Cigna Care Designation and Physician
Quality and Cost-Efficiency Displays
2015 Methodologies Whitepaper
For Health Care Professionals
February 2015
Introduction................................................................................................................................................................. 2
Cigna Physician Quality and Cost-Efficiency Display Principles ............................................................................... 2
Cigna Care Designation and Physician Quality and Cost-Efficiency Displays Overview .......................................... 3
Specialty Types Assessed for Cigna Care Designation and Physician Quality and Cost-Efficiency Displays .......... 6
Quality Evaluation ...................................................................................................................................................... 6
Evidence Based Medicine (EBM) Assessment Process ............................................................................................ 7
Cost-Efficiency Evaluation ....................................................................................................................................... 10
2015 Outlier Methodology ........................................................................................................................................ 12
Assigning the Cigna Care Designation (2015 CCD Inclusion Methodology) ........................................................... 12
Credit for Utilizing Cigna Centers of Excellence ...................................................................................................... 15
Buffer Zone Methodology ......................................................................................................................................... 15
Collaborative Accountable Care Pathway to Achieving Cigna Care Designation ................................................... 15
Data Sources ........................................................................................................................................................... 19
Additional Information and Data Limitations ............................................................................................................ 19
Process to Display Strategic Alliances Information ................................................................................................. 20
Feedback Process ................................................................................................................................................... 20
Physician Process to Correct Errors, Request Reconsideration, or Appeal ............................................................ 20
How to Register Complaints .................................................................................................................................... 21
2015 Physician Evaluation Methodology Changes.................................................................................................. 22
Appendices .............................................................................................................................................................. 23
Appendix 1: 2015 Cigna Care Designation Market Information ............................................................................... 23
Appendix 2: 2015 Quality and Cost-Efficiency Display Markets .............................................................................. 25
Appendix 3: EBM Rules Used for the 2015 Physician Evaluation ........................................................................... 26
Appendix 4: Appeals Process for Colorado Health Care Professionals .................................................................. 37
Abbreviations List ..................................................................................................................................................... 38
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
1
Introduction
We evaluate physician quality and cost-efficiency information by using a methodology consistent with national
standards and incorporating physician feedback. Using this information, we are able to provide our customers and
clients with relevant consumer-oriented information through the physician quality and cost- efficiency displays and
the Cigna Care designation (CCD) program.
The purpose of this document is to provide an overview of our Physician Quality and Cost-Efficiency Displays
Program, explain the methodology used to measure individual physicians and medical groups for quality and costefficiency results, and provide details regarding the physician quality and cost-efficiency display information used.
Cigna Physician Quality and Cost-Efficiency Display Principles
We believe that our customers and employers have a right to know information regarding the quality and costeffectiveness of physicians. We follow three key principles when providing our physician quality and costeffectiveness information to customers, clients, and physicians:
1. Standardized performance measures using the most comprehensive data set available
We use nationally recognized measures derived from those endorsed by the National Quality Forum (NQF),
®1
Ambulatory Care Quality Alliance (AQA), Healthcare Effectiveness Data Information Set (HEDIS ), or those
developed by national physician organizations such as the American Medical Association (AMA).
2. Responsible use of the information
The displays reflect a partial assessment of quality and cost-efficiency based on our claims data, and should
not be the sole basis for decision-making (as such measures have a risk of error). Cigna customers are
encouraged to consider all relevant factors and to consult with their treating physician when selecting a
physician for care. In general, the health care professionals in Cigna's networks are independent practitioners.
They are not employees or agents of Cigna. Treatment decisions are made exclusively by the treating
physician and the patient. Cigna provides its customers with helpful information to allow them to make more
informed decisions. The quality and cost-efficiency markers used in evaluating physicians for Cigna Care
designation are intended for that purpose only. Cigna does not guarantee the quality or cost-efficiency of the
actual services provided by network physicians - even those physicians that qualify for the Cigna Care
designation.
3. Collaboration and Improvement Enablement
We are committed to providing information and solutions that can support access to quality health care. A
detailed description of our methodology, information about the summary metrics, and ongoing data to help
improve performance is available to physicians and physician groups. We also continue to have ongoing
discussions with key physician organizations, ranging from national associations to large physician groups,
who provide input for future design changes.
Frequency of Reviews
The methodology for determining the Cigna Care designation and physician quality and cost-efficiency displays is
subject to change annually as tools and industry standards evolve and physician feedback is obtained. The
assessment review period for Cigna Care designation and quality and cost-effectiveness displays for 2015 is
January 1, 2012 through December 31, 2013. This review includes claims data from Cigna Managed Care and
PPO plans.
External Certification
Cigna earned Physician and Hospital Quality Certification for the third time in August 2013. The NCQA Physician
and Hospital Quality (PHQ) certification program evaluates how well health plans measure and report the quality
and cost of physicians and hospitals. NCQA Physician Quality Certification Standards meet New York state
requirements implemented in November 2007 concerning physician performance measurement, reporting and
tiering programs.
1
®
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
2
Cigna Care Designation and Physician Quality and Cost-Efficiency Displays Overview
There are two components of the Cigna Care designation and Physician Quality and Cost-Efficiency Displays
programs, each of which is explained in more detail in the following sections of this document:
1. Quality evaluation and display: Physicians are evaluated on a number of criteria that we believe are
markers of physician practice quality. The results of this evaluation are displayed in myCigna.com, our online
health care professional directory that is available to Cigna customers. Results of selected quality markers
(e.g., evidence based medicine (EBM) rule adherence and NCQA Physician Recognition) are used to qualify
physicians and physician groups for Cigna Care designation.
2. Cost-efficiency evaluation and display: Individual physicians and physician groups are evaluated for their
cost-efficiency using an industry-standard methodology (i.e., Episode Treatment Groups) that determines the
average cost of treating an episode of care for a variety of medical conditions and surgical procedures. We
then compare those episode costs to those of other physicians and medical groups of the same specialty in
the same geographical market. The results of this evaluation are displayed in our online health care
professional directory using one, two or three stars, with three stars being the highest rating (i.e., the most
cost-efficient).
Cigna Care designation: Cigna Care designation is assigned to individual participating physicians and physician
groups based on Cigna's cost-efficiency and quality criteria. If an individual physician or physician group does not
meet the Cigna Care designation criteria and the physician or physician group participates in a Cigna
Collaborative Accountable Care (CAC), they may receive Cigna Care designation if they meet certain cost and
quality thresholds (see pages 15-18 for more details).
Cost and quality evaluation provides individual physicians and physician groups that are ranked in the top 40% for
quality and the top 40% for cost-efficiency compared to all physicians and physician groups of the same group
specialty type in the same geographic market with the Cigna Care designation. In the absence of a sufficient
number of cost episodes to evaluate cost-efficiency, physicians and physician groups that rank in the top 34% for
quality compared to groups of the same specialty in their market also receive the Cigna Care designation. In the
absence of a sufficient number of quality opportunities to evaluate quality, physicians and physician groups that
rank in the top 34% for cost compared to groups of the same specialty in their market also receive the Cigna Care
designation (see page 11 for more information regarding assigning CCD based on cost and quality).
They are identified with a Symbol ( ) and “Cigna Care Designation” in the online health care professional
directory on Cigna.com and myCigna.com. (Please see the sample healthcare professional directory display on
page 5.)
Cigna Care designation benefit design: The Cigna Care designation is a benefit plan design option offered to
organizations sponsoring group health benefit plans. Available in 71 service areas, the designation distinguishes
physicians in 21 specialties (three primary care + 18 other specialties) who participate in our network, based on
their meeting the above referenced quality and cost-efficiency criteria.
The Cigna Care benefit design, which is intended to encourage Cigna customers covered by these plans to
consider using a Cigna Care designated physician, affords a lower co-payment or coinsurance for services
provided by a designated physician than if the individual were to select a participating, non-designated physician.
Overall physician reimbursement is unchanged.
Geographical markets that the Cigna Care designation benefit plan is offered in 2015 were defined by our
Network Contracting and Market Medical Executive teams. The zip code of a physician’s primary office address is
used to align a physician with a given market. The physician’s specialty and geographic market is then used to
determine the physician peer group for comparison of quality and cost-efficiency outcomes.
Please see Appendix 1 for a list of markets, the volume of physicians reviewed, and the percent of physicians
reviewed in each market that are Cigna Care designated, effective January 1, 2015.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
3
Physician Cost-Efficiency Displays
Information regarding the physician’s cost-effectiveness performance is displayed only on myCigna.com, the
secure website for Cigna customers. The displays are available in 72 markets for the 21 specialty types assessed
for Cigna Care designation, including the 18 specialty types assessed for the Cigna Care designation, and three
primary care physician (PCP) specialty types (Family Practice, Internal Medicine, and Pediatrics).
Cost-efficiency stars are used to communicate cost-efficiency performance. Three stars for cost- efficiency
represent the top 34% of physicians or physician groups when compared to other physicians and physician
groups of the same group specialty type within the geographic market. Two stars represent physicians or
physician groups in the middle 33% for cost-efficiency. Physician groups that are in the lower 33% for costefficiency receive one star.
Cost-Efficiency Symbols
Results in top category for cost-efficiency measures
Results in middle category for cost-efficiency
Results in the low category for cost-efficiency
Please see Appendix 2 for the geographical markets and volume of physicians reviewed for physician quality and
cost-efficiency displays, beginning January 1, 2015.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
4
Sample: Online health care professional directory displays (myCigna.com)
Denotes physician with
Cigna Care Designation
Quality and cost-efficiency
recognitions
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
5
Specialty Types Assessed for Cigna Care Designation and Physician Quality and Cost-Efficiency Displays
We assess a total of 21 physician specialty types including primary care, as identified in the following table. A
physician may only be assigned one specialty, tax identification number (TIN), and geographical market for Cigna
Care designation or physician quality and cost-efficiency displays. The physician’s primary specialty, as listed in
the Cigna Central Provider File, is used to establish the specialty to evaluate physicians with multiple specialties.
Assessed Specialty Types
Allergy and Immunology
Cardiology
Dermatology
Ear, Nose and Throat
Family Practice
Gastroenterology
Hematology and Oncology*
Internal Medicine
Neurology
Neurosurgery
Ophthalmology
Orthopedics and Surgery
Pulmonary
Rheumatology
*Does not include Radiation Oncology
Cardio-Thoracic Surgery
Endocrinology
General Surgery
Nephrology
Obstetrics and Gynecology
Pediatrics
Urology
Participating physicians in the 21 specialty types reviewed for the Cigna Care designation account for over 90% of
primary and specialty care and 85% of total medical and pharmaceutical spending based on our claims data.
Quality Evaluation
Information relative to specific quality criteria met by a physician is displayed in the online health care professional
directory on both the public and secure websites at Cigna.com and myCigna.com. We use five quality indicators
to review participating physicians in the 21 specialty types. Each physician qualifying for a specific quality
indicator is identified in our online healthcare professional directory.
1. National Committee for Quality Assurance (NCQA) Physician Recognition
The NCQA recognition in our online directory is given to physicians who have received recognition in any of
the six NCQA Physician Recognition Programs: back pain, diabetes, heart/stroke, physician practice
connections, and patient-centered medical home 2011 (2 versions). Effective January 1, 2015, Cigna began
recognizing the additional physician recognition - the NCQA Patient Centered Specialty Practice Program - as
a quality indicator for reviewing participating physicians in the 21 specialty types.
