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Cigna Care Designation and Physician Quality and Cost-Efficiency Displays

2013 Methodologies Whitepaper

Introduction ........................................................................................................................... 2 Cigna Care Designation and Physician Quality and Cost Efficiency Displays Overview ...... 3 Physician Quality and Cost-Efficiency Displays .................................................................... 4 Physician Specialty Types Assessed for Cigna Care Designation and Physician Quality Efficiency and Cost Displays................................................................................................. 5 Quality Evaluation ................................................................................................................. 6 Evidence-Based Medicine (EBM) Assessment Process....................................................... 6 Cost-Efficiency Evaluation .................................................................................................... 8 2012 Outlier Methodology ................................................................................................... 10 Level of Evaluation.............................................................................................................. 10 Assigning the Cigna Care Designation ............................................................................... 10 Cigna Care Designation 2012 Inclusion Algorithm.............................................................. 12 Data Sources ...................................................................................................................... 14 Credit for Utilizing Cigna Centers of Excellence ................................................................. 14 Buffer Zone Methodology.................................................................................................... 13 Additional Information and Data Limitations........................................................................ 13 Process to Display Strategic Alliances Information............................................................. 14 Feedback Process .............................................................................................................. 14 Physician Process to Correct Errors, Request Reconsideration/Appeal............................. 15 How to Register Complaints................................................................................................ 15 Registering a Complaint for Individuals in New York .......................................................... 15

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Introduction We evaluate physician quality and cost-efficiency information by using a methodology consistent with national standards and incorporating physician feedback. Using this information, we are able to provide our customers and clients with relevant consumer-oriented information through the physician quality and cost-efficiency displays and the Cigna Care designation (CCD) program. The purpose of this document is to provide an overview of our Physician Quality and Cost Efficiency Displays Program, explain the methodology used to recognize individual physicians and medical groups for quality and cost-efficiency performance, and provide details regarding the physician quality and cost efficiency displays information used. Cigna Physician Quality and Cost Efficiency Displays Principles We believe that our customers and employers have a right to know information regarding the quality and cost-effectiveness of physicians. We follow three key principles when providing physician quality and cost-effectiveness information to customers, clients, and physicians:

1. Standardized performance measures using the most comprehensive data set available We use nationally recognized measures derived from those endorsed by the National Quality Forum (NQF), Ambulatory Care Quality Alliance (AQA), Healthcare Effectiveness Data Information Set (HEDIS), or those developed by national physician organizations such as the American Medical Association (AMA). 2. Responsible use of the information The displays reflect a partial assessment of quality and cost-efficiency based on our claims data, and should not be the sole basis for decision-making (as such measures have a risk of error). Individuals with Cigna coverage are encouraged to consider all relevant factors and to consult with their treating physician when selecting a physician for care. 3. Collaboration and Improvement Enablement We are committed to providing information and solutions that support access to quality health care. A detailed description of our methodology, information about the summary metrics, and ongoing data to help improve performance is available to physicians and physician groups. We also continue to have ongoing discussions with key physician organizations, ranging from national associations to large physician groups, who provide input for future design changes.

Frequency of Reviews The methodology for determining the Cigna Care designation and physician quality and cost-efficiency displays is subject to change annually as tools and industry standards evolve and physician feedback is obtained. The assessment review period for Cigna Care designation and quality and cost-effectiveness displays for 2013 is January 1, 2010 through December 31, 2011. This review includes claims data from Cigna Managed Care and PPO plans.

External Certification We were the first national plan to receive certification under the revised and enhanced NCQA Physician Hospital Quality Standards (PHQ accreditation standards). This accreditation program certifies the use of reliable, equitable, and trustworthy methods for measuring physician quality and cost-efficiency. These standards are endorsed by the Consumer-Purchaser Disclosure Project, a leading group of more than 50 employer, consumer, and labor organizations, as well as the New York Attorney General.

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Cigna Care Designation and Physician Quality and Cost Efficiency Displays Overview There are two components of the Cigna Care designation and Physician Quality and Cost Efficiency Displays programs, each of which is explained in more detail in the following sections of this document:

1. Quality evaluation and display: Physicians are evaluated on a number of criteria that we have determined are markers of physician practice quality. The results of this evaluation are displayed in our online health care professional directory that is available to individuals, and uses a unique symbol for each quality criterion met. Results of selected quality markers (e.g., evidence based medicine (EBM) rule adherence and NCQA Physician Recognition) are used to qualify physicians and physician groups for Cigna Care designation.

2. Cost-efficiency evaluation and display: Individual physicians and physician groups are evaluated

for their cost-efficiency using an industry-standard methodology (i.e., Episode Treatment Groups) that determines the average cost of treating an episode of care for a variety of medical conditions and surgical procedures. We then compare those episode costs to those of other physicians and medical groups of the same specialty in the same geographical market. The results of this evaluation are displayed in our online health care professional directory using two or three stars, with three stars being the highest rating (i.e., the most cost-efficient). One-star ratings are not displayed.

Cigna Care designation: Individual physicians and physician groups that are ranked in the upper third for quality and the upper third for cost-efficiency compared to all physicians and physician groups of the same group specialty type in the same geographic market receive the Cigna Care designation. They are identified

with a Symbol ( ) and “Cigna Care Designation” in the online health care professional directory on Cigna.com and myCigna.com. (Please see the sample healthcare professional directory display on page 4.) To ensure that there this sufficient access to physicians in designated specialties, individual physicians and physician groups that are in the top 25% for cost-efficiency for the same specialty in the same geographical area may also receive the Cigna Care designation. Cigna Care designation benefit design: The Cigna Care designation is a benefit plan design option offered to organizations sponsoring group health benefit plans. Available in 69 service areas, the designation distinguishes physicians in 22 specialties (three primary care + 19 other specialties) who participate in our network, based on their meeting the above referenced quality and cost-efficiency criteria. The Cigna Care benefit design, which is intended to encourage individuals covered by these plans to consider using a Cigna Care designated physician, affords a lower co-payment or coinsurance for services provided by a designated physician than if the individual were to select a participating, non-designated physician. Overall physician reimbursement is unchanged. Geographical markets that the Cigna Care designation benefit plan is offered in 2013 were defined by our Network Contracting and Market Medical Executive teams. The zip code of a physician’s primary office address is used to align a physician with a given market. The physician’s specialty and geographic market is then used to determine the physician peer group for comparison of quality and cost-efficiency outcomes. Please see Appendix 1 for a list of markets, the volume of physicians reviewed, and the percent of physicians reviewed in each market that are Cigna Care designated, effective January 1, 2013.

http://www.cigna.com/

http://www.mycigna.com/

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Sample: Online health care professional directory display (myCigna.com)

Physician Quality and Cost-Efficiency Displays As previously referenced, information relative to specific quality criteria met by a physician is displayed in the online health care professional directory on both the public and secure websites at Cigna.com and myCigna.com. Information regarding the physician’s cost-effectiveness performance is displayed only on the secure website for individuals with Cigna coverage, myCigna.com. The displays are available in 69 markets for the 22 specialty types assessed for Cigna Care designation, including the 19 specialty types assessed for the Cigna Care designation and three primary care physician (PCP) specialty types (Family Practice, Internal Medicine, and Pediatrics).

Symbols are assigned to physicians or physician groups, and indicate the quality criteria that were met, and two or three stars are used to communicate cost-efficiency performance. Three stars for cost-efficiency represent the top 34% of physicians or physician groups when compared to other physicians and physician groups of the same group specialty type within the geographic market. Two stars represent physicians or physician groups falling between 2.5% and 67%, and one star represents groups in the bottom 2.5% for cost-efficiency. Please note, however, that groups with one star are not displayed in the directory (see sample health care professional online directory display on page 5).

Quality Symbols

NCQA recognized

Meets the Cigna Group board certification criteria

Adherence to Evidence-Based Medicine Standards with performance in approximately the top 34% of same-specialty practices in the physician’s geographic market

ABIM Practice Improvement Module

Certified Bariatric Center Affiliated Surgeons

Denotes physician with Cigna Care Designation Clicking on the Quality

Designations will display the designations achieved (see below)

https://centralhub.cigna.com/team/PROCOM/Provider Communications/2011 Communications/Consumer_Tools/Local Settings/Temporary Internet Files/Local Settings/OLKCIG/www.mycigna.com

http://www.cigna.com/



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Cost-Efficiency Symbols

Results in top category for cost-efficiency measures Results in middle category for cost-efficiency

Please see Appendix 2 for the geographical markets and volume of physicians reviewed for physician quality and cost-efficiency displays, beginning January 1, 2013.

