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Rewarding Provider Performance: Aligning Incentives in Medicare (Pathways to Quality Health Care Series) (2007)
Board on Health Care Services (HCS)

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Rewarding Provider Performance: Aligning Incentives in Medicare

D
MedPAC Data Runs

As requested in its congressional mandate, the committee consulted with the Medicare Payment Advisory Committee (MedPAC) in its examination of pay for performance. Specifically, MedPAC was requested by the committee to perform some limited data runs on payments associated with the treatment of three clinical conditions: coronary artery disease, chronic heart failure, and diabetes. The following tables represent data submitted to the committee by MedPAC and include breakdowns of payments by condition, as well as aggregations for those beneficiaries who were treated for more than one of the three conditions. Additionally, the data include the number of unique physician identification numbers (UPINs) submitting claims per beneficiary, as well as the types of claims (evaluation and management, major surgery, other surgery, testing, and imaging).

These data were generated from the Medicare 5 percent Standard Analytic Files for 2003 (inpatient, outpatient, and physician/supplier). Beneficiaries living in the U.S. territories are not counted in this analysis, but beneficiaries under the age of 65 and those with claims from managed care and hospice care, decedents, and new entrants are included.

These data helped inform the committee as to the nature of the care being delivered to Medicare beneficiaries and the payments associated with this care. The committee used the data to derive conclusions regarding the attribution of care and the magnitude of potential reward levels.

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180

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Rewarding Provider Performance: Aligning Incentives in Medicare D MedPAC Data Runs As requested in its congressional mandate, the committee consulted with the Medicare Payment Advisory Committee (MedPAC) in its examination of pay for performance. Specifically, MedPAC was requested by the committee to perform some limited data runs on payments associated with the treatment of three clinical conditions: coronary artery disease, chronic heart failure, and diabetes. The following tables represent data submitted to the committee by MedPAC and include breakdowns of payments by condition, as well as aggregations for those beneficiaries who were treated for more than one of the three conditions. Additionally, the data include the number of unique physician identification numbers (UPINs) submitting claims per beneficiary, as well as the types of claims (evaluation and management, major surgery, other surgery, testing, and imaging). These data were generated from the Medicare 5 percent Standard Analytic Files for 2003 (inpatient, outpatient, and physician/supplier). Beneficiaries living in the U.S. territories are not counted in this analysis, but beneficiaries under the age of 65 and those with claims from managed care and hospice care, decedents, and new entrants are included. These data helped inform the committee as to the nature of the care being delivered to Medicare beneficiaries and the payments associated with this care. The committee used the data to derive conclusions regarding the attribution of care and the magnitude of potential reward levels.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-1 Number of Beneficiaries and Payments for Beneficiaries in Groups A–G   (a) (b) (c) (d) (e) Group Number of Beneficiaries Total Payments (Inpatient, Outpatient, and Carrier) Total Physician Payments Total Physician Fee Schedule Payments Total Physician Fee Schedule Payments with Condition A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 33,156 $930,459,017.78 $190,763,248.74 $145,289,007.75 $63,478,717.18 B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 45,669 $973,068,755.23 $204,803,139.36 $156,203,604.11 $51,811,091.99 C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 20,084 $343,667,332.55 $77,771,058.17 $57,876,926.78 $17,685,633.11 D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 52,831 $650,379,010.79 $180,745,583.66 $135,706,435.84 $49,925,585.96 E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 44,624 $571,843,797.98 $133,677,894.22 $98,210,007.62 $15,564,360.34 F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 139,998 $1,278,200,988.51 $388,080,620.15 $290,563,134.95 $73,437,377.10 G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 183,021 $1,010,989,783.78 $358,203,918.84 $254,121,712.13 $58,724,822.67 X—No Condition Category Assigned 1,108,039 $3,659,514,615.32 $1,484,938,239.88 $1,038,689,792.23   Total in Groups 519,383 $5,758,608,686.62 $1,534,045,463.14 $1,137,970,829.18 $330,627,588.35 Total in File 1,627,422 $9,418,123,301.94 $3,018,983,703.02 $2,176,660,621.41 $330,627,588.35 NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. (a) All beneficiaries with at least one claim line with a valid provider number. (b) Payments from the inpatient, outpatient, and carrier file. (c) Carrier file in total, regardless of provider type and fee schedule designation. (d) Carrier file, only payments associated with the fee schedule. (e) Carrier file, payments associated with the fee schedule for the condition associated with the disease group.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-2 Number of Physician Providers per Beneficiary in Groups A–G   (a) (b) (c) Group Sum Number of Physician UPINs per Beneficiary Mean Number of Physician UPINs per Beneficiary Median Number of Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 433,829 13.3919 12 B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 500,679 11.2215 10 C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 181,513 9.2689 8 D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 417,751 8.0997 7 E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 337,732 7.7802 6 F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 953,450 6.9683 6 G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 884,283 4.9764 4 X—No Condition Category Assigned 4,118,603 3.9818 3 Total in Groups 3,681,210 7.2764 6 Total in File 7,730,303 5.0191 4 NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. (a)–(g) Carrier file; physician providers; regardless of condition. (h) Carrier file; physician providers; condition related claims only.

