Quality FAQs

Quality Frequently Asked Questions (FAQs)

What is the basis for the Quality Measures?

Quality measures are nationally recognized standards of care (e.g. Healthcare Effectiveness Data and Information Set /HEDIS) that are used in payment and public reporting programs.  Existing and evolving evidence for each measure is reviewed in a rigorous process by expert committees before it is endorsed at a national level.  The measures serve as a proxy for gauging the quality of care provided and allow providers and practices to identify improvement priorities and strategies to meet them.

What is a Gate score?

A Gate score is a tool used to monitor how well an organization, practice or PCP is performing in the Blue Cross AQC (Alternative Quality Contract) measures.  Each of the 22 AQC measures is assigned a weight based on the importance of the measure and difficulty of achieving compliance.  Each measure is also assigned a minimum and maximum threshold used to determine how many “weighted points” can be earned:

  • 0.25 measures may earn up to 1.25 weighted points
  • 0.5 measures may earn up to 2.5 weighted points
  • 1.0 measures may earn up to 5.0 weighted points
  • 3.0 measures may earn up to 15.0 weighted points

The Gate score is calculated by dividing the total earned weighted points by the total possible weighted points.  A perfect Gate score is 5.0.

What should I do with the patient lists I receive?

Throughout the year PCPs and their staff will receive patient lists from the NEPHO Quality Team:

  • Integration Report (Diabetes, Hypertension & Cancer Screening Measures)
  • Well-Child Visits due for ages 3-6 and children younger than 15 months of age
  • Adolescent Well Visits for children aged 12-21. This list will also include female patients aged 16-24 who are due for Chlamydia Screening.

Integration reports track those patients due for:

  • HbA1cs
  • Urine Micro albumin
  • Blood pressures within range and/or
  • Breast Cancer, Cervical Cancer and Colorectal Cancer Screening.

NEPHO updates these lists monthly.  When a practice manager or PCP receives their list of patients they should do the following:

  • Verify all patients have a scheduled appointment and contact the patient to arrange an office visit if they do not have one scheduled.
  • Order lab tests or screenings due and contact the patient to request that they complete the appropriate tests.
  • Consider changing medications for patients with uncontrolled diabetes or hypertension.
  • Consider referring patients to Life Style Management Institute for those patients with uncontrolled diabetes.
  • Refer patients with uncontrolled diabetes to NEPHO’s Population Health Nurse Practitioner, Alison Gustafson, NP 978-236-1709 for close monitoring.

What can I do about patients on my list who aren’t really mine?

Patients in the Quality Measures are attributed to a provider based on whom the patient has selected as their PCP with the health plan.  The only way to remove a patient from your panel is for the patient to select another primary care physician.  The best way to achieve this is to reach out to the patient to urge them select another provider.  Suggesting another PCP and offering to facilitate the switch is often helpful.  Should you need contact information for any patient, please contact the Quality Staff at the PHO.

How do I remove a patient from a measure if they don’t really meet the criteria?

The key to removing any patient from a measure for cause is documentation in the medical record.  The patient’s chart must support the appeal that the patient should be excluded from the population.  For example, to exclude a woman from the Cervical Cancer Screening Measure the chart must explicitly support the absence of the cervix through the documentation:

  • in the history of a total hysterectomy
  • in the physical exam by the mention of the absence of the cervix
  • in the actually surgical report or surgical pathology.

Documenting that a woman has had a hysterectomy without expressly indicating that the cervix was removed is not sufficient to eliminate the patient from the population of the measure.

There are only two accepted reasons by the health plans for removing a patient from the diabetes measures:  gestational diabetes and steroid induced diabetes.  If the patient has one of these conditions it should be clearly documented in the medical record.  As with most of the quality measures, the diabetes population is based on medical or pharmacy claims containing a diabetes diagnosis.  If this is a case of a coding error, the way to correct it is to make sure that the accurate diagnosis, whether it is insulin resistance or Dysmetabolic X Syndrome must be documented in the medical record.  PHO staff will be able to use that documentation to request that the patient be excluded based on a coding error.

Should you have questions about exclusions for any of the quality measures, please contact the Quality Staff at the PHO.


What does AQC stand for?

AQC stands for Alternative Quality Contract.  One of the provisions of our contract with Blue Cross of Massachusetts is that our providers will take part in an incentive program aimed at improving the quality, efficiency and affordability of care patients receive at our facilities and physician practices.

How do I get a copy of my patient lists and scorecard?

To receive a copy of any of your patient lists or your score card please contact any of the NEPHO Quality Team members.