Sample: Online health care professional directory display (myCigna.com)

Physician Specialty Types Assessed for Cigna Care Designation and Physician Quality and Cost Efficiency Displays We assess a total of 22 physician specialty types including primary care, as identified in the following table. A physician may only be assigned one specialty, tax identification number (TIN), and geographical market for Cigna Care designation or physician quality and cost-efficiency displays. The first specialty listed for a physician in the Cigna Central Provider File is used to establish the specialty to evaluate physicians with multiple specialties. Assessed Specialty Types Allergy and Immunology Cardiology Cardio-Thoracic Surgery Colon and Rectal Surgery Dermatology Ear, Nose and Throat Endocrinology Family Practice Gastroenterology General Surgery Hematology and Oncology* Internal Medicine Nephrology Neurology Neurosurgery Obstetrics and Gynecology Ophthalmology Orthopedics and Surgery Pediatrics Pulmonary Rheumatology Urology *Does not include Radiation Oncology

Participating physicians in the 22 specialty types reviewed for the Cigna Care designation account for over 90% of primary and specialty care and 85% of total medical and pharmaceutical spending based on our claims data.

Quality symbols indicate specific quality criteria met

Stars represent efficiency score

https://centralhub.cigna.com/team/PROCOM/Provider Communications/2011 Communications/Consumer_Tools/Local Settings/Temporary Internet Files/Local Settings/OLKCIG/www.mycigna.com

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Quality Evaluation We use five quality indicators to review participating physicians in the 22 specialty types. Each physician qualifying for a specific quality indicator is identified in our online healthcare professional directory with the corresponding quality symbol.

1. National Committee for Quality Assurance (NCQA) Physician Recognition The Cigna Care designation and the NCQA recognition symbol in our online directory is given to physicians who have received recognition in any of the five NCQA Physician Recognition Programs: back pain, diabetes, heart/stroke, physician practice connections or physician practice connections patient-centered medical home. Additional information about these programs is available on the NCQA website (http://www.ncqa.org > Programs > Physician Recognition).

2. Group Board Certification Group board certification criteria, based on American Board of Medical Specialties & American Osteopathic Association certification information, determine if care provided by a group is predominantly provided by board certified physicians. This standard is met if either 80% of physicians within a group are board certified and provide at least 50% of the care, or at least 80% of the care provided by the medical group is provided by board-certified physicians. 3. Adherence to Evidence-Based Medicine (EBM) Rules The quality of physician care is evaluated using a claims-based assessment based on 101 EBM rules derived from rules endorsed by the National Quality Forum (NQF), Ambulatory Care Quality Alliance (AQA), Healthcare Effectiveness Data Information Set (HEDIS), or developed by physician organizations. These rules span 48 diseases and preventive care conditions (see Appendix three), and is potentially applicable to the care provided by physicians in the 22 specialty types. For more information on the specialty types that are covered by evidence-based medicine rules, please see the chart below. 4. American Board of Internal Medicine Process Improvement Module Completion (ABIM-PIM) We display a quality symbol for physicians who have completed one or more American Board of Internal Medicine Practice Improvement modules (ABIM PIM) as part of the ABIM Maintenance of Certification program. 5. Certified Bariatric Center Affiliated Surgeons We have a comprehensive program for identifying Certified Bariatric Centers. A quality symbol is given to physicians who practice at these centers. These centers meet training and experience criteria including accreditation by the American College of Surgeons (ACS), Bariatric Surgery Center Network (BSCN), Surgical Review Corporation (SRC), American Society for Metabolic and Bariatric Surgery (ASMBS), or Bariatric Surgery Center of Excellence Program (BSCOE).

Evidence-Based Medicine (EBM) Assessment Process Evidence-based medicine rules that we currently use are applicable to 21 primary care and non-primary care specialties. Specialty Types Covered by Evidence Based Medicine Rules Allergy and Immunology Cardiology Cardiothoracic Surgery Colon and Rectal Surgery Endocrinology Family Practice Gastroenterology General Surgery Hematology and Oncology Internal Medicine Nephrology Neurology Neurosurgery Obstetrics and Gynecology

(OB/GYN) Ophthalmology

Orthopedics and Surgery Otolaryngology (ENT) Pediatrics Pulmonary Rheumatology Urology

The EBM assessment component of the Cigna Care Designation program for 2013 involves assessment of compliance with a total of 101 EBM rules (see Appendix 3) for the medical conditions displayed in the following table:

http://www.ncqa.org/

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Disease and Preventive Care Conditions Covered By Evidence Based Medicine Rules Adenoidectomy Adolescent Well-Care** Asthma

Atrial Fibrillation Attention Deficit Hyperactivity Disorder (ADHD)

Breast Cancer I & II

Breast Cancer Screening Bronchitis (Acute) Cardiac Surgery

Cerebral Vascular Accident Cervical Cancer Screening** Cervical Dysplasia

Children and Adolescents' Access to Primary Care Practitioners**

Children’s Access to Primary Care Practitioners**

Chlamydia Screening

Cholesterol Management Chronic Kidney Disease Chronic Obstructive Pulmonary Disease

Colon Cancer -II Comprehensive Ischemic Vascular Disease Care**

Congestive Heart Failure

COPD Exacerbation, Pharmacotherapy Management

Coronary Artery Disease Depression Medication Management

Diabetes Epilepsy** Hepatitis C

Hypertension Inflammatory Bowel Disease Knee Replacement

Low Back Pain Migraine Multiple Sclerosis**

Obesity and Overweight** Osteoporosis Otitis Externa (Acute)**

Otitis Media Persistence of Beta Blocker Treatment After MI

Pharyngitis

Pharyngitis** Pneumonia (Community Acquires Bacterial)**

Pregnancy Management

Prenatal Care** Prostate Cancer I & II Rheumatoid Arthritis

Rheumatoid Arthritis, Drug Therapy** Sickle Cell Anemia Sinusitis**

Tonsillectomy Tympanostomy Upper Respiratory Infection

**New for 2013 We determine the extent to which an individual physician or physician group complies with evidence-based medicine rules according to the following conventions: Determining peer or market EBM rule adherence for each geographic market:

In order for an EBM rule to be included for review at the geographic market level for a physician or

physician group, there must be at least 20 opportunities for the rule within the specialty category (primary care or non-primary care specialties) and market for the most recent two-year data review period. For 2013 displays and Cigna Care designation, that period is January 1, 2010 – December 31, 2011.

Note: Cervical Cancer Screening EBM rule adherence is based on a three-year data assessment timeframe [January 1, 2009 – December 31, 2011].

The average adherence rate for each EBM rule is calculated for the specialty category (primary care or

non-primary care specialties) for each geographic market to derive the peer/market average result.

Determining individual physician or group practice EBM rule adherence:

Opportunities and successes for each eligible EBM rule are aligned to the appropriate individual physician (using the visit requirements outlined below and relevant specialty type category).

Visit Requirements: A physician is considered responsible for adherence to the EBM rule if the following

conditions are met: o The EBM rule is relevant to the physician’s specialty (see Appendix 3). For example, the Breast

Cancer Screening EBM rule is relevant to OB/GYN, Internal Medicine, and Family Practice, but it is not relevant to other specialties.

o There have been at least two office visit encounters for an individual with Cigna coverage during the claim review period.

o At least one of the office visit encounters occurred in the last 12 months of the claim review period. .

Note: Twenty of our EBM measures require only one office visit encounter in the last 12 months of the claim review period. These measures are identified by an asterisk [*] in Appendix 3.

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Individual physicians are aligned to groups or practices, and EBM rule opportunities, successes, and expected successes are then summed to obtain medical group totals.

• A Quality Index for the medical group is calculated by dividing the physician’s or physician group’s

number of actual EBM rule adherence successes by the physician’s or physician group’s number of expected EBM rule adherence successes. Expected EBM rule adherence successes are derived by applying the geographic market average EBM rule adherence success rates to that physician’s or physician group’s particular rule mix opportunities

A 90% confidence interval around the Quality Index is determined, allowing EBM quality performance to be

measured with a strong degree of certainty. The lower bound of the 90% confidence interval for a particular physician or physician group is defined as the Adjusted Quality Index for that physician or physician group.

Physician medical groups that meet the Cigna group board-certification criteria, have 30 or more total EBM

rule adherence opportunities, and have at least 50% of their treatment episodes (used in the physician’s or medical group’s cost-efficiency (ETG) analysis) attributed to the physician specialty types that are assessed for EBM rule adherence are assessed and ranked using the Adjusted Quality Index score

Physicians or physician groups with an Adjusted Quality Index score in the best 34% of their medical group

specialty type and geographic market are placed in the best category for EBM rule adherence. Physicians or physician groups that have results in approximately the lowest 2.5%, for the specialty type in the market where there are at least 20 medical groups of that specialty type in the market, are placed in the bottom category. The remainder are in the middle category.

