Tiered NetworkPCP Quality Measurement Methodology

Blue Cross Blue Shield of Massachusetts (BCBSMA*) Tiering Overview Primary care physicians (PCPs) were tiered at the practice group level. Tiering placements were based on a combination of quality and cost measures. Each group was initially placed in the Standard Benefit tier and moved to the Enhanced Benefit or Basic Benefit tier based on cost and quality performance. Quality measures include a set of indicators reflecting nationally accepted and validated measures in two broad categories: Clinical Process and Patient Care Experience. Performance on cost was based on health status adjusted total medical expense per member per month (PMPM). Final tiering designation was based on a combination of cost and quality performance. This document explains the methodology for the quality measures. Quality Indicators Used for Tiering Quality measurement for each group was based on performance on a combination of Clinical Process and Patient Experience measures (described in our February 2008 mailing). All clinical process and patient experience measures used for this purpose derive from nationally accepted and extensively validated indicator sets (HEDIS and MHQP/CAHPS, respectively). The group was evaluated on a maximum of twenty-three (23) quality indicators (15 HEDIS and eight Patient Experience scores). For each quality indicator, BCBSMA identified the sample size required to obtain stable and reliable information about group-level performance. Groups were only evaluated on the set of measures for which they have sufficient sample to provide stable and reliable information about performance. Other measures were considered too noisy to be used for assessment of the groups performance. Sufficient Data to Evaluate Quality for Tiering Groups were only evaluated for overall quality for tiering if they had a sufficient number of eligible measures. All groups with sufficient sample on four or more HEDIS measures were considered eligible for evaluation of overall quality for the purposes of tiering. Groups with sufficient sample for only three HEDIS measures were only considered to have enough information if two of these measures were screening/well-care indicators and the third was related to either chronic or acute care management. Groups were considered to have insufficient data for purposes of evaluating quality for tiering if they had fewer than three HEDIS measures with sufficient sample for reliable measurement. Only groups with sufficient information on which to evaluate overall quality had the potential to achieve placement in the Enhanced Benefit tier. Performance Benchmark for Quality Measurement For each quality indicator, the BCBSMA benchmark for tiering was set at the median score (50th Percentile) among our provider groups, and a buffer was created around the benchmark so that groups scoring very close to the benchmark, but still below it, were treated as having met the benchmark. The buffer methodology ensures that the risk of incorrectly classifying a group as below the benchmark is less than five percent. Among groups with sufficient data to be evaluated on quality, those meeting the benchmark for at least 40 percent of their measures were designated as having passed the Overall Quality Threshold for tiering, and had the potential to be placed in the Enhanced Benefit tier. Those that did not meet the benchmark for at least 40 percent of their measures did not pass the Overall Quality Threshold for tiering, and were placed in the Basic Benefit tier. We did not allow groups to be considered below the Overall Quality Threshold based solely on the result of one or two measures. Thus, groups that could be evaluated on only three or four HEDIS measures were classified as below the Overall Quality Threshold if they did not meet the benchmark for any of their measures.

Quality Measures for Provider Groups

Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening Older Age Group Chlamydia Screening Young Age Group Cholesterol Management after Cardiac Event Colorectal Screening Diabetes Eye Exam Diabetes HbA1c Screening Diabetes LDLc Screening Diabetes Nephropathy Appropriate Testing of Children with Pharyngitis Appropriate Treatment of Children with Upper Respiratory Infection Well Care Adolescent Well Child 15 months Well Child 3-6 Years Communication Quality Knowledge of Patients Integration of Care Access

Clinical Process

Patient Experience (Adult and Pediatric)

*BCBSMA comprises Blue Cross Blue Shield of Massachusetts, Inc., and Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.
PEP-3076E (4/08)