The verbiage below reflects the display of the quality recognitions in the online directory.
•
•
•
•
•
NCQA Diabetes Physician Recognition Program (DRP) - identifies primary care physicians,
endocrinologists and diabetes specialists who provide care to people with diabetes. This program
assesses key measures specific to diabetes care, such as monitoring and management of blood
pressure, cholesterol and glucose levels, patient satisfaction, and other important measures.
NCQA Heart/Stroke Physician Recognition Program (HSRP) - identifies doctors who provide quality care
to people with heart disease or a history of strokes. This program assesses key measures specific to
heart disease and stroke care, such as blood pressure and cholesterol level control, smoking status and
advice or treatment for quitting, patient satisfaction, and other important measures.
®
NCQA Physician Practice Connections (PPC) - assesses the systematic use of information in doctors'
practices to improve the quality of care. This program recognizes physicians who consistently keep their
patients well informed about their health, who are actively engaged in improving their patients' health over
time, and who successfully use technology and other tools to prevent medical errors.
NCQA Back Pain Recognition Program (BPRP) - recognizes physicians and chiropractors who deliver
superior care to their patients suffering from low back pain. The program assesses the diagnosis process,
treatment and advice focused on helping patients return to normal activities.
TM
NCQA Physician Practice Connections - Patient-Centered Medical Home (PCMH - 2 versions) recognizes doctors that effectively manage their patient's care by coordinating with other doctors,
specialists and family members to deliver a holistic, or comprehensive, patient treatment.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
6
•
NCQA Patient Centered Specialty Practice (PCSP) –recognizes practices that have demonstrated
commitment to patient-centered care and clinical quality through: streamlined referral processes and care
coordination with referring clinicians, timely patient and caregiver-focused care management and
continuous clinical quality improvement.
Additional information about these programs is available on the NCQA website (www.NCQA.org > Programs
> Physician Recognition).
2. Group Board Certification
Group board certification criteria, based on American Board of Medical Specialties & American Osteopathic
Association certification information, determine if care provided by a group is predominantly provided by board
certified physicians. This standard is met if:
• either 80% of physicians within a group are board certified and provide 50% of the care, or at least 80% of
the care is provided by board certified physicians, OR
• for practices/groups with 4 or fewer physicians, either 65% of physicians within a group are board certified
and provide 50% of the care, or at least 65% of the care is provided by board certified physicians
3. Adherence to Evidence-Based Medicine (EBM) Rules
The quality of physician care is evaluated using a claims-based assessment based on 99 EBM rules derived
from rules endorsed by the National Quality Forum (NQF), Ambulatory Care Quality Alliance (AQA),
Healthcare Effectiveness Data Information Set (HEDIS), or developed by physician organizations. These rules
span 48 diseases and preventive care conditions (see Appendix three), and is potentially applicable to the
care provided by physicians in 20 specialty types. For a list of the specialty types that are covered by
evidence-based medicine rules, please see the Specialty Types Covered by Evidence Based Medicine Rules
chart below.
4. American Board of Internal Medicine Process Improvement Module Completion (ABIM-PIM)
We recognize physicians who have completed one or more American Board of Internal Medicine Practice
Improvement modules (ABIM PIM) as part of the ABIM Maintenance of Certification program.
Certification/recertification must be achieved every two years.
5. Evidence-Based Medicine (EBM) Assessment Process
Evidence-based medicine rules that we currently use are applicable to 20 primary care and non-primary care
specialties. Currently there are no evidence based medicine rules applicable to dermatology. Overall,
approximately 15% of physicians in the specialties noted below (including Dermatology) are associated with
groups that do not have sufficient volume to assess adherence to the EBM rules however they have sufficient
volume to assess cost-efficiency. Similarly, 4,226 or almost 1% of physicians are associated with groups that
do not have sufficient volume to assess cost-efficiency and therefore are assessed based on adherence with
the EBM rules alone.
Evidence Based Medicine (EBM) Assessment Process
Specialty Types Covered by Evidence Based Medicine Rules
Allergy and Immunology
Cardiology
Endocrinology
Family Practice
General Surgery
Hematology and Oncology
Nephrology
Neurology
Obstetrics and Gynecology (OB/GYN)
Ophthalmology
Otolaryngology (ENT)
Pediatrics
Rheumatology
Urology
Cardiothoracic Surgery
Gastroenterology
Internal Medicine
Neurosurgery
Orthopedics and Surgery
Pulmonary
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
7
The EBM assessment component of the Cigna Care Designation program for 2015 involves assessment of
compliance with a total of 99 EBM rules (see Appendix 3) for the medical conditions displayed in the following
table:
Disease and Preventive Care Conditions Covered By Evidence Based Medicine Rules
Adenoidectomy
Adolescent Well-Care
Asthma
Atrial Fibrillation
Attention Deficit Hyperactivity
Disorder (ADHD)
Breast Cancer I & II
Bronchitis (Acute)
Cardiac Surgery
Cerebral Vascular Accident
Cervical Dysplasia
Children and Adolescents' Access to Children’s Access to Primary Care
Primary Care Practitioners
Practitioners
Chlamydia Screening
Cholesterol Management
Chronic Kidney Disease
Chronic Obstructive Pulmonary
Disease
Colon Cancer -II
Comprehensive Ischemic Vascular
Disease Care
Congestive Heart Failure
COPD Exacerbation,
Pharmacotherapy
Management
Coronary Artery Disease
Depression Medication Management Diabetes
Epilepsy
Hepatitis C
Hypertension
Inflammatory Bowel Disease
Knee Replacement
Low Back Pain
Migraine
Multiple Sclerosis
Obesity and Overweight
Osteoporosis
Otitis Externa (Acute)
Otitis Media
Persistence of Beta Blocker
Treatment After MI
Pharyngitis
Pneumonia (Community Acquires
Bacterial)
Pregnancy Management
Prenatal Care
Prostate Cancer I & II
Rheumatoid Arthritis
Rheumatoid Arthritis, Drug Therapy Sickle Cell Anemia
Sinusitis
Tonsillectomy
Upper Respiratory Infection
Tympanostomy
Definitions used in the following methodology description:
1. Physician specialty type: any one of the 21 specialty types listed in the table of Assessed Specialty
Types found on page 7 of this white paper
2. Group specialty type: any one of the 21specialty types listed in the table of Assessed Specialty Types
found on p. of this white paper if the medical group is comprised of physicians all of the same specialty, or
in the case of mixed specialty groups, one of the following mixed specialty group designations:
multispecialty medical group (mixture of multiple non-PCP specialists), mixed specialty medical group
(mixture of PCPs and non-PCP specialists), primary care medical group (mixture of PCP specialists)
3. Specialty category: primary care specialties (FP, IM, PD) or non-primary care specialties (the 18 other
specialties assessed for CCD)
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
8
We determine the extent to which an individual physician or physician group complies with evidence-based
medicine rules according to the following conventions:
Determining peer or market EBM rule adherence for each geographic market:
• In order for an EBM rule to be included for review at the geographic market level for a physician or physician
group, there must be at least 20 opportunities for the rule within the specialty category (primary care or nonprimary care specialties) and market for the most recent two-year data review period. For 2015 displays and
Cigna Care designation, that period is January 1, 2012 – December 31, 2013
•
The average adherence rate for each EBM rule is calculated for the specialty category (primary care or nonprimary care specialties) for each geographic market to derive the peer/market average result.
Determining individual physician or group practice EBM rule adherence:
• Opportunities and successes for each eligible EBM rule are aligned to the appropriate individual physician
(using the visit requirements outlined below and relevant specialty type category).
•
Visit Requirements: A physician is considered responsible for adherence to the EBM rule if the following
conditions are met:
o The EBM rule is relevant to the physician’s specialty (see Appendix 3). For example, the Cervical
Dysplasia EBM rule is relevant to OB/GYN, Internal Medicine, and Family Practice, but it is not relevant to
other specialties.
o There have been at least two office visit encounters for an individual with Cigna coverage during the claim
review period.
o At least one of the office visit encounters occurred in the last 12 months of the claim review period.
Note: 19 of our EBM measures require only one office visit encounter in the last 12 months of the claim review
period. These measures are identified by an asterisk [*] in Appendix 3.
•
Individual physicians are aligned to medical groups (practices), and EBM rule opportunities, successes, and
expected successes are then summed to obtain medical group totals.
•
A Quality Index for the medical group is calculated by dividing the physician’s or physician group’s number of
actual EBM rule adherence successes by the physician’s or physician group’s number of expected EBM rule
adherence successes. Expected EBM rule adherence successes are derived by applying the geographic
market average EBM rule adherence success rates to that physician medical group’s particular rule mix
opportunities.
•
A 90% confidence interval around the Quality Index is determined, allowing EBM quality performance to be
measured with a strong degree of certainty. The lower bound of the 90% confidence interval for a particular
physician or physician group is defined as the Adjusted Quality Index for that physician medical group.
•
Physician medical groups that meet the Cigna group board-certification criteria, have 30 or more total EBM
rule adherence opportunities, and have at least 50% of their treatment episodes (used in the physician’s or
medical group’s cost-efficiency (ETG) analysis) attributed to the physician specialty types that are assessed
for EBM rule adherence are assessed and ranked using the Adjusted Quality Index score.
•
Physicians or physician groups with an Adjusted Quality Index score in the best 34% of their medical group
specialty type and geographic market are placed in the best category for EBM rule adherence. Physicians or
physician groups that have results in approximately the lowest 2.5%, for the medical group specialty types in
the market where there are at least 20 medical groups of that medical group specialty type in the market, are
placed in the bottom category. The remainder is in the middle category.
•
A threshold is set for each market and for each medical group specialty type within a market. These
thresholds are determined by specific market considerations such as geography, specialty volume, access to
specialty care and contract requirements. Thresholds range from approximately 30% - 70%. The use of
threshold adjustments allows for individual market factors to be taken into account; however, it is important to
note that when such market-specific threshold adjustments are made, all other physician medical groups in
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
9
that market of the same medical group specialty type that also meet the revised market threshold value, will
then be deemed to have met the quality requirement for Cigna Care designation.
•
We do not risk-adjust EBM (quality) measures due to the fact that the EBM rules have explicit definitions for
both the numerator and the denominator of each measure. The denominator explicitly defines the population
that is at risk; thus risk adjustment is incorporated into the definition of the measure.
Cost-Efficiency Evaluation
We use Episode Treatment Group (ETG) methodology, an industry standard, available through OPTUM to
evaluate the cost-efficiency of individual physicians and medical groups. The methodology incorporates case-mix
and severity adjustment, and claims are clustered into over 500 different episodes of care. Additional information
about the OPTUMInsight Episode Treatment Groups, including a complete listing of the ETGs, is available at
https://etg.optum.com/etg-links/.
Using the ETG methodology, we can determine how a physician medical group’s cost-efficiency compares to
other physician medical groups of the same group specialty type (primary care physician group, mixed specialty
group, multi-specialty group) in the same geographic market. For example, in the case of single-specialty primary
care medical groups, the medical group’s cost-efficiency performance is compared to the performance of other
single-specialty primary care medical groups in the same market, i.e., FP medical groups are compared to other
FP medical groups, IM medical groups are compared to other IM medical groups, and PD medical groups are
compared to other PD medical groups. A physician or physician group’s performance is a result of its fee
schedule, utilization patterns and referral patterns (e.g., use of hospitals and other facilities).