A threshold is set for each market and for each specialty type within a market. These thresholds are

determined by specific market considerations such as geography, specialty volume, access to specialty care, and contract requirements. Thresholds range from approximately 30% - 70%. The use of threshold adjustments allows for individual market factors to be taken into account; however, it is important to note that when such market-specific threshold adjustments are made, all other physicians or physician groups in that market of the same specialty that also meet the revised market threshold value, will then be deemed to have met the quality requirement for Cigna Care designation.

We do not risk-adjust EBM (quality) measures due to the fact that the EBM rules have explicit definitions

for both the numerator and the denominator of each measure. The denominator explicitly defines the population that is at risk; thus risk adjustment is incorporated into the definition of the measure.

Cost-Efficiency Evaluation We use Episode Treatment Group (ETG) methodology, an industry standard, available through INGENIX®

OPTUMInsight, Inc. to evaluate the cost-efficiency of individual physicians and medical groups. The methodology incorporates case-mix and severity adjustment, and claims are clustered into over 500 different episodes of care. Additional information about the INGENIX OPTUMInsight Episode Treatment Groups, including a complete listing of the ETGs, is available at www.ingenix.com/transparency. Using the ETG methodology, we determine how a physician’s or physician group’s cost-efficiency compares to other physicians or physician groups of the same group specialty type (primary care physician group, mixed specialty group, multi-specialty group) in the same geographic market. A physician or physician group’s performance is a result of its fee schedule, utilization patterns and referral patterns (e.g., use of hospitals and other facilities). ETG Assessment Requirements: There must be at least 10 occurrences of a specific ETG (e.g., incorporating episode severity and

treatment level, co-morbidity, complications, or the presence of Rx benefits) within the geographic market and specific physician group specialty type in order to determine the market average cost for that ETG, and thus include it in the market’s analysis.

The peer or market average for each specific ETG is established for each market and specialty type.

To reduce variation within cost-efficiency results, several ETGs are excluded from the assessment

process, including routine immunizations and other inoculations, transplants, and ETGs with low volume

http://www.ingenix.com/transparency

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or wide cost variation. Episodes with a severity level of four (the highest severity level assigned by the INGENIX OPTUMInsight ETG software), are also excluded from analysis.

Example: For the Nashville market during the data analysis period, there are 15 occurrences of ETG XX (with the same severity, treatment level, co-morbidity, complications, and presence of pharmacy benefits) that are attributed to family physicians. The average cost of ETG XX for family physicians in the Nashville market is established by computing the numerical average of the cost of all 15 occurrences of this ETG subject to the application of outlier trimming methodology outlined in the following section. This process is replicated for each ETG with at least 10 occurrences in the Nashville market for a given specialty type in order to determine the market cost average for each ETG that is eligible for evaluation in the market.

ETG Assessment Process:

Individual physicians and physician groups must have at least 30 total episodes of care during the review period in order to be reviewed for cost-efficiency. In order for an episode to be attributed to a physician (responsible physician), two criteria must be met: (1) the physician must be responsible for more costs for medical or surgical management services than any other physician providing care for the episode, and (2) the medical or surgical management costs for the physician must be at least 30% of the total episode medical or surgical management costs. If these two criteria are not met, the episode is excluded from analysis. While only the costs associated with physicians’ provision of management services are used to attribute the episode to a particular physician, total costs (physician management costs + all ancillary costs (e.g., lab, X-ray, hospital, ambulatory surgery, physical therapy, etc.) are used to characterize the total cost of the episode.

The actual cost of an episode of care for each physician group and for the physicians within that group is

compared to the market average cost of an episode of care, which is derived using their unique mix of ETGs and the peer averages.

The sum of all actual ETG episode costs for a medical group divided by the sum of all corresponding

ETG episode market average costs for that medical group’s specialty category (primary care or non-primary care) is the medical group’s Performance Index.

Example: The ABC Physician Group consisting of three family physicians in the Nashville market has five episodes of care belonging to two unique ETGs (ETG1 and ETG2) that are attributable to the group. (For the sake of simplicity, disregard for the purpose of this example the requirement that the physician or physician group must have a minimum of 30 attributable episodes in order to be reviewed for cost-efficiency.) Average episode costs for ETG1 and ETG2 have been established for all other primary care physicians or groups practicing in the Nashville market. Three episodes of ETG1 are attributable to the ABC Physician Group and two episodes of ETG2 are attributable to the ABC Physician Group. In the table below, the physician group’s cost per episode is displayed for each of the three occurrences of ETG1 and for each of the two occurrences of ETG2, along with the market average cost for an episode for ETG1 and ETG2 for all family physicians in the Nashville Market. Actual Episode Cost Market Average Cost ETG 1 2000 3500ETG 1 1000 3500ETG 1 4000 3500ETG 2 15,000 19,000ETG 2 18,000 19,000Average 8,000 9,700

Performance Index = 8,000/9,700 = 0.825

Dividing the average cost of all episodes of care attributable to the physician group by the average of all market average episode costs for the ETGs on which the physician group’s cost-efficiency performance is being evaluated yields a Performance Index (PI) of 0.825. The PI for the medical group can be interpreted as Medical Group ABC is 17.5% more cost-efficient than other family physicians (or family physician medical groups) in the Nashville market.

A 90% Confidence Interval around the Performance Index is used to determine a range of performance

within which the medical group’s true performance would fall with a high level of confidence. The upper bound of the confidence interval is defined as the Adjusted Performance Index and is used to compare cost-efficiency performance among physicians or physician groups. The upper bound of the 90%

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confidence interval is used in order to ensure that the medical group’s performance is at least as good as or better than the upper bound threshold.

A threshold is set for each market and for each specialty type within a market. These thresholds are

determined by specific market considerations such as geography, specialty volume, access to specialty care and contract requirements. Thresholds range from approximately 30% - 70%. The use of threshold adjustments allows for individual market factors to be taken into account; however, it is important to note that when such market-specific threshold adjustments are made, all other physicians or physician groups in that market of the same specialty that also meet the revised market threshold value, will then be deemed to have met the cost-efficiency requirement for Cigna Care designation.

Physicians or physician groups in the same group specialty type that meet Cigna board certification criteria

and Cigna minimum volume of 30 episodes of care are ranked using the (cost-efficiency) Adjusted Performance Index score. Those groups with an Adjusted Performance Index score in the top 34% of their respective group specialty type and market are placed in the top category for cost-efficiency and consequently meet the cost-efficiency component requirement for Cigna Care designation.

2012 Outlier Methodology In order to portray physicians’ cost-efficiency performance in the most accurate manner, the cost-efficiency evaluation includes a methodology to account for episodes that are outliers. Outliers are episodes that are substantially different from the market expected amounts. High cost episodes (ETGs) that are greater than 1.5 times the market specialty average are reduced to 1.5 times the market specialty average. Low cost outlier episodes are determined by the INGENIX software or are episodes of less than $25.00 and are excluded from the evaluation.

Level of Evaluation (Unit of Analysis) While we review participating physicians at the individual level, the majority of assessments are performed at the physician group or practice or TIN level. Individual physicians who are not part of a group are assessed if volume criteria are met. This approach provides robust data for evaluation and is consistent with the assumption that:

Individuals with Cigna coverage often chose a group rather than a specific physician within the group, and

Individuals with Cigna coverage who initially choose a specific physician frequently receive care by another physician within the practice or group.

Assigning the Cigna Care Designation (2013 CCD Inclusion Methodology) In order to receive the Cigna Care designation, a physician must qualify on the basis of both quality and cost-efficiency OR be ranked in the top 25% for cost-efficiency of an eligible specialty within their geographic market for cost-efficiency. The details of the Cigna Care designation assignment logic are outlined below and are displayed in the diagram on page 12.

• To be considered for Cigna Care designation, physicians must be MDs or DOs in one of 19 non-primary

care specialties or one of three primary care specialties. Note: We perform our evaluations at the group level. Some groups include geriatric physicians, nurse practitioners, and physician assistants who deliver primary care services as part of the group. In such cases, geriatric physicians, nurse practitioners, and physician assistants will be considered for Cigna Care designation as part of the group.

• Physicians must meet a Cigna board certification requirement. For medical groups, at least 80% of

physicians in the group must be board-certified and provide at least 50% of the total care provided by the group, OR 80% of the total care provided by the group must be provided by board-certified physicians.

• The physician practice must have at least 30 evidence-based medicine (EBM) opportunities during the

data collection period and at least 50% of the total care provided by the practice must be provided by physicians for whom there are applicable EBM rules.

• A Quality Index and Adjusted Quality Index are calculated for each practice. Physician practices are

assigned to one of three quality categories based on the Adjusted Quality Index: top 34% of practices in the market for the practice’s specialty category (non-primary care or primary care); middle 2.5% to 66% of practices in the market for the practice’s specialty category; or bottom 2.5% of practices in the market for the practice specialty category.