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Rewarding Provider Performance: Aligning Incentives in Medicare (d) (e) (f) (g) (h) Maximum Number of Physician UPINs per Beneficiary Standard Deviation Number of Physician UPINs per Beneficiary Total Number of Beneficiaries Total Number of UPINs Total Number of UPINs Related to Condition 44 8 33,156 174,016 100,639 38 7 45,669 190,398 85,129 36 7 20,084 116,830 54,526 29 5 52,831 187,777 93,058 30 6 44,624 171,838 55,812 24 4 139,998 262,774 89,953 21 4 183,021 285,479 135,033 16 3 1,108,039 389,895   30 5 519,383 363,096 212,855 23 4 1,627,422 406,984  

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-3 Proportion of Beneficiaries with 1–10+ Physicians Billing for Care   (a) (b) (c) (d) (e) Group Total Beneficiaries w/ Physician Providers 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,395 0.96% 14.14% 23.36% 61.54% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 44,618 2.01% 20.13% 26.33% 51.53% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,583 4.22% 29.95% 27.39% 38.44% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 51,576 2.99% 33.94% 31.84% 31.23% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 43,409 6.87% 35.76% 27.42% 29.95% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 136,826 4.70% 40.07% 31.75% 23.48% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 177,694 11.25% 55.46% 22.35% 10.94% X—No Condition Category Assigned 1,034,357 19.90% 56.42% 17.73% 5.94% Total in Groups 505,912 6.52% 40.69% 26.91% 25.88% Total in File 1,540,183 15.51% 51.26% 20.75% 12.49% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on Health Care Financing Administration specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-4 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider   (a) (b) (c) (d) (e) (f) Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider 20–34% of Payments to Provider 0–19% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,395 7.93% 16.70% 27.14% 37.67% 10.55% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 44,618 11.28% 18.86% 28.39% 33.97% 7.51% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,583 17.11% 21.43% 26.98% 28.52% 5.96% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 51,576 15.93% 24.47% 30.28% 25.98% 3.33% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 43,409 21.61% 22.61% 26.14% 25.14% 4.51% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 136,826 20.59% 25.83% 29.18% 21.96% 2.42% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 177,694 31.20% 27.71% 24.75% 14.68% 1.66% X—No Condition Category Assigned 1,034,357 38.66% 25.71% 20.48% 10.61% 4.54% Total in Groups 505,912 22.17% 24.72% 27.23% 22.43% 3.44% Total in File 1,540,183 33.26% 25.41% 22.73% 14.50% 4.10% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on Health Care Financing Administration specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-5 Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider for the Condition   (a) (b) (c) (d) (e) (f) Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider 20–34% of Payments to Provider 0–19% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,225 22.11% 27.09% 28.26% 20.06% 2.48% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 43,652 38.42% 28.40% 21.24% 10.79% 1.15% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,173 43.67% 27.13% 18.69% 9.46% 1.05% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 50,844 41.55% 32.17% 19.33% 6.40% 0.54% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 38,728 67.81% 18.59% 8.56% 3.49% 1.55% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 128,289 68.20% 21.93% 6.78% 1.51% 1.57% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 169,507 68.97% 21.18% 6.84% 1.61% 1.40% Total in Groups 482,071 59.03% 23.67% 11.47% 4.48% 1.35% Total in File 473,080 59.85% 23.72% 11.14% 4.00% 1.29% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only; condition related. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “”Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-6 Proportion of Beneficiaries Associated with a Percent of Physician Provider Claims Allocated to One Provider   (a) (b) (c) (d) (e) (f) Group Total Beneficiaries w/ Physician Providers 70–100% of Claims to Provider 50–69% of Claims to Provider 35–49% of Claims to Provider 20–34% of Claims to Provider 0–19% of Claims to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,395 6.24% 16.31% 23.24% 37.84% 16.37% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 44,618 8.90% 18.53% 23.51% 35.89% 13.17% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,583 16.05% 22.89% 22.64% 29.42% 8.99% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 51,576 11.88% 23.14% 26.31% 32.03% 6.64% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 43,409 19.75% 24.23% 21.37% 27.15% 7.49% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 136,826 14.47% 24.46% 25.30% 30.56% 5.21% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 177,694 28.96% 30.22% 20.48% 18.09% 2.25% X—No Condition Category Assigned 1,034,357 33.27% 30.74% 17.47% 17.08% 1.44% Total in Groups 505,912 18.80% 25.24% 23.00% 26.97% 5.99% Total in File 1,540,183 28.52% 28.95% 19.32% 20.36% 2.85% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-7 Proportion of Beneficiaries Associated with a Percent of Physician Provider Claims Allocated to One Provider for the Condition   (a) (b) (c) (d) (e) (f) Group Total Beneficiaries w/ Physician Providers 70–100% of Claims to Provider 50–69% of Claims to Provider 35–49% of Claims to Provider 20–34% of Claims to Provider 0–19% of Claims to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,225 18.30% 27.43% 22.56% 26.33% 5.38% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 43,652 29.84% 29.84% 16.79% 20.61% 2.93% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,173 41.46% 29.30% 13.73% 13.86% 1.65% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 50,844 34.28% 34.82% 16.74% 13.13% 1.04% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 38,728 59.70% 24.09% 5.29% 10.08% 0.84% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 128,289 54.73% 30.54% 6.50% 7.77% 0.46%

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Rewarding Provider Performance: Aligning Incentives in Medicare G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 169,507 68.24% 23.79% 4.23% 3.61% 0.13% Total in Groups 482,071 52.63% 27.87% 8.97% 9.60% 0.93% Total in File 473,080 53.44% 28.06% 8.77% 9.02% 0.72% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only; condition related. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-8 Payments by Type of Service for Beneficiaries Within Groups   (a) (b) Group Evaluation & Management— Payment ($) Evaluation & Management— Percent A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 86,471,514 45% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 91,924,988 45% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 36,190,515 47% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 64,463,785 36% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 60,720,321 45% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 130,330,105 34% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 132,909,072 37% X—No Condition Category Assigned 500,560,122 34% Total in Groups 603,010,300 39% Total in File 1,103,570,422 37%