ETG Assessment Requirements:
• There must be at least 10 occurrences of a specific ETG (e.g., incorporating episode severity and treatment
level, co-morbidity, complications, or the presence of Rx benefits) within the geographic market and specific
physician specialty type in order to determine the market average cost for that ETG, and thus include it in the
market’s analysis.
•
The peer or market average for each specific ETG is established for each market and physician specialty
type.
•
To reduce variation within cost-efficiency results, several ETGs are excluded from the assessment process,
including routine immunizations and other inoculations, transplants, and ETGs with low volume or wide cost
variation. Episodes with a severity level of four (the highest severity level assigned by the OPTUMInsight ETG
software), are also excluded from analysis, for most conditions.
Example: For the Nashville market during the data analysis period, there are 15 occurrences of ETG XX
(with the same severity, treatment level, co-morbidity, complications, and presence of pharmacy benefits) that
are attributed to family physicians. The average cost of ETG XX for family physicians in the Nashville market
is established by computing the numerical average of the cost of all 15 occurrences of this ETG subject to the
application of outlier trimming methodology outlined in the following section. This process is replicated for
each ETG with at least 10 occurrences in the Nashville market for a given physician specialty type in order to
determine the market cost average for each ETG that is eligible for evaluation in the market.
ETG Assessment Process:
• Individual physician medical groups must have at least 30 total episodes of care during the review period in
order to be reviewed for cost-efficiency. In order for an episode to be attributed to a physician (responsible
physician), two criteria must be met: (1) the physician must be responsible for more costs for medical or
surgical management services than any other physician providing care for the episode, and (2) the medical or
surgical management costs for the physician must be at least 30% of the total episode medical or surgical
management costs. If these two criteria are not met, the episode is excluded from analysis. While only the
costs associated with physicians’ provision of management services are used to attribute the episode to a
particular physician, total costs (physician management costs + all ancillary costs (e.g., lab, X-ray, hospital,
ambulatory surgery, physical therapy, etc.) are used to characterize the total cost of the episode.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
10
•
The actual cost of an episode of care for each physician group and for the physicians within that group is
compared to the market average cost of an episode of care, which is derived using their unique mix of ETGs
and the peer averages.
•
The sum of all actual ETG episode costs for a medical group divided by the sum of all corresponding ETG
episode market average costs is the medical group’s Performance Index.
Example: The ABC Physician Group consisting of three family physicians in the Nashville market has five
episodes of care belonging to two unique ETGs (ETG1 and ETG2) that are attributable to the group. For the
sake of simplicity, disregard for the purpose of this example the requirement that the physician or physician
group must have a minimum of 30 attributable episodes in order to be reviewed for cost- efficiency. Average
episode costs for ETG1 and ETG2 have been established for all other primary care physicians or groups
practicing in the Nashville market. Three episodes of ETG1 are attributable to the ABC Physician Group and
two episodes of ETG2 are attributable to the ABC Physician Group.
In the table below, the physician group’s cost per episode is displayed for each of the three occurrences of
ETG1 and for each of the two occurrences of ETG2, along with the market average cost for an episode for
ETG1 and ETG2 for all family physicians in the Nashville Market.
Actual Episode Cost Market Average Cost
ETG 1
2000
3500
ETG 1
1000
3500
ETG 1
4000
3500
ETG 2
15,000
19,000
ETG 2
18,000
19,000
Average
8,000
9,700
Performance Index = 8,000/9,700 = 0.825
Dividing the average cost of all episodes of care attributable to the physician group by the average of all
market average episode costs for the ETGs on which the physician group’s cost-efficiency performance is
being evaluated yields a Performance Index (PI) of 0.825. The PI for the medical group can be interpreted as
Medical Group ABC is 17.5% more cost-efficient than other family medicine physician medical groups in the
Nashville market.
•
A 90% Confidence Interval around the Performance Index is used to determine a range of performance within
which the medical group’s true performance would fall with a high level of confidence. The upper bound of the
confidence interval is defined as the Adjusted Performance Index and is used to compare cost-efficiency
performance among physician medical groups. The upper bound of the 90% confidence interval is used in
order to ensure that the medical group’s performance is at least as good as or better than the upper bound
threshold.
•
A threshold is set for each market and for each medical group specialty type within a market. These
thresholds are determined by specific market considerations such as geography, specialty volume, access to
specialty care and contract requirements. Thresholds range from approximately 30% - 70%. The use of
threshold adjustments allows for individual market factors to be taken into account; however, it is important to
note that when such market-specific threshold adjustments are made, all other physician medical groups in
that market of the same medical group specialty type that also meet the revised market threshold value, will
then be deemed to have met the cost-efficiency requirement for Cigna Care designation.
•
Physician groups in the same medical group specialty type that meet Cigna board certification criteria and
Cigna minimum volume of 30 episodes of care are ranked using the (cost-efficiency) Adjusted Performance
Index score. Those groups with an Adjusted Performance Index score in the top 40% of their respective
medical group specialty type and market are placed in the top category for cost-efficiency and consequently
meet the cost-efficiency component requirement for Cigna Care designation (provided they also score in the
top 40% for quality). To qualify for CCD on the basis of cost alone, medical groups must score in the top 34%
of their respective medical group specialty type and market.)
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
11
2015 Outlier Methodology
In order to portray physicians’ cost-efficiency performance in the most accurate manner, the cost-efficiency
evaluation includes a methodology to account for episodes that are outliers. Outliers are episodes that are
substantially different from the market expected amounts. High cost episodes (ETGs) that are greater than 1.5
times the market specialty averages are reduced to 1.5 times the market specialty average. Low cost outlier
episodes are determined by the OPTUM software or are episodes of less than $25.00 and are excluded from the
evaluation.
Level of Evaluation (Unit of Analysis)
While we review participating physicians at the individual level, the majority of assessments are performed at the
physician group or practice, or group tax identification number level. Individual physicians who are not part of a
group are assessed if volume criteria are met. This approach provides robust data for evaluation and is consistent
with the assumption that:
•
•
Patients with Cigna-administered coverage often chose a group rather than a specific physician within the
group, and;
Patients with Cigna-administered coverage who initially choose a specific physician frequently receive
care by another physician within the practice or group.
Assigning the Cigna Care Designation (2015 CCD Inclusion Methodology)
In order to receive the Cigna Care designation, a physician must qualify on the basis of both medical group
specialty quality and cost-efficiency OR be ranked in the top 34% for quality or cost-efficiency of an eligible
medical group specialty within his/her geographic market for cost-efficiency. The details of the Cigna Care
Designation assignment logic are outlined below and are displayed in the diagram on page 14.
•
To be considered for Cigna Care Designation, physicians must be MDs and/or DOs in one of 18 non- primary
care specialties or one of three primary care specialties. Note: Cigna performs its evaluations at the group
level. Some groups include geriatric physicians, nurse practitioners, and physician assistants who deliver
primary care services as part of the group. In such cases, geriatric physicians, nurse practitioners, and
physician assistants will be considered for Cigna Care designation as part of the group.
•
Physicians must meet a board certification requirement. For medical groups, this standard is met if:
o either 80% of physicians within a group are board certified and provide 50% of the care, or at least
80% of the care is provided by board certified physicians, OR
o for practices/groups with 4 or less physicians, either 65% of physicians within a group are board
certified and provide 50% of the care, or at least 65% of the care is provided by board certified
physicians
•
The physician practice must have at least 30 evidence-based medicine (EBM) opportunities during the data
collection period and at least 50% of the total care provided by the practice must be provided by physicians
for whom there are applicable EBM rules.
•
A Quality Index and Adjusted Quality Index are calculated for each practice. Physician practices are assigned
to one of three quality categories based on the Adjusted Quality Index: top 34% of practices in the market for
the practice’s group specialty type; bottom 2.5% of practices in the market for the practice group specialty
type; middle 2.5% to 66% of practices in the market for the practice’s group specialty type.
Practices in the Top 34% of Practices for Quality Based on EBM Assessment:
• If the Adjusted Quality Index for the practice is in the top 34% of all physician practices in the geographic
market of the same physician group specialty type OR if the group has 50% or more of their physicians
recognized in one of the six NCQA recognition programs, the practice meets the CCD quality requirement and
is then evaluated on its cost-efficiency.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
12
•
The practice must have at least 30 episodes available for ETG assessment during the data collection period.
A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice
Adjusted Performance Index shows the practice is in the top 40% of all practices of the same group specialty
type in the geographic market, the practice is awarded Cigna Care designation.
Practices in the Middle Category (2.5% - 66%) for Quality Based on EBM Assessment:
• If the Adjusted Quality Index for the practice is in the middle category (2.5% - 66%) of all physician practices
in the geographic market of the same specialty physician group specialty type, the practice is evaluated to
determine if it is in the top 34% of all practices for cost-efficiency.
•
The practice must have at least 30 episodes available for ETG assessment during the data collection period.
A practice Performance Index and a practice Adjusted Performance Index are calculated. If the practice
Adjusted Performance Index shows the practice is in the top 34% of all practices of the same group specialty
type in the geographic market, the practice is awarded Cigna Care designation.
Practices in the Bottom 2.5% for Quality Based on EBM Assessment:
• If the Adjusted Quality Index for the practice is in the bottom 2.5% of all physician practices in the geographic
market of the same physician group specialty type, the practice, if it is a medical group, is excluded from
Cigna Care designation. Note: Practices are only assigned to the bottom 2.5% in quality performance if there
are at least 20 or more quality ranked groups in a specific geographic market.
Practices Having Insufficient Volume to Assess Quality Based on EBM Assessment:
• If the practice has an insufficient volume of EBM opportunities (less than 30) in order to be assessed for
quality based on EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes
eligible for ETG assessment. If it meets the 30 episode criterion and the calculated practice Adjusted
Performance Index is in the top 34% of all practices of the same physician group specialty type in the
geographic market, the practice is awarded Cigna Care designation.
•
If the practice has an insufficient volume of EBM opportunities in order to be assessed for quality based on
EBM rule adherence, the practice is assessed to determine if it has at least 30 episodes eligible for ETG
assessment. If it meets the 30 episode criterion and the calculated Practice Adjusted Performance Index is
NOT in the top 34% of all practices of the same group specialty type in the geographic market, the practice is
excluded from Cigna Care designation.
Practices Having Insufficient Volume to Assess Cost Based on ETG Assessment:
• If the practice has an insufficient volume of ETG opportunities (< 30) for cost profiling but has a sufficient
number of EBM opportunities (>= 30) for quality profiling or meets the NCQA recognition criterion, the practice
is eligible for CCD designation through a quality-only pathway. If the Adjusted Quality Index of the practice
places it within the top 34% of practices of the same group specialty type in the same geographic market, the
practice is awarded Cigna Care designation.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
13
14
Credit for Utilizing Cigna Centers of Excellence
Cigna evaluates hospital patient outcomes and cost-efficiency information through the Cigna Centers of
Excellence (COE) program for all practices. Utilization of COEs by a reviewable physician practice
provides credit towards Cigna Care designation. If at least 50% of the physicians in the practice each had
at least three COE admissions during the data analysis period, then a one percentage-point increase in
the Performance Index (for cost-efficiency) and a one percentage-point increase in the Quality Index will
be granted. The increased Performance Index and Quality Index are then used to determine eligibility for
Cigna Care designation. COE admissions must be consistent with the specialty of the physician providing
the COE-related care in order to qualify.