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Practices in Top 34% of Practices for Quality Based on EBM Assessment: • If the Adjusted Quality Index for the practice is in the top 34% of all physician practices in the geographic

market of the same specialty category (non-primary care or primary care), the practice meets the Cigna Care designation quality requirement and is then evaluated on its cost-efficiency.

• The practice must have at least 30 episodes available for ETG assessment during the data collection

period. A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice Adjusted Performance Index shows the practice is in the top 34% of all practices of the same group specialty type in the geographic market, the practice is awarded Cigna Care designation.

Practices in Middle Category (2.5% - 66%) for Quality Based on EBM Assessment: • If the Adjusted Quality Index for the practice is in the middle category (2.5% - 66%) of all physician

practices in the geographic market of the same specialty category (non-primary care or primary care), the practice is evaluated to determine if it is in the top 25% of all practices for cost-efficiency.

• The practice must have at least 30 episodes available for ETG assessment during the data collection

period. A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice Adjusted Performance Index shows the practice is in the top 25% of all practices of the same group specialty type in the geographic market, the practice is awarded Cigna Care designation.

Practices in the Bottom 2.5% for Quality Based on EBM Assessment: • If the Adjusted Quality Index for the practice is in the bottom 2.5% of all physician practices in the

geographic market of the same specialty category (non-primary care or primary care), the practice (if it is a medical group) is excluded from Cigna Care designation. Note: Practices are only assigned to the bottom 2.5% in quality performance if there are at least 20 or more quality ranked groups in a specific geographic market.

• If the practice is an individual physician and the physician has received NCQA Physician Recognition (for

diabetes care, heart/stroke care, back pain care, patient-centered medical home, patient practice connections - patient-centered medical home), the individual physician is awarded Cigna Care designation.

Note: If a physician, who is a member of a physician group, has received NCQA Physician Recognition, the awarding of Cigna Care designation is applied only to the individual physician, NOT to the physician group that the physician belongs to.

Practices Having Insufficient Volume to Assess Quality Based on EBM Assessment: • If the physician group has an insufficient volume of EBM opportunities (less than 30) in order to be

assessed for quality based on EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes eligible for ETG assessment. If it meets the 30 episode criterion and the calculated practice Adjusted Performance Index is in the top 25% of all practices of the same specialty in the geographic market, the practice is awarded Cigna Care designation.

• If the practice has an insufficient volume of EBM opportunities in order to be assessed for quality based on

EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes eligible for ETG assessment. If it meets the 30 episode criterion and the calculated Practice Adjusted Performance Index is NOT in the top 25% of all practices of the same group specialty type in the geographic market, the practice is excluded from Cigna Care designation.

Practices Having Insufficient Volume to Assess Cost Based on ETG Assessment: • If the practice has an insufficient volume of ETG opportunities (< 30) for cost profiling but has a sufficient

number of EBM opportunities (>= 30) for quality profiling, the practice is eligible for CCD designation through a quality-only pathway. If the Adjusted Quality Index of the practice places it within the top 25% of practices of the same group specialty type in the same geographic market, the practice is awarded Cigna Care designation.

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Cigna Care Designation 2013 Inclusion Algorithm

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Credit for Utilizing Cigna Centers of Excellence Cigna evaluates hospital patient outcomes and cost-efficiency information through the Cigna Centers of Excellence (COE) program for all practices. Utilization of COEs by a reviewable physician practice provides credit towards Cigna Care designation. If at least 50% of the physicians in the practice each had at least three COE admissions during the data analysis period, then a one percentage-point increase in the Performance Index (for cost-efficiency) and a one percentage-point increase in the Quality Index will be granted. The increased Performance Index and Quality Index are then used to determine eligibility for Cigna Care designation. COE admissions must be consistent with the specialty of the physician providing the COE-related care in order to qualify.

Buffer Zone Methodology Variation in physician group or physician group performance (e.g., positive or negative, substantial, or minimal) is inevitable and expected in an annual review process due to various factors (e.g., changes to physician group makeup, external market factors, and practice pattern modifications). A “buffer zone” or “grandfathering” methodology addresses small-scale variation for physician groups or physician groups whose Cigna Care designation changes from the previous year. A practice may maintain its Cigna Care designation status if the group was “in” during the prior cycle and: is within 3% of this year's quality AND cost cut off, OR is within 3% of cost index. Please note that this will not apply to primary care practice groups, as they did not have prior designation.

The selected physician group must meet the standard Cigna Care designation criteria to achieve the 2013 buffer zone designation. The standard criteria applied includes meeting the physician group Board Certification criteria, the Board Certified physicians must be responsible for at least 50% of the group episodes, the group must have at least 30 episodes, and the group must not be in the bottom 2.5 market percentile for EBM quality performance in a market with greater than 20 groups within the specialty category in the market.

Data Sources The evaluation data sources and how the information from each source is used are outlined below.

Data Source How Information is Used Cigna Physician Metrics (January 2010 – December 2011) Use combined Managed Care and PPO product data with episodes of care or EBM rules attributed to the responsible physician.

• The data is used to produce ETG efficiency and EBM summary reports. Note: Data for Medicare-eligible individuals is removed.

Cigna Central Physician File (CPF) (as of April 2012)

• File extracts to identify contracted physicians, TIN, groups, specialty, board certification status, network, and products contracted.

Physician Recognition Program File obtained from National Committee for Quality Assurance (NCQA) (as of April 2012 and at least six times per year)

• The status of physicians recognized for the diabetes, heart/stroke, back pain, physician practice connections or physician practice connections patient-centered medical home recognition programs is updated based on information received from NCQA.

Cigna Certified Bariatric Facilities listing (as of April 2012 and updated monthly if new centers are identified)

• Identifies bariatric surgeons associated with the Cigna Certified Bariatric Facilities.

Cigna Utilization and Centers of Excellence (COE) Data

• Specialty groups that admit to Center of Excellence facilities (based on utilization data) will receive credit towards Cigna Care Designation inclusion

Additional Information and Data Limitations The Cigna Care designation and physician quality and cost-efficiency displays are a partial assessment of physician quality and cost-efficiency, and are intended to provide information that can assist individuals with

14

Cigna coverage in health care decision-making. It should not be used as the sole basis for decision-making (as such measures have a risk of error). Individuals with Cigna coverage are encouraged to consider all relevant information and to consult with their treating physician in selecting a physician for care.

While we use what we believe to be the best available information to create an objective assessment methodology, there are some limitations:

The EBM and cost-efficiency information are based on our data only. Aggregated claim data from multiple payers (e.g. insurance companies, self-insured, and government plans) may provide a more complete picture of physician performance. We support data aggregation initiatives, and will consider using it in evaluations when credible data are available.

We can only use received claim data in evaluations. There may be health care services performed for which no information is provided to us.

Specific service line item detail may not always be available due to the way claims may be submitted by physicians or processed by us.

Pharmacy data inclusion is limited to only those customers that we administer pharmacy benefits to.

We use Episode Treatment Groups (ETGs), an industry standard grouper, to risk-adjust for patient severity. Although ETG software is recognized as a leading risk adjustment model, perfect patient severity risk adjustment does not exist.

Many physicians or physician groups are unable to be displayed for quality and cost-efficiency due to small patient populations. We will not display results for those physicians or physician groups whose episodes or opportunities sample do not meet certain volume thresholds.

Process to Display Strategic Alliances Information Health Alliance Plan (HAP) Physicians or physician groups in the Eastern Michigan area (Genesee, Oakland, Lapeer, St. Clair, Livingston, Washtenaw, Macomb, Wayne, and Monroe counties) are evaluated using the claim data from Health Alliance Plan (HAP). HAP data reflects the contracted rates and physician utilization statistics associated with HAP membership in the Michigan area. Consistent with our methodology, HAP's 2012 physician profiling process includes NQF EBM rules, NCQA recognition, ABIM's Practice Improvement Modules, and board certification to evaluate physicians. The Cigna Care designation icon displays when physicians or physician groups in Eastern Michigan have met the quality and cost-efficiency inclusion criteria, but tiered benefits are not available in the HAP service area. Specific Market Activities California IHA P4P

• Cigna HealthCare of California participates in a statewide initiative coordinated by Integrated Health Assessment (IHA) to measure and improve clinical quality, patient experience, use of information technology, and public reporting of provider performance results.

• Incentive payments are paid annually by Cigna to physician organizations based upon performance against standard quality measures.

• The common set of key measures used for assessment relies on national standards or evidence based medicine practices.

• The measure set, audit manual, and data submission file layouts are released each year by IHA. • More information about the program and the assessment results can be found by visiting the

www.IHA.org website.

