About The Physician Organization (PO) Data
Southeast Michigan Physician Organizations (POs) agreed to allow the Greater Detroit Area Health Council to publicly report performance on quality measures. Many POs use the data to make improvements in their quality of care and service.
Data used in this Report were prepared using well-established specifications and reporting protocols. The Center for Population Health (CPH) was contracted to combine the data from the major health plans listed below, each of which voluntarily provided data for GDAHC’s myCareCompare Physician Organization (PO) Performance Report, to get one rate for each PO. CPH, in turn, provided the data to GDAHC for public reporting. The data in the Report represents approximately four million people living in Southeast Michigan.
Data from Blue Care Network, Priority Health and HAP includes only commercial HMO (Health Maintenance Organization) product membership. (“Commercial” health plan products are those paid by private companies, or employers, rather than those paid by the government; Medicare and Medicaid are government plans, NOT commercial health plan products.) Members are assigned to a primary care physician who is responsible for coordinating their care. A primary care physician is a doctor who specializes in Internal Medicine, Family Medicine, Pediatrics or General Practice. Data from Blue Cross Blue Shield of Michigan includes a sub-set of commercial PPO (Preferred Provider Organization) data. Members of PPOs are not assigned to a primary care physician; for the Blue Cross Blue Shield of Michigan data, members ae attributed or assigned the primary care physician who provided most of the member's care during the report period (see "What is a Primary Care Physician?").
Data used for the Report were based on administrative data, mostly from claims submitted by physicians to the four health plans listed above as part of the billing process. Administrative data also came from other sources. For example, data on immunizations were obtained from the Michigan Care Improvement Registry, test results ae supplied by laboratories and other data came from electronic health records in physician offices. For accurate measurement and comparison across the community, large data sets are essential. Administrative data is the only type of high volume data readily available in electronic format. Using claims data assumes physicians are billing accurately for services rendered and properly completing claims, such as including appropriate diagnosis and procedure codes.
Performance rates reported for each measure do not necessarily include data from all four health plans because not all plans provided data for all measures reported, or a particular health plan's data for a measure may have been removed due to data quality concerns. Some of the measures only include data from the HMOs (Blue Care Network and/or Health Alliance Plan and/or Priority Health).
For the most current data available in the PO Performance Report, the Greater Detroit Area Health Council used contracts that were in place as of December 31, 2014 between POs and the major commercial products of the health plans participating in the Report to determine which physicians to include in the data set. (“Commercial” health plans are those paid by private companies, or employers, rather than those paid by the government; Medicare and Medicaid are government plans, NOT commercial health plans.) The Report is based on patients assigned to the POs’ primary care physicians. (see "What is a Primary Care Physician?") Patient assignments to doctors were used to determine which data would be included in calculations for the performance rates in the Report.
The Report does not currently include care provided to patients with no health insurance, or patients covered by Medicare, Medicaid or commercial insurances not included in the list of health plans participating in the Report. Future releases of the Report will include care provided to patients with Medicaid coverage.
The POs included in the Report represent over 3,000 individual primary care physicians and approximately one million people living in Southeast Michigan.
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Data issues are common in health care quality reporting and vary in nature. Data issues can result from missing segments of data or changes in the way insurers assign patients to doctors. Data issues can also result from changes to how patients are identified within databases and differences in how the places we get the data report their information (for a full explanation of each data issue in our public report, click here).
Sometimes data issues can increase or decrease a Physician Organization’s quality score, even if the Physician Organization has not gotten better or worse at delivering care. For example, if an insurer assigns patients to primary care physicians (PCPs), cardiologists, and gynecologists in one year—and in the next year assigns these patients only to PCPs—screening scores for the Physician Organizations the insurer reports on may go down, because patients who received screenings from non-PCPs would not be counted (for more information about patient assignment to primary care physicians, see "What is a Primary Care Physician").
It is important to note that when these data issues occur, we explain them fully in the "About the Data" section of our website.
