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Measures and Methods

What is meant by "low-value" services?

Prompted by Choosing Wisely organizers, physician specialty societies identified a list of procedures that both:

Were commonly used, and
Whose necessity should be questioned and discussed

Choosing Wisely recommendations are not intended to guide coverage decisions or exclusions. Rather, they are meant to spur conversation between patient and clinician.

Qualis Health analyzed Medicare Fee-for-Service claims data for three of the measures included in reports produced by the state's Choosing Wisely task force and one additional measure that is an ongoing priority at CMS.

Measures also included in Washington's task force reports

Imaging (CT scan or MRI) for simple syncope. (2014 and 2016 reports)
While there may be instances where imaging is required, multiple organizations do not recommend it as a standard practice.

Imaging (CT scan or MRI) for uncomplicated headache. (2014 and 2016 reports)
Imaging may be warranted in some cases, but providers and patients should be familiar with the American College of Radiology's recommendation against it for most situations.

Antibiotics for upper respiratory infection. (2016 report)
Overuse of antibiotics can lead to complications for individual patients as well as the larger public; read the Infectious Diseases Society of America's recommendation on this topic.

Measure added for Qualis Health's reporting

Antipsychotic medications for the behavioral symptoms of dementia.
The risks of giving antipsychotic medications to dementia patients generally outweigh any potential benefits; read the recommendations against this practice from AMDA, the American Geriatrics Society, and the American Psychiatric Association.

Methodology

A two-phase approach was used to analyze the data—first by beneficiary then by provider.

Statewide, county-specific, and race-specific rates

As much as possible, analysis methods mirrored those used by the state's task force and specified in the national Choosing Wisely guidelines. The steps taken by Qualis Health to select the appropriate data sets and calculate the rates are outlined below.

Identify the denominator
(population of Medicare beneficiaries with targeted diagnosis)

Diagnosis

Simple Syncope

Uncomplicated Headache

Upper Respiratory Infection

Dementia

Study Period

October 2014 - September 2015

July 2014 – June 2015

For diagnosis:
October 2012 – September 2015

For medication:
July 2014 - June 2015

Enrollment

Beneficiary must have been enrolled in Part A and B for at least one month during study period

Beneficiary must have at least one instance of Part D claim during study period

Claims Source

Principle diagnosis codes in Medicare Part B

Any related diagnosis code in Medicare Part A or B

Demographics

Beneficiary must have a Washington address

Beneficiary’s address used to assign to county

(Please note that because the location designations are dependent upon the address of the beneficiary and not the care provider, some of the data included in the statewide rate may include care received out of state, and county-specific rates may include some care provided outside the county or state.)

Beneficiary's race/ethnicity is self-reported

Exclusions

Claim excluded if the provider taxonomy was radiologist, ambulance, or laboratory

Exclude beneficiaries if they had:

Exclude beneficiaries with schizophrenia, bipolar disorders, Huntington’s Disease, Tourette’s Syndrome

comorbid diagnoses within 12 months prior to index case

competing diagnoses between 30 days prior, through 7 days after, the index case

Index Case

First claim in study period

Identify the numerator
(among the denominator population, those who received the treatment of focus)

Claims Source

Procedure codes related to CT or MRI in Medicare Part B, within 30 days following the index case

National Drug Codes related to antibiotics in Medicare Part D, within three days following the index case

National Drug Codes related to antipsychotics in Medicare Part D following the index case

Divide the denominators by the numerators to generate the rates; calculate corresponding 90% Wilson confidence intervals

Methods for provider-specific rates and the identification of providers who are "high utilizers"

The Washington Choosing Wisely task force did not include provider-specific rates in its 2014 report.

Starting with the data sets described above, Qualis Health further filtered the data by:

Attributing each claim to a specific provider based on the associated National Provider Identifier (NPI) number
Removing claims associated with out-of-state providers
Removing providers with 10 or fewer index cases

To calculate the provider-specific rates, the new denominators were divided by the new numerators. To determine which providers were among the high-utilizer group, 90% Wilson confidence intervals were calculated for each provider's rate and for an aggregate of all Washington providers.