down to the nearest 0.025 for each facility and Selection Criteria ...... 16 compared to the National Cost Selection Criteria. A minimum of 5 episodes was required in at least 3 clinical categories, in order to consider Questions ...... 19 the Clinical Category Facility Cost Index valid. Any facility that did not meet this episode minimum did not meet the cost of care Selection Criteria.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 18 Blue Distinction Centers for Knee and Hip Replacement and Spine Surgery | Selection Criteria and Program Documentation

2013 Benefit Design Plan Capabilities Survey

Cost Selection Criteria About This Document ...... 1 In addition to meeting the nationally established, objective quality and business measures for BDC, a facility also must meet all of the following cost of care Selection Criteria (Table About the Blue Distinction 7) requirements to be considered eligible for the BDC+ designation for Spine Surgery. Specialty Care Program ...... 1 Table 7 – Spine Surgery Cost of Care Selection Criteria

Understanding the Evaluation Process ...... 2 COST OF CARE SELECTION CRITERIA

Knee and Hip Replacement Facility must have a minimum of 5 episodes of cost data for at least 3 clinical Quality Selection categories.4 Criteria ...... 4

The Composite Facility Cost Index must be below 1.500. Knee and Hip Replacement Business Selection Criteria ...... 8

Knee and Hip Replacement Questions Cost of Care Selection Criteria ...... 9 Contact your local Blue Plan with any questions.

Spine Surgery Quality Selection Criteria ...... 12

Spine Surgery Business Selection Criteria ...... 15

Spine Surgery Cost of Care Selection Criteria ...... 16

Questions ...... 19 Blue Distinction Centers (BDC) met overall quality measures for patient safety and outcomes, developed with input from the medical community. A Local Blue Plan may require additional criteria for facilities located in its own service area; for details, contact your Local Blue Plan. Blue Distinction Centers+ (BDC+) also met cost measures that address consumers’ need for affordable healthcare. Each facility’s cost of care is evaluated using data from its Local Blue Plan. Facilities in CA, ID, NY, PA, and WA may lie in two Local Blue Plans’ areas, resulting in two evaluations for cost of care; and their own Local Blue Plans decide whether one or both cost of care evaluation(s) must meet BDC+ national criteria. National criteria for BDC and BDC+ are displayed on www.bcbs.com. Individual outcomes may vary. For details on a provider’s in-network status or your own policy’s coverage, contact your Local Blue Plan and ask your provider before making an appointment. Neither Blue Cross and Blue Shield Association nor any Blue Plans are responsible for non-covered charges or other losses or damages resulting from Blue Distinction or other provider finder information or care received from Blue Distinction or other providers.

4 If a facility met the episode minimum for only 3 of the 4 clinical categories, then the other clinical category, for which the episode minimum was not met, was not included in the formula numerator and denominator. For example, if a facility had at least 5 episodes for each of 3 clinical categories (Lumbar Laminectomy/Discectomy, Cervical Fusion, and Cervical Laminectomy) but less than 5 episodes for remaining fourth clinical category (Lumbar Fusion), then it would have a three-part formula (as opposed to a complete four-part formula), as Lumbar Fusion would not be included in the Composite Facility Cost Index calculation.

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 19