Buffer Zone Methodology
Variation in physician group or physician group performance (e.g., positive or negative, substantial, or
minimal) is inevitable and expected in an annual review process due to various factors (e.g., changes to
physician group makeup, external market factors, and practice pattern modifications). A “buffer zone”
methodology addresses small-scale variation for physician groups or physician groups whose Cigna Care
designation changes from the previous year. A practice may maintain its Cigna Care designation status if
the group was designated during the prior cycle, is within 3% of the current year's quality AND cost
criteria, OR is within 3% of the cost index when the group does not meet cost and quality criteria.
The selected physician group must meet certain standard Cigna Care designation criteria to achieve the
2014 buffer zone designation. The standard criteria applied includes meeting the physician group Board
Certification criteria, the Board Certified physicians must be responsible for at least 50% of the group
episodes, the group must have at least 30 episodes, and the group must not be in the bottom 2.5 market
percentile for EBM quality performance in a market with greater than 20 groups within the specialty
category in the market.
Collaborative Accountable Care Pathway to Achieving Cigna Care Designation
CAC to CCD Pathway
Cigna has teamed up with selected physician groups in order to help them achieve the “triple aim” of
improving quality, improving cost-effectiveness and improving the patient experience of care. This is
called the Cigna Collaborative Accountable Care (CAC) model. Cigna's approach builds upon the
foundation of Accountable Care Organizations (ACOs) and Patient Centered Medical Home (PCMH)
models by recognizing physicians affiliated with the CACs that demonstrate improvement in medical
delivery and clinical outcomes plus achieve improvement in reducing the cost of care.
Cigna's approach is to work with physicians to provide them with resource support and data that can help
them deliver optimal care. This support can include data about ER visits, hospitalizations, potential gaps
in care, medication compliance, etc., which the physician might not otherwise have access to, and which
can support the physician in optimal management of care delivery across multiple settings. This support
can also focus on chronically ill patients by working with nurses who are part of the group practice, to
provide them with information and tools to help them manage these patients and coordinate case
management and educational support when needed.
Cigna's CAC model is designed for collaboration with large physician groups that may or may not include
specialists. These groups must meet volume thresholds for physicians and Cigna customers, as well as
other minimum criteria. The groups enter into a contract with Cigna in which they agree to be evaluated
based on quality and cost criteria that are unique to the CAC model.
For 2015, physicians and physician groups will go through the CCD assessment through the standard
CCD pathway to determine inclusion. If the physicians and physician groups were unable to achieve
designation through the standard CCD pathway described previously in this white paper but they are
affiliated with the CAC, then the CAC pathway inclusion criteria may be applied next to determine if they
can be designated. The CAC achieving a Total Medical Cost Performance Index of less than or equal to
1.03 AND a CAC Quality Index of greater than or equal to 0.99 will be assigned the Cigna Care
designation. Specialists that are affiliated with a CAC that meets the CCD criteria for inclusion and the
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
15
markets determine the specialists are to be included with the CAC; the specialists will be assigned
designation.
To be considered for Cigna Care designation, CAC physicians must be MDs and/or DOs in one of three
primary care specialties or one of 18 non-primary care specialties. Note: Cigna performs its evaluations at
the group level. Some groups include geriatric physicians, nurse practitioners, and physician assistants
who deliver primary care services as part of the group. In such cases, geriatric physicians, nurse
practitioners, and physician assistants will be considered for Cigna Care designation as part of the group.
Quality Assessment
The CAC must have at least 30 evidence-based medicine (EBM) opportunities during the data collection
period. A Quality Index is calculated for each CAC based on adherence to Evidence Based Medicine
(EBM) measures. If the CAC’s Quality Index is 0.99 or better, the quality requirement is met.
Cost-Efficiency Assessment
To contract with Cigna as a CAC, a minimum volume of Cigna customers is required so there is sufficient
volume for cost evaluation. Based on 2014 data, this results in episode counts ranging from 8,600 to
131,000 episodes per group, per year. Total Medical Cost (TMC) is used to evaluate cost-efficiency for
CAC arrangements. A Total Medical Cost Performance Index (PI) is calculated. If the group's TMC
Performance Index is 1.03 or less, the practice meets the CCD cost requirement for CCD.
The Quality Index and Total Medical Cost Index are calculated as follows:
Quality Index
The Quality Index is calculated based on adherence to Evidence Based Medicine (EBM) standards, and
EBM rules for CACs are the same as those described for primary care specialties in the section titled
"Evidence-Based Medicine (EBM) Assessment Process" which appears on pages 7-10 of this paper.
Determining CAC EBM rule adherence:
• Opportunities and successes for each eligible EBM rule are aligned to the appropriate
individual physician (using the visit requirements outlined below and relevant specialty type
category).
• Visit Requirements - A physician is considered responsible for adherence to the EBM rule if
the following conditions are met: The EBM rule is relevant to the physician’s primary care
specialty (see Appendix 3). For example, the Cervical Dysplasia EBM rule is relevant to
OB/GYN, Internal Medicine, and Family Practice, but it is not relevant to other specialties.
• There have been at least two office visit encounters for a Cigna customer
• At least one of the office visit encounters occurred in the last 12 months of the claim review
period. Note: Nineteen of our EBM measures require only one office visit encounter in the last
12 months of the claim review period. These measures are identified by an asterisk [*] in
Appendix 3.
Individual physicians are aligned to the CAC, and EBM rule opportunities, successes, and
expected successes are then summed to obtain CAC totals.
A Quality Index for the CAC is calculated by dividing the number of actual EBM rule adherence
successes for the CAC by number of expected EBM rule adherence successes. Expected EBM rule
adherence successes are derived by applying the geographic market average EBM rule adherence
success rates from primary care groups in the market.
Total Medical Cost Index
The Total Medical Cost index reflects all medical costs for Cigna customers who are aligned to PCPs in
the CAC, excluding pharmacy and non-PCP behavioral health costs.
For the CAC model, Cigna maintains a roster of all Cigna customers who are patients of the CAC.
Patients get aligned to a specific PCP if they've had at least 1 visit in the prior 12 months. If no visit is
found, the look back period is 24 months and the patient is aligned to the PCP with the most recent visits.
When there are no visits to PCPs in 24 months, then the same search is conducted for Nurse
Practitioners, Physicians Assistants and OB/GYN physicians in the group. If a patient was seen by more
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
16
than one primary care practitioner in the CAC, the patient is aligned to the practitioner with the most visits.
Once the aligned patients and practitioners are identified, the Total Medical Cost is calculated as follows:
•
Capture all claims expenses (excluding pharmacy expense) for patients who are aligned to the
CAC PCPs for the 12 month reporting period. Pharmacy costs and non- PCP Behavioral
Health costs are not included in TMC calculation.
•
Calculate member months for all aligned patients of the CAC and the market.
•
Calculate an Episode Risk score using Episode Risk Grouper (ERG) software for both the market
and the CAC. Additional information about the OPTUMInsight Episode Risk Grouper software is
available at https://etg.optum.com/etg-links/.
•
Calculate total medical cost for all aligned patients of the CAC. Outliers are identified and outlier
claim expense is capped at $100,000.
•
Calculate per Patient per Month (PPPM) expenses for both the market and the CAC practice.
(PPPM is calculated by dividing the total medical cost by member months).
•
Adjust the CAC PPPM to consider to ERG risk score for patients of the CAC.
Divide the final risk adjusted CAC PPPM score by the market PPPM score to create the TMC
performance index. When the CAC adjusted expense is the same as the market, the result will be 1.0. A
TMC Performance Index of less than 1.0 reflects that claim expenses are lower than the market average
and a TMC performance index of greater than 1.0 reflects that claim expenses are higher than the market
average.
Buffer Zone Methodology
Variation in CAC performance (e.g., positive or negative, substantial, or minimal) is inevitable
and expected in an annual review process due to various factors (e.g., changes to physician
group makeup, external market factors, and practice pattern modifications). A “buffer zone” or
“grandfathering” methodology addresses variation for physician groups or physician groups
whose Cigna Care designation changes from the previous year. A CAC may maintain its Cigna
Care designation status if the CAC was “in” during the prior cycle.
NOTE: Individual markets may adjust the grandfathering criteria for CACs at the market level, in order to
exclude from grandfathering those CACs with large scale variation in results from the prior year.
Adjustments are made at the market level and are applied to all CACs in the market.
Collaborative Accountable Care (CAC) Review Process
The evaluation methodology is applied annually (and quarterly as needed) to all existing CAC
arrangements and to new CACs that become effective.
•
•
•
CACs that do not meet criteria can be re-evaluated using quarterly data, through our
reconsideration process. If the quality and performance indexes improve and are meeting the
market criteria for inclusion during two consecutive quarters, the CAC will be given Cigna Care
Designation status.
Since CACs can earn CCD status on a quarterly basis, Cigna reserves the right to remove the
CCD status if the CAC demonstrates significant decline in performance below the required criteria
in 4 consecutive quarters, or if the CAC discontinues it collaborative agreement with Cigna and
does not meet the standard CCD criteria.
A re-evaluation occurs annually where grandfathering may be applied. As noted above, individual
markets may adjust the grandfathering criteria at the market level. When adjustments are made
at the market level they are applied to all CACs in the market.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
17
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
18
Data Sources
The evaluation data sources and how the information from each source is used are outlined below.
Data Source
How Information is Used
Cigna Physician Metrics
(January 2012 – December 2013
The data is used to produce ETG efficiency and EBM
summary reports.
Use combined Managed Care and PPO product data
with episodes of care or EBM rules attributed to the
Note: Data for Medicare-eligible individuals is removed.
responsible physician.
File extracts to identify contracted physicians, TIN,
Cigna Central Physician File (CPF)
groups, specialty, board certification status, network, and
(as of April 2014
products contracted.
The status of physicians recognized for the diabetes,
heart/stroke, back pain, physician practice connections,
patient-centered medical home 2012 or patient centered
Physician Recognition Program File obtained from
specialty practice recognition programs is updated based
National Committee for Quality Assurance (NCQA) (as on information received from NCQA.
of April 2014 and at least six times per year)
Percent of physicians recognized in an NCQA program
for a group is calculated based on the recognition and
group alignment
Physician Recognition Program obtained from the
American Board of Internal Medicine at least semiannually
To display the ABIM-PIM quality recognition in Cigna
directory
Cigna Utilization and Centers of Excellence (COE)
Data
Specialty groups that admit to Center of Excellence
facilities (based on utilization data) will receive credit
towards Cigna Care Designation inclusion
Additional Information and Data Limitations
The Cigna Care designation and physician quality and cost-efficiency displays are a partial assessment of
physician quality and cost-efficiency, and are intended to provide information that can assist Cigna customers in
health care decision-making. It should not be used as the sole basis for decision-making (as such measures
have a risk of error). Cigna customers are encouraged to consider all relevant information and to consult with
their treating physician in selecting a physician for care.