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-14 Evaluation and Management Claims for Beneficiaries with Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care Group Total Beneficiaries w/ Physician Providers 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary Less than 5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 27,991 0.67% 16.62% 17.29% 28.52% 54.19% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 35,523 1.07% 21.28% 22.35% 32.60% 45.05% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 13,119 1.49% 26.88% 28.37% 32.35% 39.28% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,155 1.19% 28.29% 29.48% 37.00% 33.52% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 25,536 1.89% 31.18% 33.07% 34.49% 32.44% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 56,770 1.47% 32.77% 34.23% 38.89% 26.88% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 39,281 2.18% 35.73% 37.91% 36.24% 25.86% X—No Condition Category Assigned 144,518 2.79% 41.30% 44.09% 35.50% 20.41% Total in File 368,810 1.97% 33.46% 35.44% 35.23% 29.34% Total in Groups 224,284 1.45% 28.42% 29.86% 35.05% 35.09% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-15 Evaluation and Management Claims for Beneficiaries with Hospitalization—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider More than 35% of Payments to Providers 20–34% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 27,991 5.40% 14.18% 24.97% 44.55% 40.33% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 35,523 6.67% 15.92% 27.32% 49.91% 38.52% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 13,119 9.72% 18.55% 27.01% 55.27% 35.16% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,155 6.37% 16.03% 28.65% 51.05% 39.29% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 25,536 10.44% 19.67% 28.01% 58.12% 34.21% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 56,770 7.26% 17.41% 29.75% 54.42% 37.99% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 39,281 10.08% 19.82% 29.83% 59.73% 33.59% X—No Condition Category Assigned 144,518 11.59% 21.19% 29.72% 62.50% 32.09% Total in File 368,810 9.31% 18.86% 28.86% 57.03% 35.20% Total in Groups 224,284 7.83% 17.37% 28.31% 53.51% 37.16% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-16 Evaluation and Management Claims for Beneficiaries without Hospitalization—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care Group Total Beneficiaries w/ Physician Providers Total Benes not Hospitalized/ total Benes (from Table 1) 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary Less than 5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 4,751 14.50% 5.87% 57.90% 63.78% 28.44% 7.79% B—Chronic Heart Failure Coronary Artery Disease; not Diabetes 9,303 20.74% 9.35% 63.49% 72.84% 22.81% 4.35% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 6,661 33.67% 13.38% 64.90% 78.28% 18.14% 3.59% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,081 49.93% 7.07% 64.94% 72.01% 24.52% 3.47% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 18,093 41.49% 18.84% 64.15% 82.99% 15.06% 1.95% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 80,628 58.55% 10.47% 67.23% 77.70% 20.23% 2.07% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 140,725 78.16% 17.53% 69.11% 86.64% 12.65% 0.71% X—No Condition Category Assigned 872,733 85.84% 27.57% 62.91% 90.48% 9.52%   Total in File 1,161,313 75.91% 24.20% 63.90% 88.09% 11.28% 0.63% Total in Groups 286,237 56.02% 14.12% 67.42% 81.54% 16.74% 1.73% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-17 Evaluation and Management Claims for Beneficiaries without Hospitalization—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider More than 35% of Payments to Providers 20–34% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 4,751 19.24% 24.92% 30.46% 74.62% 23.05% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 9,303 24.90% 28.20% 27.40% 80.49% 18.03% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 6,661 33.00% 27.86% 23.71% 84.57% 14.07% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,081 20.10% 26.74% 30.42% 77.26% 21.26% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 18,093 37.54% 27.38% 21.61% 86.53% 11.82% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 80,628 24.27% 27.33% 28.00% 79.60% 18.51% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 140,725 35.23% 29.84% 22.43% 87.50% 10.82% X—No Condition Category Assigned 872,733 38.20% 25.59% 18.29% 