Anthem / MVP Health Care / Harvard Pilgrim / CIGNA / Medicare
Metrics
Experience of Care
Open Panel / Panel open to new members
Availability / Hours outside of 8:30 – 6 Mon- Fri available for routine appointments
Personal Care and Attention / Members perception on the extent they feel the doctor/office staff listens to their questions/concerns – would they recommend to family or friends
Telephone Access / Member perception of how easy to speak to someone who could help them when the office is open
Access after hours / Members’ perception of the length of time it took for someone to return their call after hours
Reliance on ER for non-emergent care / Number of ER visits a PCP’s panel members had for conditions that would generally be treated in the office. Reported as ER visit rate/000 members.
Physician Recognition Programs
Bridges to Excellence / Bridges to Excellence Diabetes Care Link
Bridges to Excellence / Bridges to Excellence Cardiac Care Link
NCQA / NCQA Diabetes Physician Recognition Program / Transparency reporting
NCQA / NCQA Heart/Stroke Physician Recognition Program / Physician and Hospital Quality Program; Physician recognition program
Profile Quality Report / Uses HEDIS and QARR-based measures of member satisfaction, access to care and quality of care.
Resource Management Reports / Compares primary care physician utilization to that of peers within same specialty. Measures exam key areas such as specialist visits, radiology referral, non-emergent ER visits.
Resource Consumption
Resource Consumption Index / Comprehensive risk adjusted measure of utilization of medical services
Diabetes
Patients on Statin / Patient(s) with DM and CAD that are currently taking a statin.
Patients on Beta-Blocker / Patient(s) with DM and a myocardial infarction in the past who are currently taking a beta-blocker.
Patients taking ACE-inhibitor / Patient(s) taking an ACE-inhibitor or angiotensin II receptor antagonist that had a serum potassium (K+) in last 12 reported months.
Diabetic nephropathy / % of diabetics who were screened for nephropathy or evidence of nephropathy / A nephropathy screening test or evidence of nephropathy in the reporting year. / Patient(s) that had an annual screening test for diabetic nephropathy.
Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear / Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
Diabetic retinopathy / Diabetics age 18-75 who had an exam in the current or prior measurement year / % of diabetics who received a retina exam by eye care professional / An eye screening for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following:
- A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year
- A negative retinal exam (no evidence of retinopathy)by an eye care professional in the year prior to the measurement year.
Diabetic retinopathy: Communication with the Physician Managing On-going Diabetes Care / Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients / Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months
HbA1c Tests / Diabetics age 18-75 who rec’d 2 HbA1c tests, 3 months apart, during measurement year / Patient(s) that had HbA1c testing in last 12 reported months.
LDL-C Tests / Diabetics, age 18 – 75, who received 1 LDL-C test during measurement year / An LDL-C test performed during the measurement year / Patient(s) with a LDL cholesterol in last 24 months.
HbA1c Level, good control / Diabetics, 18-75, who had A1c level below 7 during measurement year / % of diabetics with A1c lass than 7.0 / Use automated laboratory data to identify the most recent HbA1c test during the measurement year. Themember is numerator compliant if the most recent automated HbA1c level is >9.0% or is missing a result or if an HbA1c test was not done during the measurement year. The member is not numerator compliant if the automated result for the most recent HbA1c test during the measurement year is < or equal to 9.0%. / Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0%
HbA1c Level, Poor Control / Diabetics, 18-75, who had A1c level above 9 during measurement year / Patient(s) with evidence of poor diabetic control, defined as the most recent HbA1c result value greater than 9.0%.