While we use what we believe to be the best available information to create an objective assessment
methodology, there are some limitations:
• The EBM and cost-efficiency information are based on our claim data only. Aggregated claim data from
multiple payers (e.g. insurance companies, self-insured, and government plans) may provide a more
complete picture of physician performance. We support data aggregation initiatives, and will consider using it
in evaluations when credible data are available.
• We can only use received claim data in evaluations. There may be health care services performed for which
no information is provided to us.
• Specific service line item detail may not always be available due to the way claims may be submitted by
physicians or processed by us.
• Pharmacy data inclusion is limited to only those customers that we administer pharmacy benefits to.
• We use Episode Treatment Groups (ETGs), an industry standard grouper, to risk-adjust for patient severity.
Although ETG software is recognized as a leading risk adjustment model, perfect patient severity risk
adjustment does not exist.
• Many physicians or physician groups are unable to be displayed for quality and cost-efficiency due to small
patient populations. We will not display results for those physicians or physician groups whose episodes or
opportunities sample do not meet certain volume thresholds.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
19
Process to Display Strategic Alliances Information
Health Alliance Plan (HAP)
Physicians or physician groups in the Eastern Michigan area (Genesee, Oakland, Lapeer, St. Clair, Livingston,
Washtenaw, Macomb, Wayne, and Monroe counties) are evaluated using the claim data from Health Alliance
Plan. HAP data reflects the contracted rates and physician utilization statistics associated with HAP membership
in the Michigan area. Consistent with our methodology, HAP's 2014 physician profiling process includes NQF
EBM rules, NCQA recognition, ABIM's Practice Improvement Modules, and board certification to evaluate
physicians. The Cigna Care designation icon displays when physicians or physician groups in Eastern Michigan
have met the quality and cost-efficiency inclusion criteria, but tiered benefits are not available in the HAP service
area.
Specific Market Activities
California IHA P4P
• Cigna HealthCare of California participates in a statewide initiative coordinated by Integrated Health
Assessment (IHA) to measure and improve clinical quality, patient experience, use of information
technology, and public reporting of physician performance results.
• Incentive payments are paid annually by Cigna to physician organizations based upon performance
against standard quality measures.
• The common set of key measures used for assessment relies on national standards or evidence based
medicine practices.
• The measure set, audit manual, and data submission file layouts are released each year by IHA.
• More information about the program and the assessment results can be found by visiting the
www.IHA.org website.
Feedback Process
Cigna customers, clients, and participating physicians are encouraged to provide feedback and suggestions for
the improvement of reports or other suggested improvements. Clients and patients with Cigna administered
plans should call the telephone number listed on the back of their Cigna ID card. Participating physicians may
provide feedback by calling our Customer Service Center at 1.800.88Cigna (882.4462). Feedback and
suggestions are reviewed, and changes to the physician evaluation methodology, reporting formats, and
processes are implemented as appropriate. Methodology changes are generally reviewed and implemented on
an annual basis.
Physician Process to Correct Errors, Request Reconsideration, or Appeal
Participating physicians or physician groups have a right to seek correction of errors and request data review for
both the Cigna Care designation and physician quality and cost-efficiency displays. Email us at
PhysicianEvaluationInformationRequest@Cigna.com or fax us at 1.866.448.5506 to request additional
information, for detail reports, to request reconsideration, to correct inaccuracies, or to submit additional
information. The request for reconsideration must include the reason for the reconsideration and any
documentation you wish to provide in support of the request.
The National Selection Review Committee process is initiated within five business days of Cigna's receipt of a
reconsideration or appeal request. A Cigna Network Clinical Manager (NCM) will contact the physician practice
or physician group to clarify information received for reconsideration and generate detail reports. The NCM may
change the physician group designation if the obtained information meets committee guidelines. These may
include, but are not limited to: a verification of board certification; a revision to the Evidence Based Medicine
(EBM) adherence score; or a verification of completion of one or more NCQA physician recognition programs.
The National Selection Review Committee will review the request if the obtained information does not meet
committee guidelines.
The National Selection Review committee participants include Cigna physicians and Cigna network clinical
performance staff. Voting committee participants include the National Medical Director and physician
representatives from the three Cigna regions, their alternates and ad hoc physicians. Non-voting participants
include the Assistant Vice President of Provider Measurement and Performance, National Network Business
Project Sr. Analyst, Health Data Senior Specialist, Marketing Product Sr. Specialist, Network Product Integration
Leads, and Network Clinical Managers.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
20
The National Selection Review Committee determination may include changing the designation, upholding the
original designation, or pending the determination for additional information. The decision notification is mailed to
the physician group after the committee determination is made. The National Selection Review Committee
process and final decision is complete within 45 days of receipt of a reconsideration or appeal request.
Colorado health care professionals should refer to Appendix 4 on page 37 of this document for Colorado specific
appeals.
How to Register Complaints
At any time, Cigna customers may register a complaint with us about the Cigna Care designation or the
physician quality and cost-efficiency displays by calling the telephone number located on the back of the Cigna
ID card.
Registering a Complaint for Cigna Customers in New York
The National Committee for Quality Assurance (NCQA) is an independent not-for-profit organization that uses
standards, clinical performance measures and member satisfaction to evaluate the quality of health plans.
NCQA serves as an independent ratings examiner for Connecticut General Life Insurance Company and Cigna
HealthCare of New York, Inc., reviewing how Cigna Care designations and physician quality and cost-efficiency
displays meet criteria required by the State of New York.
Complaints about Cigna Care designations or physician quality and cost-efficiency displays in New York may be
registered to NCQA, in addition to registering with Cigna as above, by submitting them in writing to customer
support at www.ncqa.org or to NCQA Customer Support, 1100 13th Street, NW, Suite 1000, Washington, DC
20005.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
21
2015 Physician Evaluation Methodology Changes
Changes to the Cigna 2015 physician evaluation methodology are outlined below:
Methodology Item
2015 Change/Enhancement
Details/Rationale
General Methodology
Physicians and physician groups will go through the
CCD assessment through the normal CCD pathway
for CCD inclusion.
Collaborative
Accountable Care
Pathway
Physician practices that contract
with Cigna as a Collaborative
Accountable Care (CAC) partner
have a separate process for
achieving CCD
If physicians and physician groups affiliated with the
CAC did not meet CCD inclusion criteria, then the
CAC pathway inclusion criteria will be applied to
determine if a physician can be designated.
The physicians and physician groups can be
designated if the CAC achieves a TMC Performance
Index of less than or equal to < 1.03 AND EBM
Quality Index of greater than or equal to >0.99 will
be assigned Cigna Care Designation.
Episode Treatment
Groups
Nephrology severity level 4
episodes will be added for
Nephrology specialists.
Earlier versions excluded nephrology severity level 4
due to wide variation
Specialty types
Reviewed
Colon and Rectal Surgery was
removed as a specialty for
assessment.
Low volume of episodes
Cost
Physician Practices
Display/Transparency
Cost and Quality
Thresholds
Physician Practices
Practices in the Top 34% will get 3 stars for cost.
Practices in the Middle 33% will get 2 stars for cost.
Practices in the Low 33% will get 1 star for cost.
Practices in the top 40% for cost and quality will be
assigned Cigna Care Designation. Additionally the
top 34% for cost or top 34% quality if no cost or
quality evaluated will be assigned Cigna Care
Designation.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
22
Appendices
Appendix 1: 2015 Cigna Care Designation Market Information
Volume Reviewed
4,550
Percent Designated
41.49%
Percent not
Designated
58.51%
AZ Maricopa
7,999
48.67%
51.33%
AZ All Other
1,498
28.57%
71.43%
AZ Pima
2,282
44.70%
55.30%
CA North
1,689
15.16%
84.84%
CA South
25,538
37.69%
62.31%
CA Bay Area
10,808
50.26%
49.74%
CA Sacramento
2,736
34.69%
65.31%
CA Central Valley
2,756
34.91%
65.09%
CO Front Range
7,911
38.82%
61.18%
CT Connecticut
9,241
49.20%
50.80%
DE Delaware
2,264
49.43%
50.57%
FL Jacksonville
2,350
19.28%
80.72%
FL All Other
3,942
18.21%
81.79%
FL South Florida
9,008
31.67%
68.33%
FL Orlando
5,026
33.51%
66.49%
FL Tampa
8,372
40.21%
59.79%
GA Atlanta
8,652
51.03%
48.97%
GA All Other
4,765
43.02%
56.98%
15,884
66.87%
33.13%
IL Rockford
2,620
59.20%
40.80%
IN Indianapolis
4,690
49.70%
50.30%
KS KS/MO All Other
4,542
41.96%
58.04%
LA All Other
2,405
33.72%
66.28%
LA Baton Rouge
2,376
36.87%
63.13%
LA New Orleans
2,613
49.45%
50.55%
MA Western
4,013
33.04%
66.96%
MA Boston
16,156
29.06%
70.94%
MD Maryland
Market Name
AR Arkansas
IL Chicago Metro
10,063
34.16%
65.84%
MD Northern VA
4,930
32.88%
67.12%
DC Metro North
5,674
31.67%
68.33%
ME Maine
3,822
50.37%
49.63%
NC Charlotte
4,096
19.09%
80.91%
NC East
3,450
35.54%
64.46%
NC Raleigh
4,374
30.16%
69.84%
NC Triad
3,068
33.74%
66.26%
NC W est
2,153
30.19%
69.81%
NH New Hampshire
3,980
62.51%
37.49%
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
23
Volume Reviewed
10,573
Percent Designated
38.89%
Percent not
Designated
61.11%
NJ South Jersey
4,322
35.12%
64.88%
NV Nevada
3,575
32.25%
67.75%
26,758
60.28%
39.72%
OH Northern
9,210
61.62%
38.38%
OH Central
6,101
59.78%
40.22%
OH Southern
6,025
37.93%
62.07%
OH NW Ohio
2,168
37.13%
62.87%
OR Oregon
9,771
46.56%
53.44%
PA Philadelphia
10,838
53.89%
46.11%
PA All Other
10,680
52.21%
47.79%
PA Pittsburgh/W estern
6,805
62.16%
37.84%
RI Rhode Island
2,402
30.14%
69.86%
SC Low Country
2,341
33.11%
66.89%
SC Midlands
2,041
40.96%
59.04%
SC Upstate
2,670
36.70%
63.30%
TN West
3,184
39.70%
60.30%
TN Central
5,159
32.66%
67.34%
TN East
5,424
31.60%
68.40%
TX Austin
3,587
37.47%
62.53%
TX Dallas/Ft. W orth
9,388
39.72%
60.28%
10,688
37.57%
62.43%
TX San Antonio
3,196
22.65%
77.35%
TX East Central
2,566
49.06%
50.04%
UT Wasatch Front
3,574
52.10%
47.90%
VA Hampton Roads
3,187
34.83%
65.17%
VA Richmond
2,717
37.87%
62.13%
VA W estern
3,510
34.27%
65.73%
VT Vermont
1,934
52.53%
47.47%
WA Seattle
10,134
24.89%
75.11%
WA All Other
4,786
46.89%
53.11%
WI Milwaukee/Green Bay
7,616
52.23%
47.77%
WI All Other
3,320
50.39%
49.61%
WV West Virginia
3,776
42.48%
57.52%
Market Name
NJ North Jersey
NY Metro
TX Houston
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
24
Appendix 2: 2015 Quality and Cost-Efficiency Display Markets
Market Name
Specialists Reviewed
Market Name
Specialists Reviewed
AL Alabama **
5,948 NC Charlotte
4,096
AR Arkansas
4,550 NH New Hampshire
3,980
AZ Maricopa
7,999 NJ North Jersey
10,573
AZ All Other
1,498 NJ South Jersey
4,322
AZ Pima
2,282 NV Nevada
3,575
CA North
1,689 NY Metro
26,758
CA South
25,538 OH Northern
9,210
CA Bay Area
10,808 OH Central
6,101
CA Sacramento
2,736 OH Southern
6,025
CA Central Valley
2,756 OH NW Ohio
2,168
CO All Other **
1,714 OK Oklahoma **
5,063
CO Front Range
7,911 OR Oregon
9,771
CT Connecticut
9,241 PA Philadelphia
10,838
DE Delaware
2,264 PA All Other
10,680
FL Jacksonville
2,350 PA Pittsburgh/W estern
6,805
FL All Other
3,942 RI Rhode Island
2,402
FL South Florida
9,008 SC Low Country
2,341
FL Orlando
5,026 SC Midlands
2,041
FL Tampa
8,372 SC Upstate
2,670
GA Atlanta
8,652 TN West
3,184
GA All Other
4,765 TN Central
5,159
IL Chicago Metro
15,884 TN East
5,424
IL All Other **
3,544 TX Austin
3,587
IL Rockford
2,620 TX Dallas/Ft. W orth
9,388
IN Indianapolis
4,690 TX East Central Texas
2,566
IN All Other
**
5,036 TX Houston
10,688
KS KS/MO All Other **
4,542 TX San Antonio
3,196
KS KS/MO Kansas City
4,144 UT Wasatch Front
3,574
KY Kentucky **
5,410 VA Hampton Roads
3,187
LA All Other
2,405 VA Richmond
2,717
LA Baton Rouge
2,376 VA W estern
3,510
LA New Orleans
2,613 VT Vermont
1,934
MA Western
4,013 WA Seattle
10,134
MA Boston *
16,156 WA All Other
4,786
MD Maryland
10,063 WI Milwaukee/Green Bay
7,616
MD Northern VA
4,930 WI All Other
3,320
DC Metro North
5,674 WV West Virginia
3,776
ME Maine
3,822
MS Mississippi **
3,524
NC Raleigh
4,374
NC Triad
3,068
NC West
2,153
NC East
3,450
* Indicates new market
** Indicates markets where physicians are assessed for Quality and Cost-Efficiency display only.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not
by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and
Cigna Dental Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
25
Appendix 3: EBM Rules Used for the 2015 Physician Evaluation
Summary Rule
Description
Applicable Specialist
Types
Condition
Source
Adenoidectomy
Patient(s) less than 18 years
American Academy
of age that had an
of Otolaryngology adenoidectomy and met
Otolaryngology
Head and Neck Surgery
clinical criteria for this
(AAO-HNS)
procedure.
