Diabetes Physician Recognition Program (DPRP) May 2009

2 DPRP Workshop May 2009 NCQA Overview NCQA Physician Recognition Programs DPRP Application & Survey Process P4P and Physician Recognition Session Agenda

3 DPRP Workshop May 2009 NCQA is a private, independent non-profit health care quality oversight organization founded in 1990 NCQA is committed to measurement, transparency, and accountability NCQA unites diverse groups around a common goal: improving health care quality MISSION To improve the quality of health care VISION To transform health care through quality measurement, transparency, and accountability A Brief Introduction

4 DPRP Workshop May 2009 NCQA Achieving the Mission Over 800 plans report HEDIS ® data to NCQA (Commercial, Medicaid, Medicare, HMO/PPO) Over 250 commercial MCO plans are accredited by NCQA Over 75 Medicaid plans are accredited by NCQA Over 100 Medicare Advantage plans are accredited by NCQA (more than any other accrediting body) Over 85.9 million patients are impacted through the plans NCQA accredits Over 12,000 physicians are recognized nationally by NCQA programs

5 DPRP Workshop May 2009 Current programs: DPRP, HSRP, BPRP, PPC, PCMH What measures included: Structure, process and outcomes of excellent care management Where they come from: partnership with leading national health organizations Who rewards recognized physicians: many health plans and coalitions of employers Who is recognized: over 12,000 physicians nationally NCQA Recognition Programs Physician-Level Measurement

6 DPRP Workshop May 2009 Number of Recognitions by State (as of 1/31/09) ME VT RI NJ MD MA DE NY WA OR AZ N V WI NM NE M N KS FL CO IA N C MI PA OH VA MO HI OK G A SC TN MT KY WV AR LA MS AL IN IL SD ND TX ID WY UT AK CA CT NH 0 Recognitions 1-25 Recognitions Recognitions 101+ Recognitions

7 DPRP Workshop May 2009 What is the DPRP application and survey process?

8 DPRP Workshop May 2009 Developed in partnership with American Diabetes Association (ADA); released in 1997 Voluntary program; non punitive Report only physicians who earn Recognition Use nationally recognized reliable, valid measures DPRP Basics… 3-year recognition period Over 7,000 Physicians Recognized Nationally

9 DPRP Workshop May DPRP Adult Measures Outcome Measures –HbA1c Control <7.0% –HbA1c Control >9.0%* –Blood Pressure Control <130/80 mm Hg –Blood Pressure Control ≥140/90 mm Hg* –LDL Control <100 mg/dl –LDL Control ≥130 mg/dl* Process Measures –Eye Examination –Foot Examination –Nephropathy Assessment –Smoking Status and Cessation Advice or Treatment * A measure of poor control** Pediatric measures available

10 DPRP Workshop May 2009 Improvement In Key Clinical Measures % of adult patients with * Lower is better for this measure.

11 DPRP Workshop May 2009 Who May Apply? An individual physician or a physician group To be eligible, applicants must: –have a current, non restricted license as a doctor of medicine (MD) or doctor of osteopathy (DO) –provide continuing care to patients with diabetes –have had face-to-face contact with and submit data on a sample of patients with diabetes

12 DPRP Workshop May 2009 Review program information - Purchase the “Diabetes Physician Recognition Package” -Package contains all the information needed to apply for Recognition Review materials & sign Agreement -Standards and Guidelines -Agreement and BA Addendum -Data Collection Tool (an Excel ® workbook) Identify the patient sample -Patient sample must be identified using the DPRP patient selection methodology or a random sample methodology approved in advance by NCQA Abstract medical record data Enter data in Data Collection Tool Submit completed materials to NCQA What is the Process?

13 DPRP Workshop May 2009 Guidelines for Identifying Patient Sample The patient sample must: -be identified using the DPRP patient identification methodology or a random sample methodology approved in advance by NCQA. -be selected across the entire patient population regardless of the patient's method of payment (e.g., health plan, Medicare, Medicaid, employer, self-pay or other payment mechanism.) -include all eligible patients (i.e., eligible patients must not be excluded from the sample).