Feedback Process Individuals with Cigna coverage, clients, and participating physicians are encouraged to provide feedback and suggestions for the improvement of reports or other suggested improvements. Clients and individuals with Cigna administered plans should call the telephone number listed on the back of their Cigna ID card. Participating physicians may provide feedback by calling our Customer Service Center at 1.800.88Cigna (882.4462). Feedback and suggestions are reviewed, and changes to the physician evaluation methodology, reporting formats, and processes are implemented as appropriate. Methodology changes are generally reviewed and implemented on an annual basis.

15

Physician Process to Correct Errors, Request Reconsideration, or Appeal Participating physicians or physician groups have a right to seek correction of errors and request data review for both the Cigna Care designation and physician quality and cost-efficiency displays. Email us at [email protected] or fax us at 1.866.448.5506 to request additional information, for detail reports, to request reconsideration, to correct inaccuracies, or to submit additional information. The request for reconsideration must include the reason for the reconsideration and any documentation you wish to provide in support of the request. The National Selection Review Committee process is initiated within five business days of Cigna's receipt of a reconsideration or appeal request. A Cigna Network Clinical Manager (NCM) will contact the physician practice or physician group to clarify information received for reconsideration and generate detail reports. The NCM may change the physician group designation if the obtained information meets committee guidelines. These may include, but are not limited to: a verification of board certification; a revision to the Evidence Based Medicine (EBM) adherence score; or a verification of completion of one or more NCQA physician recognition programs. The National Selection Review Committee will review the request if the obtained information does not meet committee guidelines. The National Selection Review committee participants include Cigna physicians and Cigna network clinical performance staff. Voting committee participants include the National Medical Director and physician representatives from the three Cigna regions, their alternates and ad hoc physicians. Non-voting participants include the Assistant Vice President of Provider Measurement and Performance, National Network Business Project Sr. Analyst, Health Data Senior Specialist, Marketing Product Sr. Specialist, Network Product Integration Leads, and Network Clinical Managers.

The National Selection Review Committee determination may include changing the designation, upholding the original designation, or pending the determination for additional information. The decision notification is mailed to the physician group after the committee determination is made. The National Selection Review Committee process and final decision is complete within 45 days of receipt of a reconsideration or appeal request. Colorado health care professional should refer to Appendix 4 on page 32 of this document for Colorado specific appeals.

How to Register Complaints At any time, individuals with Cigna coverage may register a complaint with us about the Cigna Care designation or the physician quality and cost-efficiency displays by calling the telephone number located on the back of the Cigna ID card.

Registering a Complaint for Individuals in New York The National Committee for Quality Assurance (NCQA) is an independent not-for-profit organization that uses standards, clinical performance measures and member satisfaction to evaluate the quality of health plans. NCQA serves as an independent ratings examiner for Connecticut General Life Insurance Company and Cigna HealthCare of New York, Inc., reviewing how Cigna Care designations and physician quality and cost-efficiency displays meet criteria required by the State of New York. Complaints about Cigna Care designations or physician quality and cost-efficiency displays in New York may be registered to NCQA, in addition to registering with Cigna as above, by submitting them in writing to customer support at www.ncqa.org or to NCQA Customer Support, 1100 13th Street, NW, Suite 1000, Washington, DC, 20005.

mailto:[email protected]

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2013 Physician Evaluation Methodology Changes Changes to the Cigna 2013 physician evaluation methodology are outlined below.

Methodology Item 2013 Change/Enhancement Details

General Methodology ETG/EBM Version Migrated from ETG/EBM Version

7.5.5 to 7.6CC1 Additional EBM rules. New EBM rules aligned more closely with HEDIS specifications

Physician Specialty Changes

19 reviewable specialties plus multi-specialty and 3 primary care physician (PCP) specialties are evaluated for CCD.

PCP specialties are now included in Cigna Care Designation.

Bariatric Certified Facility

Physicians affiliated with a Cigna Certified Bariatric Facility no longer granted CCD on that basis alone.

Removed criteria allowing provider to be automatically IN for CCD based on affiliation with Certified Bariatric Facility only.

Grandfathering Allowance of physicians who were previously IN for CCD but are now OUT if data are within certain limits

If a group was in during the prior cycle and is within 3% of this year's quality AND cost cut off, OR is within 3% of cost index, they are in. This does not apply to PCP groups, as they did not have prior designation.

Quality Evaluation Methodology Changes Change in number of EBM rules

Increased EBM rule set from 72 rules to 101 covering 48 disease and preventive care conditions

Additional rules cover more disease categories and specialties

Cost-Efficiency Methodology Changes Centers of Excellence utilization credit

Utilization of the COEs provides credit for Cigna Care designation.

If at least 50% of the physicians at the practice had three of the COE-assessed conditions and utilized a COE for the admission, a 1% increase in the performance index for Performance Index (cost-efficiency) and the Quality Index will be granted.

Cigna Care Designation Selection Methodology Changes Selection process based on EBM and ETG results

New selection criteria utilize an "AND: OR" approach. Default is that top groups for 34% EBM AND ETG; OR top 25% ETG are in.

New selection criteria utilize an "AND: OR" approach. Default is that top groups for 34% EBM AND ETG; OR top 25% ETG are in. Selection criteria are described in detail in a previous section of this white paper.

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APPENDICES

Appendix 1: 2013 Cigna Care Designation Market Information

Market Volume Reviewed

Percent Designated

Percent Not Designated

AR, Central 1676 25.24% 74.76% AZ, Maricopa 7592 32.06% 67.94% AZ, All Other 1409 29.24% 70.76% AZ, Pima 2232 27.15% 72.85% CA, North 1594 15.06% 84.94% CA, South 25022 29.63% 70.37% CA, Bay Area 10464 57.45% 42.55% CA, Sacramento 2740 61.02% 38.98% CA, Central Valley 2642 49.55% 50.45% CO, Front Range 7354 51.88% 48.12% CT, Connecticut 8515 34.68% 65.32% DE, Delaware 2007 37.77% 62.23% FL, Jacksonville 2215 26.91% 73.09% FL, All Other 3606 24.27% 75.73% FL, South Florida 8352 21.82% 78.18% FL, Orlando 4570 27.83% 72.17% FL, Tampa 7866 31.39% 68.61% GA, Atlanta 8371 42.60% 57.40% GA, All Other 4193 49.01% 50.99% IL, Chicago Metro 15266 59.78% 40.22% IL, Rockford 2397 56.57% 43.43% IN, Indianapolis 4250 44.12% 55.88% KS, KS/MO Kansas City 3903 43.99% 56.01% LA, All Other 4441 29.93% 70.07% LA, New Orleans 2455 25.05% 74.95% MA, Western 3803 40.18% 59.82% MD, Maryland/DC 14827 30.60% 69.40% MD, Northern VA 4631 41.01% 58.99% ME, Maine 3647 40.50% 59.50% NC, Charlotte 3957 52.92% 47.08% NC, East 3314 23.11% 76.89% NC, Raleigh 4141 28.11% 71.89% NC, Triad 2810 29.50% 70.50% NC, West 2096 31.06% 68.94% NH, New Hampshire 4039 31.32% 68.68% NJ, North Jersey 10269 20.92% 79.08% NJ, South Jersey 4157 28.22% 71.78%

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Market Volume Reviewed

Percent Designated

Percent Not Designated

NV, Nevada 3634 23.36% 76.64% NY, Metro 25069 54.78% 45.22% OH, Northern 10392 55.84% 44.16% OH, Central 5480 60.00% 40.00% OH, Southern 6188 33.42% 66.58% PA, Philadelphia 10834 50.23% 49.77% PA, All Other 11429 47.14% 52.86% PA, Pittsburgh/Western 5329 61.25% 38.75% RI, Rhode Island 2329 22.71% 77.29% SC, Low Country 2209 28.84% 71.16% SC, Midlands 2071 33.37% 66.63% SC, Upstate 2599 54.17% 45.83% TN, Memphis 2024 26.58% 73.42% TN, Nashville 3374 30.85% 69.15% TN, Knoxville 3206 44.29% 55.71% TN, Rural 2054 24.39% 75.61% TN, Chattanooga 1461 31.76% 68.24% TX, Austin 3315 32.01% 67.99% TX, Dallas/Ft. Worth 8760 33.45% 66.55% TX, Houston 9689 44.00% 56.00% TX, San Antonio 3120 35.45% 64.55% TX, East Central Texas 2346 30.65% 69.35% UT, Wasatch Front 3274 41.33% 58.67% VA, Hampton Roads 3034 42.85% 57.15% VA, Richmond 2730 28.24% 71.76% VA, Western 3894 27.50% 72.50% VT, Vermont 1953 34.56% 65.44% WA, Seattle 9876 28.06% 71.94% WA, All Other 4476 23.12% 76.88% WI, Milwaukee/Green Bay 7328 49.30% 50.70% WI, All Other 3959 49.61% 50.39% WV, West Virginia 3536 36.71% 63.29%