Applicable Primary
Care Specialty
Types
Internal Medicine
Family Practice
Pediatrics
National Quality
Forum/NCQA
Patient(s) with an outpatient,
intensive
outpatient or partial
hospitalization follow-up
visit with a prescribing
physician during the 30 days NA
after the initial ADHD
prescription, AND
two follow-up visits during
the 31 days through 300
days after the initial
Family Practice
Pediatrics
National Quality
Forum/NCQA
Patient(s) with an outpatient,
intensive
outpatient or partial
hospitalization follow-up
NA
visit with a prescribing
physician during the 30
days after the initial
ADHD prescription.
Family Practice
Pediatrics
NCQA
Patient(s) 12 - 21 years of
age that had one
comprehensive well-care
visit with a PCP or an
OB/GYN in the last 12
reported months.
NA
Internal Medicine
Family Practice
Pediatrics
Antidepressant
National Quality
Medication
Forum/NCQA
Management (NS)
Patient(s) with a new
episode of major depression
that remained on an
NA
antidepressant medication
during the 12 week acute
treatment phase.
Internal Medicine
Family Practice
Antidepressant
National Quality
Medication
Forum/NCQA
Management (NS)
Patient(s) with a new
episode of major depression
that remained on an
NA
antidepressant medication
during the 6 month acute
treatment phase.
Internal Medicine
Family Practice
ADHD, Follow-Up
Care for Children
Prescribed ADHD
Medication (NS)
ADHD, Follow-Up
Care for Children
Prescribed ADHD
Medication (NS)
Adolescent WellCare Visits (NS)
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
26
Summary Rule
Description
National Quality
Forum/NCQA
Patient(s) between the ages
of 12 and 50 with presumed
Allergy/Immunology
persistent asthma using an
Pulmonology
inhaled corticosteroid or
acceptable alternative.
Internal Medicine
Family Practice
Asthma, Use of
Appropriate
Medications (NS)
National Quality
Forum/NCQA
Patient(s) between the ages
of 5 and 11 with presumed
Allergy/Immunology
persistent asthma using an
Pulmonology
inhaled corticosteroid or
acceptable alternative.
Internal Medicine
Family Practice
Pediatrics
Atrial Fibrillation
American College of
Cardiology/American
Heart Association
Patient(s) taking warfarin
that had 3 or more
prothrombin time tests in
last 6 reported months.
Cardiology
Internal Medicine
Family Practice
Breast Cancer Part I
American Society of
Clinical Oncology
Patient(s) that had an
annual physician visit.
Hematology/Oncology
OB/GYN
Internal Medicine
Family Practice
Breast Cancer Part II
Patient(s) newly diagnosed
with breast cancer that
received radiation or
Ingenix - consensus
chemotherapy treatment or Hematology
opinion of experts was
had medical oncology or
OB/GYN
the primary source
radiation oncology
consultation within 120 days
of the diagnostic procedure.
Asthma, Use of
Appropriate
Medications (NS)
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Source
Condition
Internal Medicine
Family Practice
Bronchitis, Acute,
Avoidance of
National Quality
Antibiotic Treatment Forum/NCQA
in Adults (NS)*++
Patient(s) with a diagnosis
of acute bronchitis that did Otolaryngology (Ear,
not have a prescription for Nose and Throat)
an antibiotic on or three
Pulmonology
days after the initiating visit.
Internal Medicine
Family Practice
Cardiac Surgery
(name changed
from "Cardiac
Surgery (NS)")
American College of
Cardiology/American
Heart Association
Patient(s) 18 years of age
and older hospitalized for a
Cardiology
CABG procedure that have
Cardio-Thoracic
evidence of a CVA during
Surgery
the hospitalization or within
seven days of discharge.
Internal Medicine
Family Practice
American College of
Cardiology/American
Heart Association
Patient(s) 18 years of age
and older hospitalized for a
Cardiology
CABG procedure taking a
Cardio-Thoracic
lipid-lowering medication at
Surgery
admission or within seven
days of discharge.
Internal Medicine
Family Practice
Cardiac Surgery
(NS)
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
27
Summary Rule
Description
American College of
Cardiology/American
Heart Association
Patient(s) 18 years of age
and older hospitalized for a
Cardiology
CABG procedure taking a
Cardio-Thoracic
beta-blocker at admission or
Surgery
within seven days of
discharge.
Internal Medicine
Family Practice
Cerebral
American College of
Vascular Accident
Cardiology/American
& Transient
Heart Association
Cerebral Ischemia
Patient(s) taking warfarin
that had 3 or more
prothrombin time tests in
last 6 reported months.
Internal Medicine
Family Practice
Cerebral
Vascular Accident
National Quality
& Transient
Forum/Ingenix
Cerebral
Ischemia
Patient(s) with a recent
emergency room encounter
Neurology
for a transient cerebral
Neurosurgery Cardioischemic event that had any
Thoracic Surgery
physician visit within 14
days of the acute event.
N/A
Patient(s) with cervical
dysplasia that had a PAP
smear, hysterectomy, or
other cervical procedure
within 12 months of the
initial diagnosis.
Internal Medicine
Family Practice
Pediatrics
Cardiac Surgery
(NS)
Cervical
Dysplasia
Ingenix - Based on
guideline
recommendations
Gynecologists (2-4)
and expert opinion
Children and
Adolescents'
Access to Primary NCQA
Care
Practitioners (NS)
Children and
Adolescents'
Access to Primary NCQA
Care
Practitioners (NS)
Children’s'
Access to Primary
NCQA
Care Practitioners
(NS)
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Source
Condition
Neurology
Neurosurgery
OB / GYN
Patient(s) 7-11 years of age
that had a PCP visit during N/A
the report period.
Pediatrics
Patient(s) 12-19 years of
age that had a PCP visit
during the report period.
Family Practice
OB/GYN
Patient(s) 25 months to 6
years of age that had a PCP N/A
visit during the report period.
Internal Medicine
Family Practice
Pediatrics
Children’s’ Access
to
NCQA
Primary Care
Practitioners (NS)
Patient(s) 12 - 24 months of
age that had a PCP visit
NA
during the report period.
Internal Medicine
Family Practice
Pediatrics
Chlamydia
Screening (NS)*
Patient(s) 21 - 24 years of
age that had a chlamydia
screening test in last 12
reported months.
Internal Medicine
Family Practice
Pediatrics
National Quality
Forum/NCQA
OB/GYN
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
28
Condition
Source
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Chlamydia
Screening (NS)*
National Quality
Forum/NCQA
Patient(s) 16- 20 years of
age that had a chlamydia
screening test in last 12
reported months.
OB/GYN
Pediatrics
Family Practice
Internal Medicine
NCQA
Patient(s) with lab results
Cardiology
with a LDL cholesterol level Cardio-Thoracic
< 100 mg/dL.
Surgery
Internal Medicine
Family Practice
NCQA
Patient(s) with a LDL
cholesterol test during the
report period.
Internal Medicine
Family Practice
Ingenix - Expert
consensus from
K/DOQI guidelines
Patient(s) meeting the
threshold of CrCl <
60ml/min, Cr >= 1.5mg/dL
for women or Cr >=
Nephrology
2.0mg/dL for men that had a
serum phosphorus in last 12
reported months.
Internal Medicine
Family Practice
Ingenix - Expert
consensus from
K/DOQI guidelines
Patient(s) meeting the
threshold of CrCl <
60ml/min, Cr >= 1.5mg/dL
for women or Cr >=
Nephrology
2.0mg/dL for men that had a
serum calcium in last 12
reported months.
Internal Medicine
Family Practice
Ingenix - Expert
consensus from
K/DOQI guidelines
Patient(s) meeting the
threshold of CrCl <
30ml/min, Cr >= 2.0mg/dL
for women or Cr >=
Nephrology
2.5mg/dL for men, that had
a serum PTH test in last 12
reported months.
Internal Medicine
Family Practice
Patient(s) with problematic
COPD control that had a
Pulmonology
PFT in last 12 reported
months.