14 DPRP Workshop May 2009 Sample Size Requirement - Individual Individual Physician 1 physician practicing in any setting who provides continuing care to patients with diabetes Sample Size 25 patients per physician Public reporting on Web Site Listed by individual names

15 DPRP Workshop May 2009 Group A physicians An entity of 2 or more physicians: –that have used detailed protocols directly related to diabetes care for at least 1 year –that apply and monitor the protocols across all physicians –that provide feedback to physicians regarding performance against the protocols At time of application, must submit a letter that documents: –diabetes management protocols –date protocols instituted –how physician compliance with protocols is monitored –how feedback on performance is provided to physicians Sample Size * A maximum of 200 patients as shown in the table below: * If group operates more than one site every site must contribute patients to the total sample. Public reporting on Web Site Listed by group or site name only Sample Size Requirement – Group A Number of Physicians in Group Sample Size Requirement or more200

16 DPRP Workshop May 2009 Group B physicians An entity of 2 or more physicians: –who practice at the same site –who share responsibility for a common panel of patients –who do not use detailed protocols directly related to diabetes care. Sample Size A maximum of 200 patients as shown in the table below: Public reporting on Web Site Listed by group or site name only Sample Size Requirement – Group B Number of Physicians in Group Sample Size Requirement or more200

17 DPRP Workshop May 2009 Identifying the Patient Sample Pick a “Start Date” –an arbitrary date within the last 12 months Choose to go forward or backward from the start date to identify eligible patients until the required sample size is met An eligible patient: -is 5 years of age or older pediatric patients 5 – 17 years adult patients 18 – 75 years -has had a diagnosis of diabetes for at least 12 months -has been under the care of the applicant physician (or physician group*) for at least 12 months *Does not apply to physicians seeking individual recognition

18 DPRP Workshop May 2009 Abstracting Medical Record Data After identifying the patient sample, abstract medical record data: for a12-month period going back from the last visit date that occurred prior to the start date from medical record documentation (electronic or paper), administrative data systems or registries to identify required data elements

19 DPRP Workshop May 2009 How to Identify Eligible Patients Moving Backwards from Start Date - Step 1 Step 1 Establish a "Start Date" within the past 12 months The start date is an arbitrary date set at your convenience Example You select May 1, 2009

20 DPRP Workshop May 2009 How to Identify Eligible Patients Moving Backwards from Start Date – Step 2 Step 2 Identify eligible patients –On each day moving backward from the start date, consecutively evaluate each patient for eligibility who were seen at an office visit –Select patients who meet the 3 eligibility requirements –Identify eligible patients until the required sample size is met Example Moving consecutively backward from 5/1/09, you identify 25 eligible patients who had office visits on the following dates: Visit Date Identified as Eligible Number of Patients identified 4/30/093 4/29/096 4/22/095 3/26/097 3/04/094

21 DPRP Workshop May 2009 How to Determine the 12-month Abstraction Period Moving Backwards from Start Date – Step 3 Step 3 Determine 12-month Abstraction Period –When moving backward from the start date, the visit date that a patient is identified as eligible establishes that patient’s 12-month abstraction period –After determining each patient’s 12-month abstraction period, abstract data for care completed for each patient in the sample. Example 12-month abstraction periods for the 25 patients identified : Visit Date Identified as Eligible 12-month Abstraction Period Number of Patients 4/30/094/30/09 – 4/29/083 4/29/094/29/09 – 4/28/086 4/22/094/22/09 – 4/21/085 3/26/093/26/09 – 3/25/087 3/04/093/04/09 – 3/03/094