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Appendix 2: 2012 Quality and/or Cost-Efficiency Display Markets and Number of Physicians Reviewed

e Specialists Reviewed

Market Name Specialists Reviewed

Alabama** 5,290 North Carolina, Raleigh 4,141Arkansas, Central 1,676 North Carolina, Triad 2,810Arkansas All Other 2,464 North Carolina, West 2,096Arizona, Maricopa 7,592 NH New Hampshire 4,039Arizona, All Other 1,409 New Jersey, North Jersey 10,269Arizona, Pima 2,232 New Jersey, South Jersey 4,157California, North 1,594 Nevada 3,634California, South 25,022 New York, Metro 25,069California, Bay Area 10,464 Ohio, Northern 10,392California, Sacramento 2,740 Ohio, Central 5,480California, Central Valley 2,642 Ohio, Southern 6,188Colorado, All Other** 1,479 Oklahoma** 4,740Colorado, Front Range 7,354 Pennsylvania, Philadelphia 10,834Connecticut 8,515 Pennsylvania, All Other 11,429Delaware 2,007 Pennsylvania, Pittsburgh/Western 5,329Florida, Jacksonville 2,215 Rhode Island 2,329Florida, All Other 3,606 South Carolina, Low Country 2,209Florida, South Florida 8,352 South Carolina, Midlands 2,071Florida, Orlando 4,570 South Carolina, Upstate 2,599Florida, Tampa 7,866 Tennessee, Memphis 2,024Georgia, Atlanta 8,371 Tennessee, Nashville 3,374Georgia, All Other 4,193 Tennessee, Knoxville 3,206Illinois, Chicago Metro 15,266 Tennessee, Rural 2,054Illinois, All Other** 1,412 Tennessee, Chattanooga 1,461Illinois, Rockford 2,397 Texas, Austin 3,315Indiana, Indianapolis 4,250 Texas, Dallas/Ft. Worth 8,760Indiana, All Other** 4,764 Texas, Houston 9,689Kansas, KS/MO All Other** 4,275 Texas, San Antonio 3,120Kansas, KS/MO Kansas City 3,903 Texas, East Central Texas 2,346Kentucky** 4,742 Utah, Wasatch Front 3,274Louisiana, All Other 4,441 Virginia, Hampton Roads 3,034Louisiana, New Orleans 2,455 Virginia, Richmond 2,730Massachusetts, Western 3,803 Virginia, Western 3,894Massachusetts, Boston** 15,394 Vermont 1,953Maryland, Maryland/DC 14,827 Washington, Seattle 9,876Maryland, Northern Virginia, 4,631 Washington, All Other 4,476Maine 3,647 Wisconsin, Milwaukee/Green Bay 7,328Mississippi** 2,562 Wisconsin, All Other 3,959North Carolina, Charlotte 3,957 West Virginia 3,536North Carolina, East 3,314

** Indicates markets where physicians are assessed for Quality and Cost-Efficiency display only.

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Appendix 3: EBM Rules Used for the 2012 Physician Evaluation

Condition Source Summary Rule Description

Applicable Specialist Types

Applicable Primary Care Specialty Types

Adenoidectomy American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS)

Patient(s) less than 18 years of age that had an adenoidectomy and met clinical criteria for this procedure.

Otolaryngology Internal Medicine Family Practice Pediatrics

ADHD, Follow-Up Care for Children Prescribed ADHD Medication (NS)

National Quality Forum/NCQA

Patient(s) with an outpatient, intensive outpatient or partial hospitalization follow-up visit with a prescribing provider during the 30 days after the initial ADHD prescription, AND two follow-up visits during the 31 days through 300 days after the initial

NA Family Practice Pediatrics

ADHD, Follow-Up Care for Children Prescribed ADHD Medication (NS)


Patient(s) with an outpatient, intensive outpatient or partial hospitalization follow-up visit with a prescribing provider during the 30 days after the initial ADHD prescription.

NA Family Practice Pediatrics

Adolescent Well-Care Visits (NS)

NCQA Patient(s) 12 - 21 years of age that had one comprehensive well-care visit with a PCP or an OB/GYN in the last 12 reported months.

NA Internal Medicine Family Practice Pediatrics

Antidepressant Medication Management (NS)


Patient(s) with a new episode of major depression that remained on an antidepressant medication during the 12 week acute treatment phase.

NA Internal Medicine Family Practice

Antidepressant Medication Management (NS)


Patient(s) with a new episode of major depression that remained on an antidepressant medication during the 6 month acute treatment phase.

NA Internal Medicine Family Practice

21

Asthma, Use of Appropriate Medications (NS)


Patient(s) between the ages of 12 and 50 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative.

Allergy/Immunology Pulmonology

Internal Medicine Family Practice

Asthma, Use of Appropriate Medications (NS)


Patient(s) between the ages of 5 and 11 with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative.

Allergy/Immunology Pulmonology

Internal Medicine Family Practice Pediatrics

Atrial Fibrillation American College of Cardiology/American Heart Association

Patient(s) taking warfarin that had 3 or more prothrombin time tests in last 6 reported months.

Cardiology Internal Medicine Family Practice

Breast Cancer - Part I

American Society of Clinical Oncology

Patient(s) that had an annual physician visit.

Hematology/Oncology OB/GYN


Breast Cancer - Part II

Ingenix - consensus opinion of experts was the primary source

Patient(s) newly diagnosed with breast cancer that received radiation or chemotherapy treatment or had medical oncology or radiation oncology consultation within 90 days of the diagnostic procedure.

Hematology OB/GYN


Breast Cancer Screening (NS)*


Patient(s) 42 - 69 years of age that had a screening mammogram in last 24 reported months.

OB/GYN Internal Medicine Family Practice

Bronchitis, Acute, Avoidance of Antibiotic Treatment in Adults (NS)*++


Patient(s) with a diagnosis of acute bronchitis that did not have a prescription for an antibiotic on or three days after the initiating visit.

Otolaryngology (Ear, Nose and Throat) Pulmonology


Cardiac Surgery (name changed from "Cardiac Surgery (NS)")

American College of Cardiology/American Heart Association

Patient(s) 20 years of age and older hospitalized for a CABG procedure that have evidence of a CVA during the hospitalization or within seven days of discharge.

Cardiology Cardio-Thoracic Surgery


Cardiac Surgery (NS)


Patient(s) 20 years of age and older hospitalized for a CABG procedure taking a lipid-lowering medication at admission or within seven days of discharge.



22

Cardiac Surgery (NS)


Patient(s) 20 years of age and older hospitalized for a CABG procedure taking a beta-blocker at admission or within seven days of discharge.



Cerebral Vascular Accident & Transient Cerebral Ischemia


Patient(s) taking warfarin that had 3 or more prothrombin time tests in last 6 reported months.

Neurology Neurosurgery


Cerebral Vascular Accident & Transient Cerebral Ischemia

National Quality Forum/Ingenix

Patient(s) with a recent emergency room encounter for a transient cerebral ischemic event that had any physician visit within 30 days of the acute event.

Neurology Neurosurgery Cardio-Thoracic Surgery

N/A

Cervical Cancer Screening (NS)


Patient(s) that had a cervical cancer screening test in last 36 reported months.

General Surgery Hematology/Oncology OB/GYN


Cervical Dysplasia

Ingenix - Based on guideline recommendations Gynecologists (2-4) and expert opinion

Patient(s) with cervical dysplasia that had a PAP smear, hysterectomy, or other cervical procedure within 12 months of the initial diagnosis.

OB / GYN Internal Medicine Family Practice Pediatrics

Children and Adolescents' Access to Primary Care Practitioners (NS)

NCQA Patient(s) 7-11 years of age that had a PCP visit during the report period.

N/A Pediatrics

Children and Adolescents' Access to Primary Care Practitioners (NS)

NCQA Patient(s) 12-19 years of age that had a PCP visit during the report period.

OB/GYN Family Practice

Children’s' Access to Primary Care Practitioners (NS)

NCQA Patient(s) 25 months to 6 years of age that had a PCP visit during the report period.

N/A Internal Medicine Family Practice Pediatrics

Children’s’ Access to Primary Care Practitioners (NS)

NCQA Patient(s) 12 - 24 months of age that had a PCP visit during the report period.

NA Internal Medicine Family Practice Pediatrics

Chlamydia Screening (NS)*


Patient(s) 21 - 25 years of age that had a chlamydia screening test in last 12 reported months.

OB/GYN Internal Medicine Family Practice Pediatrics

23

Chlamydia Screening (NS)*


Patient(s) 16- 20 years of age that had a chlamydia screening test in last 12 reported months.