Sometimes there is a big increase or decrease in a quality score from one year to the next that cannot be explained (i.e. there are no known changes in the way care was delivered and there are no identifiable data issues). When this occurs, we remove the data in question from our quality reports. We also remove data if explaining these issues would be too complex or confusing.
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Description of HMO and PPO
An HMO or Health Maintenance Organization is a type of managed care organization that provides a form of health care coverage through its contracts with hospitals, doctors, and other providers. An HMO only covers care provided by the doctors and other health care professionals that have agreed to treat patients according to the HMO's guidelines and restrictions, in exchange for a continual flow of customers. Data from the following southeast Michigan HMOs are included in the Physician Organization Performance Report: Blue Care Network and Health Alliance Plan.
A PPO, or Preferred Provider Organization, is a type of health care plan. For PPO members, coverage under the plan is usually better when the member uses a “preferred” provider, or one who is contracted with the PPO. PPOs typically contract with providers to set fee schedules and create a network that they sell to companies who insure themselves; some PPOs also offer other services, such as pre-processing claims, or bills for health care services and products. Data from the following southeast Michigan PPO is included in the Physician Organization Performance Report: Blue Cross Blue Shield of Michigan's PPO.
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The myCareCompare PO Performance Report was developed by a team of physicians, Physician Organization leaders, health plan staff, and employers who purchase health care coverage for their employees. The team began meeting in 2006 to prepare for the first public report of physician performance and continues meeting to oversee updates to the first Report. The team’s work included developing criteria to be used in selecting measures to be included in the report. (See "How Were These Topics Selected for Measurement?") Prior to the first public report, a prototype Report was developed and shared with POs in one-on-one meetings to collect feedback from POs on the report process and next steps. Recommendations from these meetings were incorporated into the final report production. Templates were created for health plans to use in submitting data to ensure consistency in data collection across health plans and for ease of compiling data. Prior to each public posting of the report, draft reports are provided to POs for their review and feedback. The reports provided to the POs include additional detail that is not publicly reported to help POs evaluate the data and for the POs to use in improving performance. Finally, POs are able to preview a draft version of the report Web site and feedback and recommendations from the POs are incorporated into the final version of the Report before it is publicly posted.
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The commercial HMO data is audited. Blue Care Network, Priority Health and Health Alliance Plan provided the commercial HMO product data for this Report. (See "Description of HMO and PPO".) Past validation efforts indicate that the data from Blue Cross Blue Shield of Michigan adheres to the same specifications, data completion and accuracy.
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The data is not risk adjusted. Risk adjustment is a statistically valid process of modifying data to account for factors that affect provider performance rates, such as patient age, gender, acuity and severity of illness, and complications. To understand risk adjustment, it is first necessary to realize that different providers may treat different types of patient populations. For example, a Physician Organization may have more physicians who treat patients with more complicated illnesses than another Physician Organization. Risk adjustment helps address differences between factors that are within the provider’s control and those that are not under the provider’s control, thus allowing for a more fair, level field for comparisons, or a more “apples-to-apples” comparison.
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Data in this Report were prepared using well-established specifications and reporting protocols. Most of the quality measures are drawn from national standards, including four diabetes care measures, cancer screening, antibiotic use, child health care and back care. They are part of the Healthcare Effectiveness Data and Information Set (HEDIS®) that measures performance on important aspects of care. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The Michigan Quality Improvement Consortium (MQIC) developed the measure for cholesterol medication use for adults with diabetes. MQIC is a consortium that includes physicians, health plan administrators, researchers, quality improvement experts, and specialty societies whose goals include establishing standard ways of collecting and reporting performance information throughout the State of Michigan.
The reported measure is from HEDIS Combo 10.
This is the first year reporting this measure. Due to small denominators, rates for nine POs are not reported.
The Physician Organization Report includes a southeast Michigan regional average. This benchmark provide a comparison between how well a PO performs relative to physicians in the majority of POs in southeast Michigan.