Internal Medicine
Family Practice
Cholesterol
Management for
Patients with
Cardiovascular
Conditions (NS)
Cholesterol
Management for
Patients with
Cardiovascular
Conditions (NS)
Chronic Kidney
Disease
Chronic Kidney
Disease
Chronic Kidney
Disease
Chronic
American Thoracic
Obstructive
Society
Pulmonary Disease
Cardiology
Cardio-Thoracic
Surgery
Ingenix/ NCCN Practice Patient(s) newly diagnosed
Colon Cancer - Part
Guidelines in
with colon cancer that had a Gastroenterology
II
Oncology
full colonoscopy.
Hematology/Oncology
Internal Medicine
Family Practice
Comprehensive
Ischemic
Vascular Disease
Care (NS)
N/A
NCQA (similar)
Patient(s) with lab results
Cardiology
with a LDL cholesterol level Cardio-Thoracic
< 130 mg/dL.
Surgery
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
29
Source
Summary Rule
Description
Comprehensive
Ischemic
Vascular Disease
Care (NS)
National Quality
Forum/NCQA
Cardiology
Patient(s) with a lipid profile
Cardio-Thoracic
test during the report period.
Surgery
N/A
Congestive Heart
Failure
American College of
Cardiology/American
Heart Association
Patient(s) currently taking a
beta-blocker specifically
Cardiology
recommended for CHF
management.
Internal Medicine
Family Practice
Congestive Heart
Failure
American College of
Cardiology/American
Heart Association
Patient(s) currently taking a
Cardiology
beta-blocker.
Internal Medicine
Family Practice
Congestive Heart
Failure (NS)
National Quality
Forum/AMA/PCPI
Patient(s) with CHF and
atrial fibrillation currently
taking warfarin.
Internal Medicine
Family Practice
NCQA
Patient(s) 40 years of age
and older with COPD
exacerbation that received a
Pulmonology
systemic corticosteroid
within 14 days of the
hospital or ED discharge.
Internal Medicine
Family Practice
COPD
Exacerbation,
Pharmacotherapy
Management
(NS)
NCQA
Patient(s) 40 years of age
and older with COPD
exacerbation that received a
Pulmonology
bronchodilator within 30
days of the hospital or ED
discharge.
Internal Medicine
Family Practice
Coronary Artery
Disease (NS)
National Quality
Forum/ AMA-PCPI
Patient(s) prescribed lipid- Cardiology
lowering therapy during the Cardio-Thoracic
measurement year.
Surgery
Internal Medicine
Family Practice
Coronary Artery
Disease (NS)
National Quality
Forum/ AMA-PCPI
Patient(s) with CAD and
diabetes and/or CHF
Cardiology
prescribed ACE-inhibitor or
Cardio-Thoracic
angiotensin II receptor
Surgery
antagonist therapy during
the measurement year.
Internal Medicine
Family Practice
Coronary Artery
Disease (NS)
National Quality
Forum/ AMA-PCPI
Patient(s) with a lipid profile
Cardiology
(or ALL component tests)
Cardio-Thoracic
during the measurement
Surgery
year.
Internal Medicine
Family Practice
National Quality
Forum/ AMA-PCPI
Patient(s) with a prior
myocardial infarction
prescribed beta-blocker
therapy during the
measurement year.
Cardiology
Cardio-Thoracic
Surgery
Internal Medicine
Family Practice
NCQA (similar)
Patient(s) 18-75 years of
age with lab results with
most recent LDL result
<100 mg/dL.
Endocrinology
Internal Medicine
Family Practice
COPD
Exacerbation,
Pharmacotherapy
Management
(NS)
Coronary Artery
Disease (NS)
Diabetes Care
(NS)
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Condition
Cardiology
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
30
Source
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
NCQA (similar)
Patient(s) 18-75 years of
age with lab results with
most recent HbA1c result
value less than 8.0%.
Endocrinology
Internal Medicine
Family Practice
NCQA (similar)
Patient(s) 18 - 75 years of
age with lab results that
have evidence of poor
diabetic control, defined
as the most recent HbA1c
result value greater than
9.0%.
Endocrinology
Internal Medicine
Family Practice
NCQA (similar)
Patient(s) 18-75 years of
age with lab results with
most recent LDL result
<130 mg/dL.
Endocrinology
Internal Medicine
Family Practice
Diabetes Care
(NS)
NCQA (similar)
Patient(s) 18 - 75 years of
age that had annual
Endocrinology
screening for nephropathy OB/GYN
or evidence of nephropathy.
Internal Medicine
Family Practice
Diabetes Care
(NS)
AQA/NCQA
Patient(s) 18 - 75 years of
Endocrinology
age with an LDL cholesterol
OB/GYN
in last 12 months.
Internal Medicine
Family Practice
Diabetes Care
(NS)
National Quality
Forum/NCQA
Patient(s) 18 - 75 years of
Endocrinology
age that had an HbA1c test
OB/GYN
in last 12 reported months.
Internal Medicine
Family Practice
Diabetes Care
(NS)*
NCQA (similar)
Patient(s) 18 - 75 years of
age that had an annual
screening test for diabetic
retinopathy.
Diabetes Care
NS
National Quality
Forum/NCQA
Patient(s) 5 - 17 years of
Endocrinology
age that had an HbA1c test
OB / GYN
in last 12 reported months.
Internal Medicine
Family Practice
Pediatrics
Diabetes Mellitus
National Quality
Forum/Ingenix
Adult(s) that had a serum
creatinine in last 12 reported Endocrinology
months.
Internal Medicine
Family Practice
National Quality
Forum/NCQA
Patient(s) who had a
prescription, dispensed for a
disease modifying antiRheumatology
rheumatic drug (DMARD)
during the report period.
Internal Medicine
Family Practice
Pediatrics
Condition
Diabetes Care
(NS)
Diabetes Care
(NS)
Diabetes Care
(NS)
DiseaseModifying AntiRheumatic Drug
Therapy for
Rheumatoid
Arthritis (NS)
Endocrinology
Internal Medicine
OB/GYN Ophthalmology Family Practice
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
31
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Condition
Source
Epilepsy
Patient(s) with one or more
hospitalizations or two or
Ingenix/The National
more emergency room
Collaborating Centre for
Neurology
encounters for epilepsy that
Primary Care guidelines
had neurology consultation
in last 3 reported months.
Internal Medicine
Family Practice
Epilepsy
Ingenix/The National
Patient(s) that had an
Collaborating Centre for
annual physician visit.
Primary Care guidelines
Internal Medicine
Family Practice
Hepatitis C
Ingenix/AHRQ
Patient(s) with cirrhosis that
had a liver imaging test in Gastroenterology
last 12 reported months.
Internal Medicine
Family Practice
Hepatitis C
Ingenix/AHRQ
Patient(s) 18 years and
older that had an annual
physician visit.
Gastroenterology
Internal Medicine
Family Practice
Hepatitis C
Ingenix/AHRQ
Patient(s) with indications
that had gastroenterology
consultation in last 12
reported months.
Gastroenterology
Internal Medicine
Family Practice
Hypertension*
National Quality
Forum/Ingenix
Patient(s) that had a
serum creatinine in last
12 reported months.
Cardiology
Endocrinology
Nephrology Neurology
Internal Medicine
Family Practice
Inflammatory
Bowel Disease
Patient(s) with inflammatory
Ingenix - consensus
bowel disease complications
Gastroenterology
opinion of experts was that had gastroenterology
General Surgery
the primary source
consultation in last 3
reported months.
Knee
Replacement++
Ingenix/ AAOS
Adults(s) that had a knee
MRI prior to knee
replacement surgery.
Orthopedics and
Surgery
Internal Medicine
Family Practice
Knee
Replacement
Ingenix/ AAOS
Adults(s) that had a knee xOrthopedics and
ray prior to knee
Surgery
replacement surgery.
Internal Medicine
Family Practice
Low Back Pain,
Use of Imaging
Studies (NS)++
National Quality
Forum/NCQA
Patient(s) with
uncomplicated low back
pain that did not have
imaging studies.
Orthopedics and
Surgery
Rheumatology
Internal Medicine
Family Practice
Migraine
Headache
Ingenix/American
Academy of
Neurology
Patient(s) with frequent
ER encounters or frequent
acute medication use that
had an office visit in last 6
reported months.
Neurology
OB/GYN
Internal Medicine
Family Practice
Pediatrics
Neurology
N/A
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
32
Condition
Source
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Migraine
Headache
National Quality
Forum/ Ingenix/
American Academy of
Neurology
Adult patient(s) with
frequent use of acute
medications that also
received prophylactic
medications.
Neurology
OB/GYN
Internal Medicine
Family Practice
Pediatrics
Multiple Sclerosis
Patient(s) with more than
one magnetic resonance
imaging (MRI) scan of the
Ingenix - consensus
head in last 12 reported
opinion of experts was
months (excluding patient(s) Neurology
the primary source of
with neurologic
this recommendation
manifestations or
complications suggesting a
new disease state).
Internal Medicine
Family Practice
Obesity and
Overweight
Ingenix/Clinical
Patient(s) with bariatric
research and the
surgery who had a defined
Endocrinology
consensus opinion of complication during
General Surgery
experts was the primary hospitalization or
source
30 days after discharge.
Internal Medicine
Family Practice
Obesity and
Overweight
Ingenix/Clinical
Patient(s) with bariatric
research and the
surgery who had a defined
Endocrinology
consensus opinion of complication during
General Surgery
experts was the primary hospitalization or
source
180 days after discharge.
Internal Medicine
Family Practice
Osteoporosis
Management in
National Quality
Women Who Had a Forum/NCQA
Fracture (NS)
Women 67 years of age or
older who were treated or OB/GYN Orthopedics
tested for osteoporosis
and
within six months of a
Surgery
fracture.
Otitis Externa,
Acute*
National Quality
Forum/Ingenix/
American Academy of
Otolaryngology-Head
and Neck Surgery
(AAO-HNS)
Otitis Media,
Acute*
Patient(s) on antibiotic
Ingenix/American
therapy with acute otitis
Academy of Pediatrics
media that received
and American Academy
amoxicillin, a first line
of Family Physician
antibiotic.
Persistence of
Beta-Blocker
Treatment after a
Heart Attack (NS)
National Quality
Forum/NCQA
Patient(s) 2 years of age
and older with acute otitis
externa who were NOT
prescribed systemic
antimicrobial therapy.
Internal Medicine
Family Practice
Otolaryngology (Ear,
Nose and Throat)
Internal Medicine
Family Practice
Pediatrics
Otolaryngology (Ear,
Nose and Throat)
Internal Medicine
Family Practice
Pediatrics
Patient(s) hospitalized with
an acute myocardial
Cardiology
infarction (AMI) persistently Cardio-Thoracic
taking a beta- blocker for six Surgery
months after discharge.
Internal Medicine
Family Practice
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
33
Condition
Source
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Pharyngitis,
National Quality
Appropriate Testing
Forum/NCQA
for Children (NS)*
Patient(s) treated with an
antibiotic for pharyngitis that Otolaryngology (Ear,
had a Group A
Nose and Throat)
streptococcus test.
Internal Medicine
Family Practice
Pediatrics
Pneumonia,
CommunityAcquired
Bacterial (CAP)
Ingenix/AMA/PCPI
(similar)
Adult(s) with communityacquired bacterial
pneumonia who have a
CXR.