OB/GYN Pediatrics Family Practice Internal Medicine

Cholesterol Management for Patients with Cardiovascular Conditions (NS)

NCQA Patient(s) with lab results with a LDL cholesterol level < 100 mg/dL.



Cholesterol Management for Patients with Cardiovascular Conditions (NS)

NCQA Patient(s) with a LDL cholesterol test during the report period.



Chronic Kidney Disease

Ingenix - Expert consensus from K/DOQI guidelines

Patient(s) meeting the threshold of CrCl < 60ml/min, Cr >= 1.5mg/dL for women or Cr >= 2.0mg/dL for men, that had a serum phosphorus in last 12 reported months.

Nephrology Internal Medicine Family Practice



Patient(s) meeting the threshold of CrCl < 60ml/min, Cr >= 1.5mg/dL for women or Cr >= 2.0mg/dL for men, that had a serum calcium in last 12 reported months.




Patient(s) meeting the threshold of CrCl < 30ml/min, Cr >= 2.0mg/dL for women or Cr >= 2.5mg/dL for men, that had a serum PTH test in last 12 reported months.


Chronic Obstructive Pulmonary Disease

American Thoracic Society

Patient(s) with problematic COPD control that had a PFT in last 12 reported months.

Pulmonology Internal Medicine Family Practice

Colon Cancer - Part II

Ingenix/ NCCN Practice Guidelines in Oncology

Patient(s) newly diagnosed with colon cancer that had a full colonoscopy.

Colon and Rectal Surgery Gastroenterology Hematology/Oncology


Comprehensive Ischemic Vascular Disease Care (NS)

NCQA (similar) Patient(s) with lab results with a LDL cholesterol level < 130 mg/dL.


N/A

Comprehensive Ischemic Vascular Disease Care (NS)


Patient(s) with a lipid profile test during the report period.


N/A

24



Patient(s) currently taking a beta-blocker specifically recommended for CHF management.




Patient(s) currently taking a beta-blocker.


Congestive Heart Failure (NS)

National Quality Forum/AMA/PCPI

Patient(s) with CHF and atrial fibrillation currently taking warfarin.


COPD Exacerbation, Pharmacotherapy Management (NS)

NCQA Patient(s) 40 years of age and older with COPD exacerbation that received a systemic corticosteroid within 14 days of the hospital or ED discharge.


COPD Exacerbation, Pharmacotherapy Management (NS)

NCQA Patient(s) 40 years of age and older with COPD exacerbation that received a bronchodilator within 30 days of the hospital or ED discharge.


Coronary Artery Disease (NS)

National Quality Forum/ AMA-PCPI

Patient(s) prescribed lipid-lowering therapy during the measurement year.





Patient(s) with CAD and diabetes and/or CHF prescribed ACE-inhibitor or angiotensin II receptor antagonist therapy during the measurement year.





Patient(s) with a lipid profile (or ALL component tests) during the measurement year.





Patient(s) with a prior myocardial infarction prescribed beta-blocker therapy during the measurement year.



Diabetes Care (NS)

NCQA (similar) Patient(s) 18-75 years of age with lab results with most recent LDL result <100 mg/dL.

Endocrinology Internal Medicine Family Practice

Diabetes Care (NS)

NCQA (similar) Patient(s) 18-75 years of age with lab results with most recent HbA1c result value less than 8.0%.


25

Diabetes Care (NS)

NCQA (similar) Patient(s) 18 - 75 years of age with lab results that have evidence of poor diabetic control, defined as the most recent HbA1c result value greater than 9.0%.


Diabetes Care (NS)

NCQA (similar) Patient(s) 18-75 years of age with lab results with most recent LDL result <130 mg/dL.


Diabetes Care (NS)

NCQA (similar) Patient(s) 18 - 75 years of age that had annual screening for nephropathy or evidence of nephropathy.

Endocrinology OB/GYN


Diabetes Care (NS)

AQA/NCQA Patient(s) 18 - 75 years of age with a LDL cholesterol in last 12 months.



Diabetes Care (NS)


Patient(s) 18 - 75 years of age that had a HbA1c test in last 12 reported months.



Diabetes Care (NS)*

NCQA (similar) Patient(s) 18 - 75 years of age that had an annual screening test for diabetic retinopathy.

Endocrinology OB/GYN Ophthalmology


Diabetes Care NS


Patient(s) 5 - 17 years of age that had a HbA1c test in last 12 reported months.

Endocrinology OB / GYN


Diabetes Mellitus National Quality Forum/Ingenix

Adult(s) that had a serum creatinine in last 12 reported months.


Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (NS)


Patient(s) who had a prescription, dispensed for a disease modifying anti-rheumatic drug (DMARD) during the report period.

Rheumatology Internal Medicine Family Practice Pediatrics

Epilepsy Ingenix/The National Collaborating Centre for Primary Care guidelines

Patient(s) with one or more hospitalizations or two or more emergency room encounters for epilepsy that had neurology consultation in last 3 reported months.

Neurology Internal Medicine Family Practice

Epilepsy Ingenix/The National Collaborating Centre for Primary Care guidelines



26

Hepatitis C Ingenix/AHRQ Patient(s) with cirrhosis that had a liver imaging test in last 12 reported months.

Gastroenterology Internal Medicine Family Practice

Hepatitis C Ingenix/AHRQ Patient(s) 18 years and older that had an annual physician visit.


Hepatitis C Ingenix/AHRQ Patient(s) with indications that had gastroenterology or infectious disease consultation in last 12 reported months.


Hypertension* National Quality Forum/Ingenix

Patient(s) that had a serum creatinine in last 12 reported months.

Cardiology Endocrinology Nephrology Neurology


Inflammatory Bowel Disease

Ingenix - consensus opinion of experts was the primary source

Patient(s) with inflammatory bowel disease complications that had gastroenterology consultation in last 3 reported months.

Gastroenterology General Surgery Colon and Rectal Surgery

N/A

Knee Replacement++

Ingenix/ AAOS Adults(s) that had a knee MRI prior to knee replacement surgery.

Orthopedics and Surgery


Knee Replacement

Ingenix/ AAOS Adults(s) that had a knee x-ray prior to knee replacement surgery.

Orthopedics and Surgery


Low Back Pain, Use of Imaging Studies (NS)++


Patient(s) with uncomplicated low back pain that did not have imaging studies.

Orthopedics and Surgery Rheumatology


Migraine Headache

Ingenix/American Academy of Neurology

Patient(s) with frequent ER encounters or frequent acute medication use that had an office visit in last 6 reported months.

Neurology OB/GYN


Migraine Headache

National Quality Forum/ Ingenix/ American Academy of Neurology

Adult patient(s) with frequent use of acute medications that also received prophylactic medications.

Neurology OB/GYN


Multiple Sclerosis Ingenix - consensus opinion of experts was the primary source of this recommendation

Patient(s) with more than one magnetic resonance imaging (MRI) scan of the head in last 12 reported months (excluding patient(s) with neurologic manifestations or complications suggesting a new disease state).


27

Obesity and Overweight

Ingenix/Clinical research and the consensus opinion of experts was the primary source

Patient(s) with bariatric surgery who had a defined complication during hospitalization or 30 days after discharge.

Endocrinology General Surgery


Obesity and Overweight

Ingenix/Clinical research and the consensus opinion of experts was the primary source

Patient(s) with bariatric surgery who had a defined complication during hospitalization or 180 days after discharge.

Endocrinology General Surgery


Osteoporosis Management in Women Who Had a Fracture (NS)


Women 67 years of age or older who were treated or tested for osteoporosis within six months of a fracture.

OB/GYN Orthopedics and Surgery


Otitis Externa, Acute*

National Quality Forum/Ingenix/American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)

Patient(s) 2 years of age and older with acute otitis externa who were NOT prescribed systemic antimicrobial therapy.

Otolaryngology (Ear, Nose and Throat)


Otitis Media, Acute*

Ingenix/American Academy of Pediatrics and American Academy of Family Physician

Patient(s) on antibiotic therapy with acute otitis media that received amoxicillin, a first line antibiotic.



Persistence of Beta-Blocker Treatment after a Heart Attack (NS)


Patient(s) hospitalized with an acute myocardial infarction (AMI) persistently taking a beta-blocker for six months after discharge.



Pharyngitis, Appropriate Testing for Children (NS)*


Patient(s) treated with an antibiotic for pharyngitis that had a Group A streptococcus test.



Pneumonia, Community-Acquired Bacterial (CAP)

Ingenix/AMA/PCPI (similar)

Adult(s) with community-acquired bacterial pneumonia who have a CXR.


Potentially Harmful Drug-Disease Interactions in the Elderly (NS)

NCQA Elderly patients with dementia who took a tricyclic antidepressant or anticholinergic agent after the earliest record of dementia (HEDIS criteria).

