November Reports Available, Thresholds Set

November 29, 2016

Episode of care (EOC) reports were released from the Managed Care Organizations (MCO) between November 8 and 15. Both preview and performance reports were released and are available to Quarterbacks (QB) for analysis.

EOC performance reports cover the first and second quarters for the 2016 calendar year performance period. Performance reports for physician QBs are available for both first and second waves. Episodes include perinatal, total joint replacement (TJR), non-acute PCI, outpatient and non-acute cholecystectomy and screening and surveillance colonoscopy where the physician is the QB.

Equally important to the performance reports are the preview reports. Preview reports deliver cost and quality statistics to the QB before the performance period begins. This is a great time for practices to evaluate cost and quality performance and begin to make necessary changes to their practice prior to the performance reporting period. Episodes from the third and fourth waves include: upper GI endoscopy (EGD), respiratory infection, urinary tract infection (outpatient), attention deficit and hyperactivity disorder (ADHD), bariatric surgery and oppositional defiant disorder (ODD).

Finally, cost and quality metric thresholds have been set for the calendar year 2017 performance period (waves 1-4). TennCare sets the acceptable threshold and the MCOs each set their own commendable thresholds. Note, if a QB has an average cost higher than the acceptable threshold, the provider is at risk for sharing the excess costs above the acceptable line. In contrast, information on commendable thresholds is available from each MCO.

There were adjustments to the cost (acceptable) and quality metrics thresholds for asthma and COPD (where the facility is the QB). However, there were no changes to the perinatal, TJR, colonoscopy, outpatient and non-acute cholecystectomy and non-acute PCI episode acceptable thresholds (set by TennCare) for waves 1 and 2.  However, there may be changes to the commendable thresholds. Please be sure to get the episode specific information from each of the MCOs.

The Tennessee Payment Reform website has more information related to cost and quality metric thresholds for Waves 1- 4.