State of Connecticut and Embold Providers of Distinction
The state of Connecticut health plan is working with Embold Health, a physician-led healthcare analytics company, to update our list of high-performing doctors in our Providers of Distinction program.
Primary Goals in Establishing Providers of Distinction Criteria:
- Clinical specifically relevant to the existing/legacy Providers of Distinction program
- Emphasize higher quality over lower cost, but still consider both.
- Balance the approach of setting a high standard for inclusion, while considering member access to providers who would qualify for the benefit.
Selection Process and Criteria
Providers do not need to apply. Embold uses data from the source of a Health Verity claim that covers over 160 million lives. The sample represents commercial and their associated managed plans such as Medicare Advantage and Medicaid managed plans. The provider review period runs from January 1-March 30 of each year. Some providers’ scores fell 10 percentage points below the criteria. These providers must meet the threshold by the next review period or they will lose their designation starting July 1, 2025. Should you have any questions or comments on the selection process, please email the Healthcare Policy and Benefits Division at CARE.COMPASS@CT.GOV.
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Effective January 1, 2024 – present.
Clinical Criteria for Quality Scoring By Service
Embold Health creates scores for Providers of Distinction. For confidence, their standard requires a provider to have at least ten observations (in the data period) to be scored in a measure, and at least four clinical quality measures plus at least one cost measure to be scored overall. Furthermore, to be considered for the clinical focus scoring used for the State of Connecticut program, they must have at least 30 observations across the relevant measures listed below. Cost and quality measures for each Provider of Distinction are combined for overall Quality and Cost scores for use in the program criteria (further described below). Scores are created by comparing measure rates to the national peer group average and rank ordered for CT.
Endoscopy and Colonoscopy
- ED visit within 7 days after colonoscopy
- Adenoma detection rate in screening colonoscopy
- ED visit within 7 days after upper endoscopy
- Admission within 7 days after upper endoscopy
- Repeat screening colonoscopy within 1 year.
- Upper and lower endoscopy on separate days
- Upper endoscopy overuse in GERD patients without alarm symptoms
- Upper endoscopy use in GERD patients with alarm symptoms
Maternity Care
- Cesarean delivery rate in low-risk delivery
- Percent of stays of 3 days or less
- Transfusion after delivery in low-risk pregnancy
- ICU admission within 30 days after delivery in low-risk pregnancy
- Infection after delivery in low-risk pregnancy
- ED visit or readmission within 30 days after delivery in low-risk pregnancy
- Overly frequent use of ultrasounds in low-risk pregnancy
- Receipt of appropriate prenatal testing
- Overly frequent use of forceps or vacuum in low-risk pregnancy.
- Overly frequent use of episiotomy in low-risk pregnancy
- Follow-up for behavioral health diagnosis
Hip Care and Hip Replacement
- PT within 4 months prior to hip replacement
- Overly frequent use of preoperative stress testing
- MRI within 4 months prior to hip replacement
- PT within 4 months prior to elective hip arthroscopy
- SNF admission after hip replacement
- Surgical revision after hip replacement
- Hip replacement within 1 year of new osteoarthritis diagnosis.
- MRI in the first year after diagnosis of hip pain
- PT in the first 4 months of new hip pain
- Opioid prescribing within 28 days in patients with new joint pain
- Complication rate after hip replacement
Knee Care and Knee Replacement
- PT within 4 months prior to knee replacement
- Overly frequent use of preoperative stress testing
- MRI within 4 months prior to knee replacement
- PT within 4 months prior to elective knee arthroscopy
- SNF admission after knee replacement
- Surgical revision after knee replacement
- Arthroscopy overuse in patients with new osteoarthritis
- Knee replacement within 1 year of new osteoarthritis diagnosis.
- MRI in the first year after diagnosis of knee pain
- PT in the first 4 months of new knee pain
- Opioid prescribing within 28 days in patients with new joint pain
- Complication rate after knee replacement
Spine Pain Management
- PT within 4 months prior to cervical spine surgery
- PT within 4 months prior to lumbar spine surgery
- Surgery within 1 year for new lumbar degenerative disc disease
- Surgery within 1 year for new cervical degenerative disc disease
- Surgery within 1 year for new lumbar pain
- Surgery within 1 year for new cervical pain
- PT in the first 4 months of new lumbar spine pain
- PT in the first 4 months of new cervical spine pain
- Opioid prescribing in patients with new lumbar spine pain
- Opioid prescribing in patients with new cervical spine pain
Lumbar Spine Surgery
- PT within 4 months prior to lumbar spine surgery
- Skilled nursing facility admission after lumbar spine surgery
- Complication rate after lumbar spinal surgery
- Hardware removal after lumbar spine surgery
- Surgery within 1 year for spondylolisthesis
- Surgery within 1 year for new lumbar degenerative disc disease
- Surgery within 1 year for new lumbar pain
- PT in the first 4 months of new lumbar spine pain
- Opioid prescribing in patients with new lumbar spine pain
Summary of the Embold criteria and the estimated number of Providers of Distinction:
- For all services, the Quality Criteria is 60th Percentile or above on the relevant quality score and 50th Percentile above on their cost score.
- For Hip care and Hip Replacement, Knee Care and Knee Replacement, and Lumbar Spine Surgery, there is an additional criterion: confirmation that the provider specifically performs Hip, Knee, or Low Back surgery, respectively. This is done via independent validation in Embold’s claims data source.
- The state of Connecticut will promote the Provider of Distinction program to its plan members through various marketing campaigns, including this member-facing Providers of Distinction webpage. Members can also use the ‘Find Provider’ tool to locate providers as needed, which displays the selected provider’s “Provider of Distinction” recognition.
If you would like more detailed information about your scoring or how to improve your scoring to become a Provider of Distinction, please review the FAQs, visit emboldhealth.com/solutions/physicians, or email care.compass@ct.gov.
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