UnitedHealthcare Premium Designation Program

Practice and Technology

January 25, 2008


This is the first in a series of articles designed to help clinical neurologists and their staffs achieve success in today's - and tomorrow's - medical environment.

By William S. Henderson, FACMPE
Administrator, Upstate Neurology Consultants
Member, AAN.com Practice and Technology Editorial Board
Member, Practice Management and Technology Subcommittee
Member, BRAINS
Author Disclosure

After the release earlier this year of its physician premium designation program, UnitedHealthcare (UHC) has made some beneficial changes to the way physicians are educated about the program in the second data analysis of physicians in 2007. (Note that this program may not be available in your market.) The purpose of the program is to help "health care consumers make more informed choices in selecting physician and hospitals" and to "support physicians in providing higher quality and more cost efficient medical care to their patients." All of us in health care endorse efforts to help physicians provide higher quality care in a cost-efficient manner. The UHC program aims to educate physicians about best practices while not imposing financial penalties on them; at the same time UHC believes the program will eventually direct more patients to a designated physician.

UHC has done a good job in explaining what the program entails; I want to highlight some key items that each neurologist should review:

  1. The cover letter, page one, lets the neurologist know if she or he met the premium designation program criteria and if not, why not. One of the most common reasons not to be designated is insufficient data.
  2. The second page of the letter contains the crucial information necessary to review the data UHC has on file for the physician. How to log on to the UHC webpage is explained in detail in the accompanying document entitled "Where and How to view the UHC Premium Designation Assessment Report." Every physician needs to print out the report (or have your administrator or office manager do so). Make sure to make note of the new password you create when you log in to the site.
  3. The package contains a more detailed brochure that explains the UHC Premium Designation Program. The information neurologists need to review is found on page 3. At the top of page 5 you can see how physicians within a market and specialty will be ranked and order listed in the on-line directories. The most prominent listing is given to those physicians who meet quality and efficiency of care levels while the lowest level is reserved for those physicians who are "not displayed upon physician request."
  4. The package also contains a brochure entitled "Common Reconsideration Questions" which explains how a physician can have UHC reconsider the physician's current designation level.
  5. One major change in the program is how the data is used. David Stumpf, MD, National Medical Director for UHC, states "Designation status does not affect your participation in the UHC network. All UHC network physicians, regardless of designation status, remain part of our broad national network. Additionally, the designation program is not a 'pay-for-performance' or bonus program and does not impact reimbursement."

Examining the Designation Program in More Detail

The medical conditions for which neurologists can be measured are: MS, low back pain, migraine headache, hypertension, hyperlipidemia, depression, epilepsy, cerebral vascular accident and transient cerebral ischemia.

When a physician is evaluated for the premium designation, UHC uses a product called Symmetry EBM to review claims data. It is crucial to understand what this means – the decision is based on claims data and not clinical data. It is also based on Symmetry's Episode Treatment Grouper (ETG) in which the ETG applies its rules to associate all the physician, ambulatory, ancillary, inpatient and pharmaceutical claims associated with a patient and then assigned "appropriately" to a physician. To determine the efficiency of care score a neurologist's actual episode costs are compared to the risk-adjusted market average episode costs for the same spectrum of episodes. If a physician's risk-adjusted efficiency score is less than or equal to the market threshold, she will then earn a designation for efficiency of care.

In reviewing your data please note that UHC has used patient data from 2005 through February 2007 according to the cover letter. However, on the Reconsideration brochure, in the answer to question 6, it states that the actual range for neurologists' data is 2/18/06 to 2/18/07.


As an administrator of a neurology practice my concern is with the overall methodology of ranking and data sourcing for each physician. In the past I have dealt with several insurers who have used similar "rules-based" analysis products. In reviewing the data those insurers provided to us, I discovered that the data was incomplete, had assigned drugs and procedures in error to our physicians as the "responsible ordering party" and had failed to understand the risk basis of diagnoses.