N/A Internal Medicine Family Practice

Potentially Harmful Drug-Disease Interactions in the Elderly (NS)

NCQA Elderly patients who had an accidental fall or hip fracture who took a tricyclic antidepressant antipsychotic or sleep agent after the incident (HEDIS criteria).

N/A Internal Medicine Family Practice

28

Pregnancy Management*

National Quality Forum/Ingenix/American College of Obstetricians and Gynecologist/USPSTF

Pregnant women that had syphilis screening.



National Quality Forum/ Ingenix

Pregnant women that had HIV testing.


Pregnancy Management

Ingenix/American College of Obstetricians and Gynecologists

Pregnant women less than 25 years of age that had chlamydia screening.



National Quality Forum/Ingenix/American College of Obstetricians and Gynecologist/USPSTF

Pregnant women that had HBsAg testing.




Pregnant women that received rubella immunity screening.




Pregnant women that had hemoglobin testing.


Prenatal Care (NS)*

NCQA Women with deliveries of live births that received a prenatal care visit in the first trimester.

OB/GYN Internal Medicine Family Practice

Prostate Cancer - Part I

Ingenix/American Urological Association

Patient(s) that had a prostate specific antigen test in last 12 reported months.

Hematology/Oncology Urology


Prostate Cancer - Part I

Ingenix/American Urological Association




Prostate Cancer - Part II

Ingenix/The consensus opinion of experts was the primary source

Patient(s) newly diagnosed with prostate cancer that had medical oncology, radiation oncology or urology consultation in last 6 reported months.



Rheumatoid Arthritis

Ingenix/American College of Rheumatology (NQF Patient Safety)

Patient(s) taking methotrexate, sulfasalazine, gold, or leflunamide that had a CBC in last 3 reported months.



Ingenix - EBM Connect consultant panel process

Patient(s) taking chronic corticosteroids that had rheumatology consultation in last 6 reported months.


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Ingenix/American College of Rheumatology

Patient(s) with complex RA treatment regimens or complications that had rheumatology consultation in last 6 reported months.




Patient(s) taking methotrexate, sulfasalazine, or leflunomide that had serum ALT or AST test in last 3 reported months.



Ingenix/American College of Rheumatology

Patient(s) taking hydroxychloroquine (Plaquenil) that had an eye exam in last 12 reported months.




Patient(s) taking methotrexate or sulfasalazine that had a serum creatinine in last 6 reported months.


Sickle Cell Anemia

Ingenix - consensus opinion of experts was the primary source/American Academy of Pediatrics

Patient(s) that had a reticulocyte count in last 12 reported months.

Hematology/Oncology Internal Medicine Family Practice Pediatrics

Sickle Cell Anemia

Ingenix - consensus opinion of experts was the primary source/American Academy of Pediatrics

Patient(s) that had a hemoglobin/hematocrit in last 12 reported months.

Hematology/Oncology Internal Medicine Family Practice Pediatrics

Sinusitis, Acute Ingenix - Sinus and Allergy Health Partnership

Patient(s) treated with an antibiotic for acute sinusitis that received a first line antibiotic.

Otolaryngology (Ear, Nose and Throat) Pulmonology Allergy/Immunology


Sinusitis, Acute Ingenix - Sinus and Allergy Health Partnership

Patient(s) that had a sinus computerized axial tomography (CT) or magnetic resonance imaging (MRI) test.

Otolaryngology (Ear, Nose and Throat) Pulmonology Allergy/Immunology


Tonsillectomy Ingenix/American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)

Patient(s) less than 21 years of age that had a tonsillectomy and met clinical criteria for this procedure.


Tympanostomy Tube Placement

Ingenix/American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)

Patient(s) less than 12 years of age that had tympanostomy tube placement and met clinical criteria for this procedure.


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Upper Respiratory Infection (URI), Appropriate Treatment for Children (NS)*


Patient(s) with a diagnosis of upper respiratory infection (URI) that did not have a prescription for an antibiotic on or three days after the initiating visit.



* Measures requiring one office visit in the most recent 12 months of the review period. ++ Atypical rule – measure indicates over-utilization of services. Compliance for the measure requires absence of the service. Compliance rates are inverted for reporting and comparison purposes.

Abbreviations List

Abbreviation Organization Abbreviation Organization

AAP American Academy of Pediatrics HEDIS Healthcare Effectiveness Data Information Set

ACC American College of Cardiology HOPE Heart Outcomes Prevention Evaluation Study

ACOG American College of Obstetrics and Gynecology ICSI Institute for Clinical Systems Improvement

ACP-ASIM The American College of Physicians- American Society of Internal Medicine

IDSA Infectious Diseases Society of America

ADA American Diabetes Association K/DOQI Kidney Disease Outcomes Quality Improvement

AHA American Heart Association NHLBI National Heart Lung Blood Institute

AHRQ Agency for Healthcare Research and Quality NIH National Institutes of Health

AMA American Medical Association NQF National Quality Forum

AMA-PCPI American Medical Association- Physician Consortium for Performance Improvement

USPHS United States Preventive Health Service

FDA Food and Drug Administration Individuals with Cigna coverage can request specifications for any of the listed measures by calling Cigna at the telephone number located on the back of their Cigna ID card. Participating physicians can request additional specifications by email to [email protected] or fax to 1.866.448.5506.

“Cigna” is a registered service mark and the “Tree of Life” logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc.

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Appendix 4: Appeals Process for Colorado Health Care Professionals Procedures to Obtain Additional Information To review additional quality and cost-efficiency information, obtain a full description of the methodology and data that our decisions were based on or declined, the physician should submit the request by email at [email protected] or by faxing the request to 866.448.5506. A Network Clinical Manager will contact the physician to provide additional details about the process and the results. If the request is regarding the methodology and data that the designation decisions were based on or declined, we will provide the physician or physician group with this information within 45 days of our receipt of the request. Where the law or our contractual obligations with a third party prevents disclosure of the data required to be disclosed, we will provide sufficient information to allow the physician or physician group to determine how the withheld data affected the designation. After disclosure of the description of the methodology described above, the physician or physician group may request further information related to the designation decisions. Such further information, if it exists and has not been previously disclosed, will be provided by us within 30 days of the request. The “Cigna Care Designation and Physician Quality and Cost Efficiency Profiles Methodology” is available on the Cigna for Health Care Professionals website at CignaforHCP.com. Request an Appeal of the Designation Decision To request an appeal of Cigna Care designation and quality and cost-efficiency displays in Colorado (including the opportunity for a face-to-face meeting), have corrected data relevant to the designation decision considered, have the applicability of the methodology used in the designation decision considered, or to submit additional information, the physician should contact the email or fax number noted above. A Network Clinical Manager will contact the physician or physician group to provide additional details about the process and the results. The National Selection Review Committee, who review all appeal requests, is a national committee that reviews appeal and reconsideration requests with Cigna participants in locations other than Colorado. The committee participants are listed below. Voting Committee Participants

• National Medical Director for Network Clinical Performance and Improvement (Chair) • Physician representatives from the four regions, their alternates, and ad hoc physicians

Non-voting Committee Participants • Assistant Vice President, Provider Measurement and Performance • National Network Business Project Senior Analyst – Network Management • Health Data Senior Specialist, Clinical Insights Provider Metrics • Marketing Product Senior Specialist • Network Clinical Managers

Non-voting and Ad hoc Committee Participants • Network Product Integration Lead when a reconsideration is pertinent to their market • Market Medical Executive when a reconsideration is pertinent to their market

Upon request, the physician will be provided with the name, title, qualifications, and relationship to Cigna of the persons participating on the National Selection Review Committee who are responsible for making a determination on the physician’s appeal. If requested, a face-to-face meeting will be arranged at a location reasonably convenient to the physician; other participants can join the meeting using teleconference. The physician has the right to be assisted by a representative. The physician should provide the name and credentials of the representative to the Network Clinical Manager at least two weeks in advance of the scheduled Selection Review Committee meeting. If the physician requests an explanation of the designation decision which is the subject of the appeal to be considered as part of the appeal, it will be included.

mailto:[email protected]

http://www.cignaforhcp.com/

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The physician or physician group will receive a written decision regarding the physician’s appeal that states the reasons for upholding, modifying, or rejecting the physician’s appeal. The appeal process will be completed within 45 days from the date the data and methodology are disclosed unless otherwise agreed to by the parties to the appeal. No change or modification of a designation that is the subject of an appeal shall be implemented or used until the appeal is final. We will update any changes to designations previously disclosed publicly within 30 days after the appeal is final.

cigna care designation and physician quality and cost ...cigna.benefitnation.net/cigna/ccn.pdf · 6...

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