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2019 & 2020 Facility Scoring Methodology for Cost & Quality

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2019 & 2020 Facility Scoring Methodology for Cost & Quality Designations In keeping with its goal of providing members with high-quality, lower-cost health care, Blue Cross Blue Shield of North Carolina (BCBSNC) developed the following methodology to best evaluate the quality and efficiency of partner facilities. Based on evaluation results, BCBSNC will designate PPO network facilities as Low Cost High Quality, High Quality, or Not Designated (NOTE: Critical Access facilities will maintain their Critical Access designation). This document describes the methodology used by Blue Cross NC for the 2019 and 2020 Cost & Quality Designations and is provided for informational purposes only. Designation Overview BCBSNC will base its designations on quality and efficiency. Any facility that does not meet the quality criteria will not be designated. Any practice that meets the quality criteria will also be assessed on efficiency criteria to determine its final designation. Please note, the designation is made at the facility level and only includes In-network Facilities contracted with BCBSNC. The initial driver of eligibility is the ability to meet the quality standards set forth in BCBSNC’s Facility-level standards (described below). Facilities that are unable to meet the quality standard for the network are not designated. Facilities that qualify for designation based on their quality evaluation will then be evaluated against BCBSNC’s efficiency criteria (described below) to determine if the organization meets the standards for the Low Cost High Quality designation. Facilities that meet both the quality and efficiency standards are designated as Low Cost High Quality. Facilities that meet the quality standard, but do not attain the efficiency standard, are designated as High Quality. Tiered Network Product Quality Thresholds for Facilities The quality scoring methodology considers measures from the Hospital Compare plus a risk adjusted readmission rate measure from BCBSNC claim data. These measures assess Health Outcomes and Patient Safety (70%), Resource Use (10%), and Patient Experience (20%). The performance on each measure derives is scored based on percentile and combined into an overall score. A facility’s quality score must be above the lower quartile compared to all partner facilities to be considered a pass of the quality evaluation. See Appendix below for underlying measures and methodology. Efficiency Threshold for Facilities With the quality standards in place, BCBSNC then analyzed claims to stratify facilities on the basis of efficiency performance.The objective of this analysis was to distinguish between the Low Cost High Quality designation and the High Quality designation. Facilities were assigned to cohorts based on bed size, total volume, transfers and the provision of certain types of services including burns, trauma, transplants, maternity, hip and knee arthroplasty, spine surgery, oncology, complex cardiology, and complex neurology.Bed size was obtained from the NC Division of Health Services Regulation and service volume was determined from claims from October 2016 through September 2017. Peer cohorts were established using Cohort Analysis, which identifies patterns of similarity in the selected characteristics and then classifies Facilities into groups, called “Peer Cohorts” here forward. 1 Cluster Variable Defined as DRGs/MDCs defining service line Hospital Beds Total hospital beds (Source: NC Division of N/A Health Services Regulation, downloaded 2/9/17 from www.ncdhhs.gov/dhsr/reports.htm) Total Volume Total volume All Transfer Dichotomous indicator if volume of cases as All a result of a transfer from another facility designated by discharge status => 10 Maternity Volume of maternity cases / total volume MDC 14 Hip & Knee Volume of hip and knee arthroplasty DRGs 469, 470, 480, 481, 461, 462, 483, Arthroplasty cases/total volume 468, 466, 467 Spine Surgery Dichotomous indicator if volume of spinal DRGs 460, 455, 456, 457, 458, 453, 454, surgery cases => 10 471, 472, 473, 459, 515, 516 Oncology Dichotomous indicator if volume of MDC 17, DRGs 054, 055, 333, 334, 374, oncology cases >= 10 375, 376, 435, 436, 437, 582, 583, 666, 667, 668, 669, 670, 711, 712, 722, 723, 736, 737, 738, 739, 740, 741, 744, 826, 827, 745, 754, 755, 756, 686, 687, 656, 657, 658, 584, 585, 597, 598, 688, 828, 829, 830, 843, 844, 845 Complex Dichotomous indicator if volume of complex DRGs 216, 217, 218, 219, 220, 221, 231, Cardiology cardiology cases >= 10 232, 233, 234, 228, 229, 230, 235, 236, 242, 243, 244, 21, 217, 218, 231, 232, 228, 229, 260, 261, 270, 271, 224, 225, 226, 227, 273, 274 Complex Dichotomous indicator if volume of DRGs 023, 024, 025, 026, 027, 031, 032, Neurology