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Using UnitedHealth Premium Designations The UnitedHealth Premium® designation program is intended as a resource for informational purposes only. Display of Designations Designations are displayed in UnitedHealthcare on-line physician directories at mamsiUnitedHealthcare.com. You should always consult mamsiUnitedHealthcare.com for the most current information. The Premium designation program may not be available in certain geographic regions. Premium Designations are a Guide Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing the physicians from whom you receive care. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. You may also wish to discuss a physician's designation with him or her, prior to selecting the physician. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. For example, these ratings, which are based on aggregated claims data, do not guarantee that you will receive a particular level of care from a physician that has achieved a quality designation or, conversely, that a physician who is not ranked will provide poor quality care. How We Evaluate the Quality and Cost Efficiency of Physicians The Premium designation program for physicians uses criteria and measures from nationally recognized organizations, such as the National Quality Forum, Ambulatory Care Quality Alliance and the National Committee for Quality Assurance, that identify evidence-based and/or consensus-based standards for treating medical conditions. Practically speaking, evidence based guidelines are those standards, based on science, which define how a patient should be treated to receive optimal care for his or her condition. Consensus-based guidelines are those standards agreed to by leading physician organizations when science-based guidelines do not exist and which define optimal patient treatment. We measure a physician's performance against these optimal treatment standards. To be evaluated, a physician must have at least five patients or surgical procedures treating UnitedHealthcare members within the period evaluated for the conditions and surgical procedures we evaluate in the program. Physicians who do not have at least five patients or procedures treating UnitedHealthcare members are displayed as having “insufficient data with UnitedHealthcare.” Designation is a two stage process. The first stage is an evaluation of
quality based on analysis of 12-36 months of collected claims and/or practice
data for UnitedHealthcare members compared to specialty specific national
quality standards. Physicians whose claims data demonstrates that they
meet or exceed quality criteria, as measured against national quality standards,
are designated by a quality star Only physicians who receive a Premium designation for quality of care are further evaluated for the cost efficiency of the care that they provide. Cost efficiency is based on factors such as the use and price of diagnostic testing, prescribed medications, procedures and follow-up care in comparison to other physicians in the same specialty in the same geographic area. In order to make an "apples to apples" comparison in the cost efficiency for doctors, we make an adjustment to account for the types of patients, severity of illness and patients' conditions that the particular doctor treats. Patients are grouped based on similar characteristics using complete "episodes of care," which includes physician care, inpatient and outpatient hospital services, laboratory testing, x-rays, drug and other available claims associated with each patient for treatment of a condition. A cost efficiency score is calculated by comparing a doctor's actual episode costs to the local market average for similar episodes treated by similar specialists. Doctors who are more efficient in comparison to the local market average will receive the UnitedHealth Premium cost efficiency designation, which is shown as a second star. As part of the development of the UnitedHealth Premium program, we solicit input and feedback from consumers, consumer advocates, employers, labor and physicians. We have established national and local physician advisory committees and we gain additional input from surveys and meetings with physicians, consumers, consumer advocates and employers. Such input and feedback is incorporated into the program on an ongoing basis. Individual and Group Evaluations Only individual physicians that meet UnitedHealth Premium designation quality criteria for that specialty, or physicians that are part of medical groups that meet UnitedHealth Premium criteria for group practices in that specialty, may receive the Premium quality of care designation. Physicians in a particular group may be evaluated on an aggregate, not an individual, basis. Therefore, a physician in a eligible group practice who has insufficient data on his or her own may qualify for designation if his or her specialty in that group met the quality or quality and cost efficiency designation criteria. (Oncologists, however, are not designated on a group practice basis.) Important Notes about the Program The information from the Premium designation program is not an endorsement of a particular physician or health care professional's suitability for your health care needs. UnitedHealthcare does not provide health care services nor practice medicine. Physicians are solely responsible for medical judgments and treatments. The designation of a physician does not guarantee the quality of health care services you will receive from a doctor and does not guarantee the outcome of any health care services you will receive. Likewise, the fact that a physician may not be designated by this program does not mean that the physician does not provide quality health care services. All physicians in the UnitedHealth Network have met certain minimum credentialing requirements. Regardless of whether a physician has received a designation, you have access to all physicians in the UnitedHealth Network, as further described under your benefit plan. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error. There is a risk of error in the claims data used in the evaluation, the calculation used in the evaluation and the way the program determined that an individual physician was responsible for the treatment of the patient’s condition. It is important that you consider many factors and information from as many sources as possible when selecting a physician. How We Determine which Physician Specialties are Included in the Premium Program The specialties that may receive designation are Allergy, Cardiology (non-interventional), Cardiothoracic Surgery, Electrophysiology, Endocrinology, Family Medicine, Infectious Disease, Internal Medicine, Interventional Cardiology, Nephrology, Neurology, Oncology, OB/GYN, Orthopedic Surgery, Pediatrics, Pulmonology, Rheumatology, Spine Surgery, Sports Medicine, and Total Joint Replacement. We evaluate specialties that have national quality standards that can be evaluated using claims data. (Note: There is one exception. Oncologists are evaluated against quality criteria only, based on survey responses, and are not evaluated based on claims.) No Designation Not all physicians in the UnitedHealth Network will have a Premium designation. There are several possible reasons. Physicians may: decline to display their designation; have insufficient claims data with UnitedHealthcare for evaluation; practice in a specialty that is not evaluated under the program; not have met criteria for designation; or practice in a market where the Premium program is not available. The Premium designation status of a physician is re-evaluated on a regular basis. Questions or Complaints?