22 DPRP Workshop May 2009 How to Identify Eligible Patients Moving Forward from Start Date – Step 1 Step 1 Establish a "Start Date" within the past 12 months The start date is an arbitrary date set at your convenience Attention Moving forward is in “real-time”. Patients are identified as they present for an office visit. Example You select May 1, 2009

23 DPRP Workshop May 2009 How to Identify Eligible Patients Moving Forward from Start Date – Step 2 Step 2 Identify eligible patients –On each day moving forward from the start date, consecutively evaluate each patient for eligibility at the time the patient presents for an office visit –Select patients who meet the 3 eligibility requirements –Identify eligible patients until the required sample size is met Example Moving consecutively forward from 5/1/09, you identified 25 eligible patients who had office visits on the following dates: Visit Date Identified as Eligible Number of Patients identified 5/05/093 5/07/096 5/18/095 6/04/097 6/11/094

24 DPRP Workshop May 2009 How to Determine the 12-month Abstraction Period Moving Forward from Start Date – Step 3 Step 3 Determine 12-month Abstraction Period –When moving forward from the start date, the last office visit prior to the start date establishes the patient’s 12- month abstraction period –After determining each patient’s 12-month abstraction period, abstract data for care completed for each patient in the sample. Example 12-month abstraction periods for the 5 patients identified on 5/18/09. Start Date: May 1, 2009 Patient Identification Direction: Forward Visit Date Patients (5) Identified as Eligible Visit Date prior to Start Date 12-month Abstraction Period 5/18/0912/31/0812/31/08 – 1/1/08 5/18/094/17/094/17/09 – 4/16/08 5/18/094/03/09 4/03/09 – 4/02/08 5/18/091/1/091/1/09 – 12/31/08 5/18/092/4/09 2/04/09 – 2/03/08

25 DPRP Workshop May 2009 Scoring of Measures Scored Measures Threshold Weight (% of patients in sample) HbA1c Control <7.0% 40% 10.0 HbA1c Control >9.0 % *  15% 15.0 Blood Pressure Control <130/80 mm Hg 25% 10.0 Blood Pressure Control >140/90 mm Hg *  35% 15.0 LDL Control <100 mg/dl 36% 10.0 LDL Control >130 mg/dl *  37% 10.0 Eye Examination 60% 10.0 Foot Examination 80% 5.0 Nephropathy Assessment 80% 5.0 Smoking Status and Cessation Advice or Treatment 80% 10.0 Total Points = Points to Achieve Recognition = 75.0 * A measure of poor control

26 DPRP Workshop May 2009 Data Abstraction Data elements –Date and value of most recent HbA1c performed within the 12-month abstraction period (2-month grace period allowed) Tips –To receive credit for the measure of poor control, no more than 15% of patients can have HbA1c results >9.0% –May use date drawn or date received HbA1c Testing and Control Proportion w/HbA1c > 9.0%* Proportion w/HbA1c  7.0% * A measure of poor control

27 DPRP Workshop May 2009 Data Abstraction Data elements –Record date and value of most recent blood pressure measurement performed within the 12- month abstraction period Tips –To receive credit for the measure of poor control, no more than 35% of patients can have B/P measurements >/= 140/90 Blood Pressure Measurement Proportion >/= 140/90 mm Hg * Proportion < 130/80 mm Hg * A measure of poor control

28 DPRP Workshop May 2009 Data Abstraction Data element –Record date and value of most recent LDL within the 12-month abstraction period (2-month grace period allowed) Tips –To receive credit for the measure of poor control, no more than 37% of patients can have LDL results >/= 130 mg/dl Lipid Control Proportion w/LDL >/=130mg/dl * Proportion w/LDL <100mg/dl * A measure of poor control

29 DPRP Workshop May 2009 Data Abstraction Data element –Record date of most recent dilated retinal exam or retinal photograph performed within the 12- month abstraction period May use date within the past two years if patient showed no evidence of retinopathy in the 12 months prior to the abstraction period Tips –Patient self-report is not acceptable –Use notes, reports, letters or photographs from eye care professionals –If exam performed by a non eye care professional documentation must state dilated exam Eye Exam or Retinal Photographs