LDL-C Level / Diabetics, 18-75, with LDL-C level below 100 during the measurement year / % of diabetics with LDL-c less than 100 / Use automated laboratory data to identify the most recent LDL-C test during the measurement year. The member is numerator compliant if the most recent automated LDL-C level is <100 mg/dL. If the automatedresult for the most recent LDL-C test during the measurement year is >_100 mg/dL, or is missing, or if an LDL-C test was not done during the measurement year, the member is not numerator compliant. / Patient(s) with most recent LDL result < 100mg/dL. / Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dl)
LDL-C level / Diabetics, 18-75, with LDL-C level below 130 during the measurement year
Flu Shot / % of diabetics 50-64 who received an influenza vaccination
BMI Documented / % of diabetics where BMI was documented
Blood Pressure / % of diabetics whose blood pressure was is less than 140/90 / Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/80 mmHg)
Asthma
Appropriate Medication Use / Asthmatics, 2-56, who had at least one dispensed prescription for inhaled corticosteroids,nedocromil, cromolyn sodium, leukotriene modifiers,or methylxanthines in the measurement year. / % of asthmatics who filled an RX for more than one SABA in a 4 month period, and were also on a long-term controller medication. / The percentage of members 5–56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. / Patient(s) with presumed persistent asthma using an inhaled corticosteroid or acceptable alternative. / Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment
Assessment / Percentage of patients aged 5 through 40 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms
Cardiac (Heart Failure, CAD, AMI)
LDL-C Test / Members with CVC, 18-17, who received one LDL-C test in measurement year / Patient(s) with an LDL cholesterol test in last 12 reported months.
LDL-C Levels / Members with CVC, 18-75, who had an LDL-C level below 100 during measurement year / Patient(s) with most recent LDL result < 100mg/dL.
AMI / The percentage of members 18–75 years of age who were discharged alive for acute myocardial infarction
(AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to measurement year, who had an LDL-C screening during the measurement year. / Patient(s) hospitalized with an acute myocardial infarction (MI) taking a beta-blocker at admission or within seven days of discharge.
AMI - Aspirin at Arrival / Percentage of patients, regardless of age, with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay
Atrial Fib / High risk patient(s) currently taking warfarin (coumadin).
Atrial Fib / Patient(s) taking digoxin that had serum creatinine test in last 12 reported months.
Atrial Fib / Patient(s) taking digoxin that had serum potassium test in last 12 reported months.
Blood Pressure / Members with CVC, 18-75, with a blood pressure below 140/90 during measurement year.
Heart Failure / Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD who were prescribed ACE inhibitor or ARB therapy
CAD ACE-inhibitor / Patient(s) currently taking an ACE-inhibitor.
CAD ACE-inhibitor / Patient(s) taking ACE-inhibitor that had serum potassium test in last 12 reported months.
CAD ACE-inhibitor / Patient(s) taking ACE-inhibitor that had serum creatinine test in last 12 reported months.
CAD ACE-inhibitor / Patient(s) with CAD and diabetes and/or CHF prescribed ACE-inhibitor or angiotensin II receptor antagonist therapy during the measurement year.
CAD Antiplatelet / Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy
CAD – Beta Blocker / Patient(s) with a prior myocardial infarction prescribed beta-blocker therapy during the measurement year. / Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery / Percentage of patients aged 18 years and older undergoing isolated CABG surgery using an IMA graft
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery / Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received a beta-blocker within 24 hours prior to surgical incision
Coronary Heart Failure / Patient(s) taking ACE-inhibitor, angiotensin II receptor blocker, selective aldosterone receptor antagonist, or digoxin that had serum potassium test in last 12 reported months.
Coronary Heart Failure / Patient(s) taking ACE-inhibitor, angiotensin II receptor blocker, selective aldosterone receptor antagonist, or digoxin that had serum creatinine test in last 12 reported months.
Coronary Heart Failure / Patient(s) prescribed ACE-inhibitor or angiotensin II receptor antagonist therapy during the measurement year.
Coronary Heart Failure / Patient(s) prescribed beta-blocker therapy during the measurement year.
Coronary Heart Failure / Patient(s) with CHF and atrial fibrillation currently taking warfarin.
Lipid Lowering Therapy / Patient(s) prescribed lipid-lowering therapy during the measurement year.
Lipid Tests / Patient(s) with a lipid test during the measurement year.
Hyperlipidemia / Patient(s) taking a statin-containing medication, nicotinic acid or fibric acid derivative that had an annual serum ALT or AST test.
Hyperlipidemia / Patient(s) with CHD, DM or other CHD equivalent with the most recent LDL result <100mg/dL.