82.08% 8.82% Total in File 1,161,313 36.17% 26.27% 19.94% 82.38% 10.35% Total in Groups 286,237 30.26% 28.51% 25.00% 83.77% 14.54% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-18 Evaluation and Management Claims Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care Group Total Beneficiaries w/ Physician Providers 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary Less than 5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,545 3.28% 42.82% 46.09% 37.11% 16.80% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 44,347 5.17% 50.55% 55.72% 32.79% 11.49% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,586 8.06% 57.62% 65.68% 26.81% 7.52% D—Diabetes &Coronary Artery Disease; not Chronic Heart Failure 52,038 5.35% 57.14% 62.49% 29.90% 7.61% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 43,012 12.20% 60.68% 72.88% 22.45% 4.67% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 137,266 7.91% 61.31% 69.22% 25.81% 4.97% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 179,095 15.06% 66.60% 81.66% 16.42% 1.92% X—No Condition Category Assigned 1,013,335 24.79% 62.48% 87.26% 11.98% 0.76% Total in File 1,524,716 19.81% 61.65% 81.46% 15.96% 2.59% Total in Groups 507,067 10.02% 60.53% 70.55% 24.04% 5.41% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-19 Evaluation and Management Claims Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider More than 35% of Payments to Providers 20–34% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 32,545 10.99% 20.11% 29.55% 60.66% 33.62% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 44,347 15.12% 22.59% 29.02% 66.73% 29.08% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 19,586 21.96% 25.77% 27.15% 74.88% 22.15% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 52,038 15.63% 24.15% 30.50% 70.28% 26.81% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 43,012 27.08% 26.25% 25.43% 78.76% 18.88% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 137,266 19.42% 25.12% 29.08% 73.62% 23.74% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 179,095 31.21% 28.88% 24.18% 84.27% 13.86% X—No Condition Category Assigned 1,013,335 35.47% 25.56% 19.80% 80.83% 10.99% Total in File 1,524,716 31.25% 25.63% 22.24% 79.12% 14.52% Total in Groups 507,067 23.06% 25.97% 27.18% 76.20% 21.17% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-20 Evaluation and Management Claims for Beneficiaries with Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care Group Total Beneficiaries w/ Physician Providers 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary Less than 5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 27,755 2.83% 40.02% 42.85% 38.61% 18.54% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 35,157 4.00% 46.63% 50.64% 35.42% 13.94% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 12,942 5.25% 52.95% 58.20% 31.41% 10.39% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,000 3.58% 48.44% 52.02% 35.57% 12.42% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 24,932 7.25% 57.42% 64.68% 28.10% 7.22% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 56,449 4.15% 52.38% 56.53% 34.12% 9.35% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 38,834 5.60% 55.50% 61.10% 30.61% 8.29% X—No Condition Category Assigned 142,327 6.84% 58.52% 65.35% 27.98% 6.66% Total in File 364,383 5.45% 53.70% 59.15% 31.41% 9.44% Total in Groups 221,524 4.57% 50.73% 55.30% 33.69% 11.00% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-21 Evaluation and Management Claims for Beneficiaries with Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider More than 35% of Payments to Providers 20–34% of Payments to Provider A—Diabetes, Chronic Heart Failure & Coronary Artery Disease 27,755 9.56% 19.23% 29.35% 58.14% 35.53% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 35,157 12.39% 20.96% 29.33% 62.68% 32.16% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 12,942 16.01% 24.57% 28.78% 69.36% 26.60% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,000 10.99% 21.25% 30.43% 62.67% 32.64% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 24,932 19.16% 25.26% 28.26% 72.68% 24.30% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 56,449 12.26% 21.84% 30.69% 64.79% 31.44% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 38,834 15.76% 24.65% 30.46% 70.87% 25.85% X—No Condition Category Assigned 142,327 17.65% 24.95% 29.15% 71.75% 25.21% Total in File 364,383 15.06% 