Internal Medicine
Family Practice
NCQA
Elderly patients with
dementia who took a
tricyclic antidepressant or
N/A
anticholinergic agent after
the earliest record of
dementia (HEDIS criteria).
Internal Medicine
Family Practice
NCQA
Elderly patients who had an
accidental fall or hip fracture
who took a tricyclic
antidepressant
N/A
antipsychotic or sleep agent
after the incident (HEDIS
criteria).
Internal Medicine
Family Practice
Pregnant women that had
syphilis screening.
OB/GYN
Family Practice
Pregnant women that had
HIV testing.
OB/GYN
Family Practice
Pregnancy
Management
Ingenix/American
Pregnant women less than
College of Obstetricians 25 years of age that had
OB/GYN
and Gynecologists
chlamydia screening.
Family Practice
Pregnancy
Management*
National Quality
Forum/Ingenix/
American College of
Obstetricians and
Gynecologist/
USPSTF
Pregnant women that had
HBsAg testing.
OB/GYN
Family Practice
Pregnancy
Management*
Ingenix/American
Pregnant women that
College of Obstetricians received rubella immunity
and Gynecologists
screening.
OB/GYN
Family Practice
Pregnancy
Management*
Ingenix/American
Pregnant women that had
College of Obstetricians
hemoglobin testing.
and Gynecologists
OB/GYN
Family Practice
Potentially
Harmful DrugDisease
Interactions in the
Elderly (NS)
Potentially
Harmful DrugDisease
Interactions in the
Elderly (NS)
Pregnancy
Management*
Pregnancy
Management*
Prenatal Care
(NS)*
National Quality
Forum/Ingenix/
American College of
Obstetricians and
Gynecologist/
USPST
National Quality
Forum/ Ingenix
NCQA
Pulmonology
Women with deliveries of
live births that received a
OB/GYN
prenatal care visit in the first
trimester.
Internal Medicine
Family Practice
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
34
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Condition
Source
Summary Rule
Description
Prostate Cancer Part I
Ingenix/American
Urological
Association
Patient(s) that had a
Hematology/Oncology
prostate specific antigen test
Urology
in last 12 reported months.
Internal Medicine
Family Practice
Prostate Cancer Part I
Ingenix/American
Urological
Association
Patient(s) that had an
annual physician visit.
Hematology/Oncology
Urology
Internal Medicine
Family Practice
Prostate Cancer Part II
Patient(s) newly diagnosed
Ingenix/The consensus with prostate cancer that
opinion of
had medical oncology,
Hematology/Oncology
experts was the primary radiation oncology or
Urology
source
urology consultation in last 6
reported months.
Internal Medicine
Family Practice
Rheumatoid
Arthritis
Ingenix/American
College of
Rheumatology (NQF
Patient Safety)
Patient(s) taking
methotrexate,
sulfasalazine, gold, or
leflunomide that had a
CBC in last 3 reported
months.
Rheumatology
Internal Medicine
Family Practice
Pediatrics
Rheumatoid
Arthritis
Ingenix - EBM
Connect consultant
panel process
Patient(s) taking chronic
corticosteroids that had
rheumatology consultation
in last 6 reported months.
Rheumatology
Internal Medicine
Family Practice
Pediatrics
Rheumatoid
Arthritis
Ingenix/American
College of
Rheumatology
Patient(s) with complex
RA treatment regimens or
complications that had
rheumatology consultation
in last 6 reported months.
Rheumatology
Internal Medicine
Family Practice
Pediatrics
Rheumatoid
Arthritis
Ingenix/American
College of
Rheumatology (NQF
Patient Safety)
Patient(s) taking
methotrexate, sulfasalazine,
or leflunomide that had
Rheumatology
serum ALT or AST test in
last 3 reported months.
Internal Medicine
Family Practice
Pediatrics
Rheumatoid
Arthritis
Ingenix/American
College of
Rheumatology
Patient(s) taking
hydroxychloroquine
(Plaquenil) that had an eye Rheumatology
exam in last 12 reported
months.
Internal Medicine
Family Practice
Pediatrics
Rheumatoid
Arthritis
Ingenix/American
College of
Rheumatology (NQF
Patient Safety)
Patient(s) taking
methotrexate or
sulfasalazine that had a
serum creatinine in last 6
reported months.
Internal Medicine
Family Practice
Pediatrics
Rheumatology
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
35
Condition
Source
Summary Rule
Description
Applicable Specialist
Types
Applicable Primary
Care Specialty
Types
Sickle Cell
Anemia
Ingenix - consensus
opinion of experts
was the primary
source/American
Academy of
Pediatrics
Patient(s) that had a
reticulocyte count in last
12 reported months.
Hematology/Oncology
Internal Medicine
Family Practice
Pediatrics
Sickle Cell
Anemia
Ingenix - consensus
opinion of experts was Patient(s) that had a
the primary
hemoglobin/hematocrit in
source/American
last 12 reported months.
Academy of Pediatrics
Hematology/Oncology
Internal Medicine
Family Practice
Pediatrics
Sinusitis, Acute
Ingenix - Sinus and
Allergy Health
Partnership
Patient(s) treated with an
antibiotic for acute sinusitis
that received a first line
antibiotic.
Otolaryngology (Ear,
Nose and Throat)
Pulmonology
Allergy/Immunology
Internal Medicine
Family Practice
Pediatrics
Sinusitis, Acute
Ingenix - Sinus and
Allergy Health
Partnership
Patient(s) that had a sinus
computerized axial
tomography (CT) or
magnetic resonance
imaging (MRI) test.
Otolaryngology (Ear,
Nose and Throat)
Pulmonology
Allergy/Immunology
Internal Medicine
Family Practice
Pediatrics
Tonsillectomy
Ingenix/American
Academy of
Otolaryngology-Head
and Neck Surgery
(AAO-HNS)
Patient(s) less than 21 years
of age that had a
tonsillectomy and met
Otolaryngology
clinical criteria for this
procedure.
Internal Medicine
Family Practice
Pediatrics
Tympanostomy
Tube Placement
Ingenix/American
Academy of
Otolaryngology-Head
and Neck Surgery
(AAO-HNS)
Patient(s) less than 12 years
of age that had
tympanostomy tube
Otolaryngology
placement and met clinical
criteria for this procedure.
Internal Medicine
Family Practice
Pediatrics
National Quality
Forum/NCQA
Patient(s) with a diagnosis
of upper respiratory infection
(URI) that did not have a
Otolaryngology (Ear,
prescription for an antibiotic Nose and Throat)
on or three days after the
initiating visit.
Internal Medicine
Family Practice
Pediatrics
Upper
Respiratory
Infection (URI),
Appropriate
Treatment for
Children (NS)*
* Measures requiring one office visit in the most recent 12 months of the review period.
++ Atypical rule – measure indicates over-utilization of services. Compliance for the measure requires absence of the
service. Compliance rates are inverted for reporting and comparison purposes.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
36
Appendix 4: Appeals Process for Colorado Health Care Professionals
Procedures to Obtain Additional Information
To review additional quality and cost-efficiency information, obtain a full description of the methodology and
data that our decisions were based on or declined, the physician should submit the request by email at
PhysicianEvaluationInformationRequest@Cigna.com or by faxing the request to 866.448.5506.
A Network Clinical Manager will contact the physician to provide additional details about the process and the
results. If the request is regarding the methodology and data that the designation decisions were based on or
declined, we will provide the physician or physician group with this information within 45 days of our receipt of
the request. Where the law or our contractual obligations with a third party prevents disclosure of the data
required to be disclosed, we will provide sufficient information to allow the physician or physician group to
determine how the withheld data affected the designation. After disclosure of the description of the
methodology described above, the physician or physician group may request further information related to
the designation decisions. Such further information, if it exists and has not been previously disclosed, will be
provided by us within 30 days of the request.
The “Cigna Care Designation and Physician Quality and Cost-Efficiency Profiles Methodology” is available on
the Cigna for Health Care Professionals website at CignaforHCP.com.
Request an Appeal of the Designation Decision
To request an appeal of Cigna Care designation and quality and cost-efficiency displays in Colorado
(including the opportunity for a face-to-face meeting), have corrected data relevant to the designation
decision considered, and have the applicability of the methodology used in the designation decision
considered, or to submit additional information, the physician should contact the email or fax number noted
above. A Network Clinical Manager will contact the physician or physician group to provide additional details
about the process and the results.
The National Selection Review Committee, who review all appeal requests, is a national committee that
reviews appeal and reconsideration requests with Cigna participants in locations other than Colorado. The
committee participants are listed below:
Voting Committee Participants
• National Medical Director for Network Clinical Performance and Improvement (Chair)
• Physician representatives from the four regions, their alternates, and ad hoc physicians
Non-voting Committee Participants
• Assistant Vice President, Provider Measurement and Performance
• National Network Business Project Senior Analyst – Network Management
• Health Data Senior Specialist, Clinical Insights Provider Metrics
• Marketing Product Senior Specialist
• Network Clinical Managers
Non-voting and Ad hoc Committee Participants
• Network Product Integration Lead when a reconsideration is pertinent to their market
• Market Medical Executive when a reconsideration is pertinent to their market
Upon request, the physician will be provided with the name, title, qualifications, and relationship to Cigna of
the persons participating on the National Selection Review Committee who are responsible for making a
determination on the physician’s appeal. If requested, a face-to-face meeting will be arranged at a location
reasonably convenient to the physician; other participants can join the meeting using teleconference. The
physician has the right to be assisted by a representative. The physician should provide the name and
credentials of the representative to the Network Clinical Manager at least two weeks in advance of the
scheduled Selection Review Committee meeting. If the physician requests an explanation of the designation
decision which is the subject of the appeal to be considered as part of the appeal, it will be included.
The physician or physician group will receive a written decision regarding the physician’s appeal that states
the reasons for upholding, modifying, or rejecting the physician’s appeal. The appeal process will be
completed within 45 days from the date the data and methodology are disclosed unless otherwise agreed to
by the parties to the appeal. No change or modification of a designation that is the subject of an appeal shall
be implemented or used until the appeal is final. We will update any changes to designations previously
disclosed publicly within 30 days after the appeal is final.
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
37
Abbreviations List
Abbreviation
Organization
Abbreviation Organization
AAP
American Academy of Pediatrics
HEDIS
Healthcare Effectiveness Data
Information Set
ACC
American College of Cardiology
HOPE
Heart Outcomes Prevention
Evaluation Study
American College of Obstetrics and
Gynecology
ICSI
Institute for Clinical Systems
Improvement
The American College of PhysiciansAmerican Society of Internal Medicine
IDSA
Infectious Diseases Society of
America
ACOG
ACP-ASIM
ADA
American Diabetes Association
K/DOQI
Kidney Disease Outcomes
Quality Improvement
AHA
American Heart Association
NHLBI
National Heart Lung Blood
Institute
Agency for Healthcare Research and
Quality
NIH
National Institutes of Health
American Medical Association
NQF
National Quality Forum
AHRQ
AMA
AMA-PCPI
FDA
American Medical Association- Physician
Consortium for Performance Improvement
USPHS
United States Preventive Health
Service
Food and Drug Administration
”Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna
Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by
Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance
Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental
Health, Inc. THN-2014-046. © 2015 Cigna. Some content provided under license.
38