In the first release of the UHC Premium Designation Program earlier in 2007, we compared the data UHC had for our physicians against the clinical data we had on our patients. Because we use an integrated EHR we could drill down by diagnosis group to determine what drugs or ancillary services had been ordered by our physicians. In a number of cases the Episode Treatment Grouper made incorrect assumptions as to which physicians were responsible for ordering what tests. Such assumptions potentially drive up the resulting cost of episodic care for certain patients. We also found that not all patients were included in the analysis even though they were UHC patients with the identified diagnoses. At a roundtable discussion earlier this year at a conference I attended, we discovered that in some markets where the UHC program had been rolled out, problems developed with practice responses. In one case a group informed UHC that the patient data was flawed. A UHC manager demanded that the physicians provide proof of their analysis. When the administrator argued that the data was clinically based and proprietary, UHC changed the ranking of the physicians in the group from "Insufficient data" to "Not displayed upon physician request" on the webpage.

The problems we have faced in analyzing reports of this type are due to the fact that while we often possess the full clinical data on our patients, the analysis done by insurers is based on claims data or data provided from other clearinghouses (such as a PBM). To give an example of the confusion this causes, consider this type of incident. We treated a patient for migraine headaches for another insurer. Medications for migraine treatment were prescribed by our physician. Two days later the patient returned to their primary care physician, and that doctor prescribed an antidepressant for the patient. In the claims analysis on this patient, our physician was "charged" as prescribing the antidepressant. While such data errors can be corrected, it places the burden of proof on the physician and requires the time of the staff to submit the documentation. Furthermore, it only ensures the correction of the data analysis for that time period; the same methodology and insurer data will be used at the next analysis, requiring additional response by the practice to the insurer.


We have not as yet completed our in-house analysis of the latest round of UHC data. We are hopeful that the accuracy and delineation of the data from the Symmetry EBM product will be better than the first time we reviewed UHC data. I strongly urge each neurologist to examine the UHC data and compare it to the clinical data you have. While this may involve you reviewing a patient's paper chart, it will be insightful in showing how insurers evaluate what medical care you provide and how they determine your costs of care. In the months ahead you can expect more insurers to provide such quality and efficiency "scorecards" for physicians. Maybe now would be a good time to consider purchasing an EHR that will help you quickly analyze your clinical data and help you keep insurers accurate in their analyses of how you practice medicine.


Mr. Henderson has nothing to disclose.

Episode Treatment Groups

ETG™ is patented by Symmetry and is a methodology for an episode building system that uses routinely collected in-patient and outpatient claims data. From this data clinically related homogeneous groups are created by diagnoses [currently about 575 groups] that are adjusted for severity by a patient's complications/co-morbidities that affect resource allocation. 

ETGs have similarities to DRGs, but they differ in this important respectETGs measure the entire episode of care for a patient, both in-patient and out-patient. Based on insurer, there can be a set period of care, which allows ongoing tests and treatments [including prescriptions] to be included in the care cost totals which occurs in that time period. The groups can be adjusted for patient severity, intensity and complexity.

The ETG groups are initially defined by primary diagnosis codes, while each CPT code, HCPCS and NDC code have been mapped to one [or more] of the groups
. It is possible, based on additional diagnoses, that an episode of care may then be 'shifted' to a neighboring ETG group. This shifting also occurs if the patient has contributing health conditions. Each ETG group has an assigned 'time frame' in which treatments done within that time are 'counted' toward that episode of care. For instance, a 5 year child diagnosed with bronchitis may have a 60 day window before the ETG is said to be clean, or finished.

Because this process gathers all medical care costs, including supporting costs such as radiology, pharmaceuticals and laboratory tests it can show the cost of care of each patient by episode
. This data gathering can then identify cost by physician. The average cost of an ETG can be compared across all providers in a specialty to demonstrate the average cost of care and to identify outliers. Since patient acuity has been factored into the ETG, the comparison is deemed to be statistically accurate.

Symmetry's methodology has been marketed by Ingenix, a company which describes the product in its promotional material as follows:

"Designed to provide a consistent and reliable measurement tool for gauging the provision and financing of health care services, ETGs can serve:

  •  as an analytical unit for measuring and comparing the utilization and financial performance of health care providers (provider profiling)
  •  as a clinically useful unit for measuring health care demand
  •  as a basis for establishing disease management strategies, especially with the inclusion of pharmaceutical claims
  •  as a basis for evaluating whether physicians are adhering to treatment guidelines and protocols"