Cigna Care Designation and Physician Quality and Cost ...

1 1 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 10 Assigning the Cigna Care Designation .. 10 Cigna Care Designation 2012 Inclusion Data Sources .. 14 Credit for Utilizing Cigna Centers of Excellence .. 14 Buffer Zone Methodology ..13 Additional Information and Data Process to Display Strategic Alliances Information ..14 Feedback Process ..14 Physician Process to Correct Errors, Request How to Register Registering a Complaint for Individuals in New York ..15 2 Introduction We evaluate Physician Quality and cost-efficiency information by using a methodology consistent with national standards and incorporating Physician feedback.

2 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).

3 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.

4 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. 3 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.

5 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 ( , 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 ( , 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.

6 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 ( , 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 and (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 .

7 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.

8 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. 4 Sample: Online health care professional directory display ( ) 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 and Information regarding the Physician s cost-effectiveness performance is displayed only on the secure website for individuals with Cigna coverage, 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).

9 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 and 67%, and one star represents groups in the bottom 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) 5 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.

10 Sample: Online health care professional directory display ( ) 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