craniotomy cases >= 10 033 Burns or Trauma Dichotomous indicator if total volume of MDC 22, 24 trauma or burns => 10 Transplants Dichotomous indicator if total volume of DRGs 001, 002, 005, 006, 007, 008, 014, transplants => 5 016, 017, 652 Next, two metrics of efficiency performance were constructed based on inpatient and outpatient claims for Facilities within each peer cohort. Data preparation and analytical approaches for the evaluation are described below. Inpatient Costs Analyses were conducted on inpatient case data for services performed between October 2016 – September 2017. Includes Inpatient allowed facility costs only (i.e. no professional or ancillary costs) Lines of business: Blue Options (Group Underwritten, ASO, State Health Plan, Blue Select/Blue Select Plus, CDHP), Blue Advantage (Individual, CDHP). Excludes denials, Medicare crossovers, COB, and State Health Plan retirees. To reduce the effect of outliers, allowed costs were truncated at the 95th percentile by MS DRG. Analysis is limited to those MS DRGs performed at least 30 times at a minimum of two facilities statewide. Two inpatient cost metrics were computed for each facility called “observed” and “expected” costs. o Expected costs were determined by calculating the average cost for each MS DRG within a peer cohort if there were at least 30 cases in a minimum of 2 facilities; if there was insufficient volume within a peer cohort, the expected costs reflect the average cost for Facilities statewide. o Observed costs are equivalent to the allowed costs. Observed and expected costs were summed for all cases with sufficient MS DRG volume. 2 All DRGs were evaluated. If DRGs are missing, there was not enough volume to be evaluated. In the following table, "Cohort" refers to the DRG analysis within the cohort only. "Statewide" refers to the DRG analysis done statewide due to the low volume. MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 003 ECMO OR TRACH W MV 96+ HRS OR PDX EXC statewide statewide statewide cohort FACE, MOUTH & NECK W MAJ O.R. 004 TRACH W MV 96+ HRS OR PDX EXC FACE, statewide statewide statewide statewide statewide MOUTH & NECK W/O MAJ O.R. 014 ALLOGENEIC BONE MARROW TRANSPLANT statewide 016 AUTOLOGOUS BONE MARROW TRANSPLANT W statewide CC/MCC 023 CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX statewide statewide cohort CNS PDX W MCC OR CHEMO IMPLANT 025 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide cohort cohort PROCEDURES W MCC 026 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide statewide statewide cohort PROCEDURES W CC 027 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide statewide cohort cohort PROCEDURES W/O CC/MCC 029 SPINAL PROCEDURES W CC OR SPINAL statewide statewide cohort NEUROSTIMULATORS 030 SPINAL PROCEDURES W/O CC/MCC statewide statewide cohort 039 EXTRACRANIAL PROCEDURES W/O CC/MCC statewide statewide cohort cohort statewide 054 NERVOUS SYSTEM NEOPLASMS W MCC statewide statewide statewide cohort 055 NERVOUS SYSTEM NEOPLASMS W/O MCC statewide statewide statewide statewide cohort 057 DEGENERATIVE NERVOUS SYSTEM DISORDERS statewide statewide statewide statewide statewide statewide W/O MCC 060 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA statewide statewide statewide statewide W/O CC/MCC 064 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide statewide cohort cohort INFARCTION W MCC 065 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide cohort cohort cohort cohort statewide INFARCTION W CC OR TPA IN 24 HRS 066 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide cohort cohort cohort cohort statewide INFARCTION W/O CC/MCC 069 TRANSIENT ISCHEMIA statewide statewide statewide cohort statewide statewide 070 NONSPECIFIC CEREBROVASCULAR DISORDERS W statewide statewide statewide statewide MCC 074 CRANIAL & PERIPHERAL NERVE DISORDERS W/O statewide statewide cohort statewide statewide MCC 076 VIRAL MENINGITIS W/O CC/MCC statewide statewide statewide statewide statewide 087 TRAUMATIC STUPOR & COMA, COMA <1 HR statewide statewide statewide cohort W/O CC/MCC 091 OTHER DISORDERS OF NERVOUS SYSTEM W statewide statewide statewide statewide MCC 092 OTHER DISORDERS OF NERVOUS SYSTEM W CC statewide statewide statewide statewide statewide 093 OTHER DISORDERS OF NERVOUS SYSTEM W/O statewide statewide statewide statewide statewide CC/MCC 100 SEIZURES W MCC statewide statewide statewide statewide statewide 101 SEIZURES W/O MCC statewide cohort cohort cohort cohort statewide 103 HEADACHES W/O MCC statewide statewide cohort cohort cohort statewide 132 CRANIAL/FACIAL PROCEDURES W/O CC/MCC statewide statewide cohort statewide 134 OTHER EAR, NOSE, MOUTH & THROAT O.R. statewide statewide statewide statewide PROCEDURES W/O CC/MCC 149 DYSEQUILIBRIUM statewide statewide statewide statewide statewide 153 OTITIS MEDIA & URI W/O MCC statewide statewide statewide
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