30 DPRP Workshop May 2009 Data Abstraction Data element –Record date of most recent foot exam within the 12-month abstraction period (2-month grace period allowed) Tips –May use notes, reports, letters or assessments from podiatrists, PCP or your own examination –Documentation must support that feet were examined with shoes and socks off Foot Examination

31 DPRP Workshop May 2009 Data Abstraction Data Element –Record date of most recent nephropathy assessment within the 12-month abstraction period (2-month grace period allowed) Tips –Documentation must include one of the following: –Microalbuminuria test –Positive urinalysis for protein –Medical attention for nephropathy –Evidence of ACE/ARB therapy Nephropathy Assessment

32 DPRP Workshop May 2009 Data Abstraction Data Element –Document smoking status Tips –If there is documentation that the patient is a non- smoker, no further documentation is required –Smokers: Record date that documents smoking cessation counseling or treatment within the abstraction period Smoking Status

33 DPRP Workshop May 2009 Data Collection Tool

34 DPRP Workshop May 2009 Data Submission Materials to submit: Completed physician/physician group Application Form Signed DPRP Agreement (2 copies) –Includes Business Associate Addendum Completed Data Collection Tool Application fee –Payable by check or credit card

35 DPRP Workshop May 2009 What Happens Next? Within 30 days of receiving all information needed to complete the application, NCQA reviews and makes recognition determinations –5 percent of applications are randomly selected for audit Physicians or groups achieving Recognition receive: –letter of recognition –posting to the Recognized Physician Directory –certificate of recognition –media kit/marketing and advertising guidelines

36 DPRP Workshop May 2009 RECOGNITION: REWARDED IN MANY WAYS Provider Directories Data Collection Assistance Active Steering To Recognized MDs Network Entry Financial Incentives Specialty Board Maintenance of Certification

37 DPRP Workshop May 2009 Pay rewards and/or applications fees BCBS Alabama - Alabama Health Improvement Initiative BCBS (SC)/ BlueChoice BTE (KY, MA, NY, OH, GA, CO) CareFirst (DC-MD- GA) ConnectiCare HealthAmerica (PA) Oxford (NY) Health First (FL) Silicon Valley (CA) (Examples of Current and Past Initiatives) Recognition Program Rewards Distinction in Provider Directory 1. Aetna 2. BCBS Delaware 3. CareFirst 4. CIGNA 5. GeoAccess 6. HealthAmerica 7. Humana 8. Lumenos 9. Medical Mutual (OH) 10. MVP Healthcare 11. United Actively steer patients to recognized MDs BTE (KY, OH) Help practices with data collection BTE (KY, MA, OH, NY) Oxford (NY) United (4 areas) Use for network entry Aetna, CIGNA, United

38 DPRP Workshop May 2009 Bridges to Excellence (BTE) BTE ProgramsNCQA Measure Set Physician Activation Cardiac Care Link (CCL) Heart/Stroke Recognition Program (HSRP) Up to $200 pcppy Diabetes Care Link (DCL) Diabetes Physician Recognition Program (DPRP) Up to $100 pdppy Physician Office Link (POL) Physician Practice Connection Up to $50 pmpy Spine Care Link (SCL)Back Pain Recognition Program Up to $50 pscppy

39 DPRP Workshop May 2009 Mailing Address NCQA Diabetes Physician Recognition Program th Street, NW, Suite 1000 Washington, DC Customer Support (questions on DPRP in general, purchasing the workbook, etc.) DPRP Staff (questions on sampling methodology, measures, etc.) Web DPRP Contact Information

40 DPRP Workshop May 2009 NCQA would like to thank our Diabetes Physician Recognition Program (DPRP) Sponsors Founding Sponsor Champion Sponsor