If you have questions or a complaint about the Premium designation
program, you may call Member Services at the number found on the
back of your ID
card. Learn More about the Methods We Use to Evaluate Quality and Cost Efficiency in the Premium Program Non-Surgical Specialties The quality of care evaluation compares all UnitedHealthcare claims information for the doctor to see how often the doctor adhered to established medical care rules created for over 30 common conditions such as coronary artery disease, heart failure, diabetes, and asthma. Based on the analysis of UnitedHealthcare claims data, patients who have received treatment for one or more of these conditions are assigned to the primary doctor treating the condition. Physician data is then reviewed against the national evidence and consensus-based quality criteria for their assigned patients and compared to an established quality benchmark. Doctors whose claims data meet this quality benchmark are eligible to move to the next step– an evaluation of cost efficiency. If the physician's claims data does not meet the quality benchmark, they are not evaluated for cost efficiency. Example: We review the medical claims submitted to us from each eligible doctor and identify all of his or her patients who are diagnosed with coronary artery disease. We then review each individual doctor's treatment provided to his or her patients to determine if the doctor followed the national quality criteria set up for coronary artery disease. These rules are based on guidelines as recommended by The American College of Cardiology and the American Heart Association®. Examples of these rules include prescribing cholesterol lowering medication and prescribing beta-blocker medication after a heart attack. Information from medical specialty societies suggests that these treatments can improve the patient's overall physical functions, their quality of life, and can reduce their risk of another cardiac event. Note: Oncologists are not evaluated using claims data. Oncologists are evaluated based on the results of a survey questionnaire they complete and return to UnitedHealthcare. Cost Efficiency Cost Efficiency is based on factors such as the use and price of diagnostic testing, prescribed medications, procedures and follow-up care in comparison to other physicians in similar specialties in the same geographic area. In order to make an "apples to apples" comparison in the efficiency of care for doctors, we make an adjustment to account for the types and severity of patients' conditions that the particular doctor treats. Patients are grouped based on similar characteristics using complete "episodes of care" which includes physician care, inpatient and outpatient hospital services, laboratory testing, x-rays, drug and other claims associated with each patient for treatment of a condition. A cost efficiency score is calculated by comparing a doctor's actual episode costs to the local average for similar episodes for similar specialties. Doctors who are more efficient in comparison to the local average will receive the UnitedHealth Premium cost efficiency designation. Note: Oncologists are not evaluated for cost efficiency. Specialty and Medical Conditions Measured
Surgical Specialties Doctors specializing in the treatment of more complex diseases that involve surgical procedures (i.e., implantation of a stent for coronary artery disease, a pacemaker placement, or removal of a vertebra from the lower back) are measured for such services as the use of non-surgical treatments, use and timing of diagnostic testing, follow-up care, and recurring surgeries for the same medical condition. This information is then compared to other doctors, in the local area, in the same specialties, who perform these procedures. In the comparison, we adjust for the severity level of the patients. Doctors whose claims data meet the quality benchmarks receive the UnitedHealth Premium quality of care designation. Cost Efficiency Cost Efficiency is based on factors such as the use and price of diagnostic testing, prescribed medications, procedures and follow-up care in comparison to other physicians in similar specialties in the same geographic area. In order to make an "apples to apples" comparison, we make an adjustment to account for the types and severity of patients' conditions that the particular doctor treats Patients are grouped based on similar characteristics using complete "episodes of care" which includes doctor fees, diagnostic testing, inpatient facility costs and follow-up ancillary monitoring testing after the initial surgical procedure for a minimum of 12 months. A cost efficiency score is then calculated by comparing a doctor's actual episode costs to the local area average for similar episodes. Doctors who are at or are more efficient than the local average acceptable range will receive the UnitedHealth Premium cost efficiency designation. Surgical Specialties and Procedure/Condition of Measurement
All UnitedHealthcare contracted doctors, regardless of designation status,
remain part of the UnitedHealthcare network. The UnitedHealth Premium designation
program is not a separate network or a network within a network. |
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