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The Harvard Pilgrim Health Care’s “Rewards for
Excellence” program (R4E) has been active since 2003. Through this
program HPHC recognizes and rewards exemplary performance achieved by
local physicians and physician groups. MedNet has earned rewards each
year since its inception. The following are the areas of concentration
for large adult practices like MedNet and a brief description of the
criteria for each. Each year, HPHC focuses on five or six of these
topics for the rewards program.
Percentage of members with diabetes (Type
1 and Type 2) age 18 – 75 who were continuously enrolled during the
measurement year, who had a HbA1c test.
Percentage of members with diabetes (Type
1 and Type 2) age 18 – 75 who were continuously enrolled during the
measurement year, who had a retinal eye exam.
- Diabetes 3: Cholesterol Screening
Percentage of members with diabetes (Type
1 and Type 2) age 18 – 75 who were continuously enrolled during the
measurement year, who had an LDL-C test.
- Diabetes 4: Nephropathy Screening*
Percentage of members with diabetes (Type
1 and Type 2) age 18 – 75 who were continuously enrolled during the
measurement year, who had kidney disease monitored.
Percentage of enrolled members who were
identified as having persistent asthma and who were appropriately
prescribed medication during the measurement year.
- Depression: Optimal Practitioner Contacts
for New Medication Management (18+)
Percentage of members who were diagnosed
with a new episode of depression, treated with antidepressant
medication, and who had at least three follow-up contacts with a PCP or
behavioral health provider coded with a mental health diagnosis during
the 84 day acute treatment phase. At least one of the three f/u
contacts must be with a prescribing practitioner.
- Depression: Effective Continuation Phase
Treatment (18+)
Percentage of patients who were diagnosed
with a new episode of depression, were treated with antidepressant
medication and who remained on an antidepressant drug for at least 180
days (6 Mo).
- Chlamydia Testing (ages 16-26)
Percentage of women who were identified
as sexually active, who were continuously enrolled during the
measurement year, and who had at least one test for Chlamydia during the
measurement year. Criteria for sexually active is derived from pharmacy
data (contraceptives) or from encounter data related to contraceptive
procedures, tubal ligations, IVF procedures, childbirth-related
procedures, abortion procedures, D&Cs, OB Ultrasound, fetal echoes,
pregnancy related lab work and pathology.
* Acceptable tests for Nephropathy Screening (Microalbuminuria) include:
- 82042 – Albumin Serum, urine, quantitative
- 82043 – Albumin serum, urine, microalbumin, quantitative
- 82044 – Albumin serum, urine, microalbumin, semi-quantitative (e.g. reagent strip assay)
- 84155 + – Protein; Total, except refractometry
- 84160 + – Protein, Total, regractometric
- 84165 + – Protein, Total, electgrophoretic fractionation and quantitation
+ code must be accompanied by CPT code 81050 to indicate test was
urinalysis
The above measures have been defined by the Health Plan Employer Data and Information Set (HEDIS®)
program of the National Committee for Quality Assurance (NCQA). The measures are obtained from HPHC
claims-based data, consistent with how HEDIS collects data to rate health plans. The dollar amount of the
reward depends on the size of our membership (MM) and how many of the targets we achieve. The
performance threshold for receiving an award is set by Harvard Pilgrim, at the National
HEDIS 90th percentile level.
2005 Program Results
This year, for service year 2005, MedNet again
will receive significant funds for outstanding performance. As is
evident in the grid below, our scores were at or above the target 90th
% in four out of the six of the chosen measures. Last year, MedNet
earned rewards for Depression (Optimal contacts), Chlamydia, and
Diabetes Eye and Nephropathy testing. We were 5% below the target % in
our Asthma work and the Depression 6 mo F/U was not part of the study.
This year, we significantly improved our asthma management score but our
Depression coverage dropped. With a MM count of 67,915, this means a
$50,936 loss in potential revenue. In spite of that, our total is a
generous $84,895.
|
Performance Measure |
# Cases |
HEDIS 2005 |
Max $ PMPM |
MedNet $ PMPM |
Total $ |
|
MedNet Score |
Target Score |
|
Diabetes: Eye Exam |
180 |
78.58% |
64.11% |
.25 |
.25 |
$16,979 |
|
Diabetes: Nephropathy |
180 |
70.96% |
61.56% |
.25 |
.25 |
$16,979 |
|
Chlamydia 16-25 |
128 |
46.41% |
42.25% |
.25 |
.25 |
$16,979 |
|
Asthma 5-56 |
61 |
91.89% |
78.04% |
.50 |
.50 |
$33,957 |
|
AntiDepressant Optimal Contacts |
29 |
25.69% |
32.11% |
.25 |
.00 |
|
|
AnitDepressant Cont Phase 6 Mo |
29 |
53.28% |
54.90% |
.50 |
.00 |
|
|
Other MedNet Scores (Awards
restricted to smaller practices) |
|
Breast Cancer Screening |
371 |
87.21% |
83.02% |
n/a |
n/a |
|
|
Cervical Cancer Screening |
716 |
93.95% |
87.92% |
n/a |
n/a |
|
|
Total Reward $ |
$84,895 |
We are happy see that, while there is no cash award associated with it for MedNet providers,
we remain a healthy percentage above the 90th
percentile in both Breast and Cervical Cancer Screening. All this adds up to good patient care and improved quality
of life for our chronically ill patients.
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