Optics
Primary Open Angle Glaucoma (POAG) / Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during one or more office visits within 12 months
Age-Related Macular Degeneration / Percentage of patients aged 50 years and older with a diagnosis of AMD who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months
Child and Adolescent Well Care Visits
Well Child Visits / Age 3 – 5, who received a well care visit during the measurement year
Adolescent Well Care / Age 11 – 18 who received a well care visit during measurement year
Children with Pharyngitis test / Age 2-18 who were diagnosed with pharyngitis or tonsillitis, prescribed an antibiotic, and received a group A
Streptococcus test for an episode in the measurement year. / * For CIGNA this pertains to all patients in the panel, NOT JUST CHILDREN.
Patient(s) treated with an antibiotic for pharyngitis that had a Group A streptococcus test. / Percentage of children aged 2 through 18 years with a diagnosis of pharyngitis, who were prescribed an antibiotic and who received a group A streptococcus (strep) test for the episode
Childhood Immunizations / 4 DTPs, 3 Polios,
1 MMR, 3 Hep Bs, 3 Hibs, 1 VZV— Members who
turned 2 during the measurement year and received all immunizations listed above on or before their
2nd birthday.
Adolescent Immunizations / Members who turned 13 during
the measurement year and received all immunizationslisted above on or before their 13th birthday.
Alcohol/Drug Screening / % of 14-18 year old where there is medical record documentation that an assessment, counseling or education about the risks of substance abuse was performed
Depression Screening / % of 14-18 year olds where there is medical record documentation that an assessment for depression was performed
Smoking Screening / % of 14-18 year olds where there is a medical record that an assessment, counseling or education was performed regarding risk of tobacco use
Sexuality Screening / % of 14-18 year olds where there is a medical record that counseling or education on risk behaviors associated with sexual activity and preventive actions was performed.
Exercise / % of 14-18 year olds where there is a medical record that an assessment for exercise was performed
Nutrition / % of 14-18 year olds where there is a medical record that an assessment for nutrition was performed
BMI / % of 14-18 year olds where there is a medical record that a BMI measure was done
Lead testing / % of patients who turned 2 during the reporting period and who received a capillary or venous blood test for lead poisoning by the end of the 25th month of life
Varicella / % of patients who turned 2 during the reporting period and received at least one VZV vaccine on or between their first and second birthdays
MMR / % of patients who turned 2 during the reporting period and receive at least MMR on or between the first and second birthdays.
Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use / Percentage of children aged 3 months through 18 years with a diagnosis of URI who were not prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service
Depression
Depression Screening / Members with CVC and/
or diabetes, age 18 to 75, who were screened for depression and/or depression follow up visit during the measurement year. / % of patients over 18 where there is a medical record that an assessment for depression was performed. / Percentage of patients aged 18 years and older diagnosed with new episode of MDD and documented as treated with antidepressant medication during the entire 84-day (12-week) acute treatment phase
Depression Med Mgmt – 12 weeks / Patient(s) with a new episode of depression that remained on an antidepressant medication during the 12 week acute treatment phase.
Depression Med Mgmt – 6 months / The percentage of Members 18 years of age and older as of April 30 of the measurement year who were diagnosed with a new episode of major depression and treated with anti-depressant medication and who remained on an antidepressant drug for at least 180 days (6 months). / Patient(s) with a new episode of depression that remained on an antidepressant medication during the 6 months acute treatment phase.
Major Depressive Disorder (MDD): Diagnostic Evaluation / Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was identified during the measurement period
Major Depressive Disorder (MDD): Suicide Risk Assessment / Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period
Technology Measures
EMR/EHR / Implemented and in use prior
to January 1, 2010, that is used to manage patient documentation for at least some of your patients on a regular basis. / Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted and be using a certified/qualified EHR
E-RX / Implemented and in use prior to January 1, 2010. The practice must beusing this tool to generate prescriptions in place of handwritten prescriptions. It is not required that the product electronically submits prescriptions directlyto the pharmacy.
Electronic Disease/Patient Registry / Implemented and in use prior to January 1, 2010. The system mustbe able to produce lists of patients with chronic diseases/conditions, such as diabetes, and must be able to produce patient lists that can be used for