May 29, 2014
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement Practice Management
The California Medical Association (CMA) has learned that United Healthcare (UHC) will be rolling out its Healthcare Management Summary Reporting program in July. Separate from its Premium Designation program, the Healthcare Management Summary Reporting program will target contracted commercial PPO physicians whose performance on identified quality and cost measures identified quality and cost measures rank outside of United’s established benchmarks as compared within the local peer group.
Although United touts this program as an educational resource “to support physicians by identifying practice patterns that may represent opportunities to improve quality and decrease unwarranted variation in utilization,” the payor has advised CMA that the data for those who continue to rank higher in cost and quality measures will also be considered by its network management staff at the time of physician contract renewal.
Physicians will be evaluated on data from 2011 and 2012 patient encounters, with only those physicians meeting the minimum number of episodes of treatment (100 for primary care and 50 for specialists) to be included in the program. The United analysis includes evaluation of out-of-network services utilization, antibiotics usage, E&M visit costs, preventative screening adherence and pharmacy-prescribing patterns (i.e, use of brand name vs. low cost pharmaceuticals). Physicians whose practice patterns identify them as potential “outliers” will receive a notice from United along with a copy of their Healthcare Management Summary. Physicians wishing to obtain specific data will be directed to an online web portal to access their individual data utilized in the development of their report.
United reports that it will re-evaluate physicians at six-, 12- and 18-month intervals to see if there have been changes in practice patterns. Those physicians who demonstrate a 25 percent increase in performance for two consecutive reporting periods will be removed from the monitoring process.
Physicians are encouraged to closely review their individual Healthcare Management Summary report and contact United Healthcare with any concerns or inaccuracies with the data or specialty classification.
Contact: United Healthcare Customer Service, (877) 282-8608.