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 through 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.

A Gate score is a tool used to monitor how well an organization, practice or PCP is performing in the Blue Cross AQC measures. 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 the affordability of care patients receive at our facilities and physician practices.

Each of the 11 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
  • 5.0 measures may earn up to 25.0 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.

Other commercial insurance providers such as Tufts and Harvard Pilgrim use nationally recognized benchmarks to monitor quality performance.  For example, the 90th percentile for controlling blood pressure is 74.2% compliance and the 90th percentile for A1c control is 79.2%.

How can I track my performance across the various health plans?

The Quality Team will send reports that show each provider’s compliance rate as well as the number of patients needed to meet the desired percentile for each measure. Providers may request an updated performance report at any time.

How will I know which patients need to be contacted?

The Quality Team will outreach to the office managers and quality contacts at each practice via email letting them know which patients are due for appointments and tests. In addition, Quality Staff will alert practice staff to any patients who have results that are of range so those patients can be scheduled for follow-up appointments.

The Quality Team will also contact providers directly through EMR messages alerting them to patients who have results that are out of range. We will also put alerts in the appointment notes or pop-ups depending on the EMR, to let staff know if patients are due for tests or if they have abnormal results.

Currently the Quality Team is assisting with pre-visit planning for diabetic patients to help provide more complete care for these patients. In a pre-populated note Quality Staff will alert providers to any measures, (including cancer screenings) that are due and whether or not each patient is up to date with foot exams, eye exams as well as compliance with certain medications.

The Quality Team may send lists, such as patients in need of HPV vaccinations, to office staff at certain times during the year.

What can I do about patients 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 to 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 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:

  • documented history of a total hysterectomy
  • in the physical exam by the mention of the absence of the cervix
  • an actual 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.

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