23.36% 29.59% 68.01% 28.23% Total in Groups 221,524 13.43% 22.39% 29.91% 65.73% 30.12% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-22 Evaluationand Management Claims for Beneficiaries without Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries with 1–10+ Physicians Billing for Care Group Total Beneficiaries w/ Physician Providers 1 Physician UPIN per Beneficiary 2–5 Physician UPINs per Beneficiary Less than 5 Physician UPINs per Beneficiary 6–9 Physician UPINs per Beneficiary 10+ Physician UPINs per Beneficiary A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 4,757 5.91% 59.41% 65.31% 28.61% 6.08% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 9,299 9.51% 64.77% 74.28% 22.45% 3.27% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 6,653 13.53% 66.62% 80.15% 17.81% 2.04% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,002 7.13% 65.92% 73.06% 24.27% 2.68% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 18,016 19.10% 65.39% 84.49% 14.70% 0.81% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 80,798 10.54% 67.57% 78.11% 20.00% 1.88% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 140,048 17.71% 69.78% 87.49% 12.51%   X—No Condition Category Assigned 872,829 27.66% 62.99% 90.65% 9.35%   Total in File 1,155,308 24.42% 64.43% 88.85% 11.16%   Total in Groups 285,293 14.26% 68.19% 82.44% 16.57% 0.99% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-23 Evaluation and Management Claims for Beneficiaries without Hospitalization Excluding Place of Service 21—Proportion of Beneficiaries Associated with a Percent of Physician Provider Payments Allocated to One Provider Group Total Beneficiaries w/ Physician Providers 70–100% of Payments to Provider 50–69% of Payments to Provider 35–49% of Payments to Provider More than 35% of Payments to Providers 20–34% of Payments to Provider A—Diabetes, Chronic Heart Failure, & Coronary Artery Disease 4,757 19.45% 25.37% 30.84% 75.66% 22.33% B—Chronic Heart Failure & Coronary Artery Disease; not Diabetes 9,299 25.24% 28.50% 27.56% 81.30% 17.44% C—Chronic Heart Failure & Diabetes; not Coronary Artery Disease 6,653 33.50% 28.05% 23.73% 85.29% 13.48% D—Diabetes & Coronary Artery Disease; not Chronic Heart Failure 26,002 20.28% 27.06% 30.57% 77.91% 20.80% E—Chronic Heart Failure; not Diabetes & Coronary Artery Disease 18,016 38.15% 27.70% 21.52% 87.37% 11.17% F—Coronary Artery Disease; not Diabetes & Chronic Heart Failure 80,798 24.43% 27.42% 27.95% 79.79% 18.33% G—Diabetes; not Chronic Heart Failure & Coronary Artery Disease 140,048 35.54% 30.10% 22.41% 88.05% 10.36% X—No Condition Category Assigned 872,829 38.31% 25.61% 18.25% 82.17% 8.72% Total in File 1,155,308 36.49% 26.44% 19.93% 82.86% 9.91% Total in Groups 285,293 30.55% 28.76% 25.03% 84.34% 14.08% NOTES: Claim lines with invalid provider numbers have been removed from the physician file for all tables. Carrier file data only. Outliers above 99 percent have been removed. Outlier threshold is calculated for each group and in total, therefore, the “Total in File” and “Total in Groups” will not equate to the sum of the groups. Only physician providers are included in this analysis. Physician provider designation is based on HCFA specialty code. The beneficiary is counted once in the highest provider category.

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Rewarding Provider Performance: Aligning Incentives in Medicare TABLE D-24 Evaluation and Management Claims—Percent of Beneficiaries Seeing Five or Fewer Physicians   E&M Claims E&M Claims with Hospitalization E&M Claims without Hospitalization E&M Claims: Outpatient Care Only E&M Claims: Outpatient Care with Hospitalization E&M Claims: Outpatient Care without Hospitalization Total in File 75.42% 35.44% 88.09% 81.46% 59.15% 88.85% Total in Groups 58.79% 29.86% 81.54% 70.55% 55.30% 82.44% TABLE D-25 Evaluation and Management Claims—Percent of Payments Made to 35 Percent or More Providers   E&M Claims E&M Claims with Hospitalization E&M Claims without Hospitalization E&M Claims: Outpatient Care Only E&M Claims: Outpatient Care with Hospitalization E&M Claims: Outpatient Care without Hospitalization Total in File 76.33% 57.03% 82.38% 79.12% 68.01% 82.86% Total in Groups 70.48% 53.51% 83.77% 76.20% 65.73% 84.34% NOTE: Percent of beneficiaries not hospitalized for total in file = 76%; total in groups = 56% (see Table D-16).

Representative terms from entire chapter:

uncorrected proofs