Quality Focus

Outcomes Measures (A1c <9, DM BP Control <139/89 & HTN Control <139/89)

One of the NEPHO Quality Team 2022 goals is to reach the minimum threshold in the 3 “outcomes” measures by year end, i.e. those measures which are results based as opposed to claims based.  There are 3 outcomes measures:

  • Diabetes A1c Control
  • Diabetes BP Control
  • Hypertension Controlling Blood Pressure (<139/89)

Harvard Pilgrim and Tufts Health Plan measure performance against the HEDIS 90th percentile (Healthcare Effectiveness Data and Information Set). The HEDIS 90th percentile rates quality performance in relation to other organizations on a national level.  Performing at or above the 90th% puts organizations in the top 10% nationally.  The HEDIS performance thresholds can vary annually based on national performance rates.

Blue Cross HMO & PPO measure performance based on thresholds set by Blue Cross.  Blue Cross also applies “weights” to quality measures with the outcomes measures weighted 5x more than the process measures (cancer screenings, chlamydia screening, DM eye exam, etc.). 

Payer A1c Thresholds DM BP Control Thresholds HTN Control Thresholds Weight
HPHC HEDIS 90th % N/A HEDIS 90th% N/A
THP HEDIS 90th % HEDIS 90th % HEDIS 90th% N/A
BC HMO 79.6/91.3 81.8/93.9 80.7/94.6 5
BC PPO 79.6/91.3 81.8/93.9 80.7/94.6 5

The most recent NEPHO performance for these measures, provided by BILHPN, is based on claims paid through 5/31/22 and clinical data through 5/31/22.

Outcomes Measures BC HMO BC PPO BCBS Max Threshold THP HPHC HEDIS
90th %
A1c Control 62.7% 55.1% 91.3% 53.7% 57.7% 79.2%
DM BP Control 59.40% 46.2% 93.9% 56.1% 77.9%
HTN Control 56.20% 51.9% 94.6% 46.1% 57.5% 74.2%

The number of patients needed to reach the maximum threshold/HEDIS 90th% for each insurance plan is found in the table below:

Outcomes Measures BC HMO
# to Max
BC PPO
# to Max
BCBS Max Threshold THP
# to Max
HPHC
# to Max
HEDIS
90th %
A1c Control 78 58 91.3% 21 42 79.2%
DM BP Control 94 76 93.9% 18 77.9%
HTN Control 286 272 94.6% 51 73 74.2%

What will the NEPHO Quality Team do to help meet our Quality goals?  Here are select examples:

  • Our DM Composite Outreach Team Has been meeting weekly for months to identify and work with patients with gaps in care. The Team has held 2 clinics for diabetes patients, the first providing an opportunity for patients to have a retinal scan, BP check & point of care A1c testing and the second clinic offering an opportunity for a BP check & point of care A1c.
  • Our Population Health Specialist manages the Concierge Mammogram Scheduling Program, scheduling patients who are due for mammograms, following with reminder calls and following up cancelations or no shows.
  • Our data analysts will work closely with your office manager and quality contacts to identify patients who need an appointment and/or labs by distributing regular Needs Appointment lists.
  • Our Unhealthy BP Outreach Team will meet weekly to identify patients with gaps in care for the Hypertension Control Measure. The clinical members of the Team will work directly with your patients to support them in managing their hypertension, encouraging adherence to medications and making healthier lifestyle choices, as well as encouraging them to attend follow up appointments with PCP and specialists.
  • Our Population Health team will continue to identify quality care gaps for providers by entering pre-visit planning notes for diabetes patients with scheduled visits, as well as applying appointment notes in Epic and registration notes in Centricity.

What can you and your practice do to help optimize the NEPHO Quality performance in 2022?  Below are some suggestions:

  • Schedule an appointment for anyone who has not yet had a blood pressure reading in 2022. Patients with digital home blood pressure monitors may report their BP reading during a virtual visit with a provider.
  • Order an HBA1c for any patient who does not yet have a result in 2022.
  • Review diabetes related medications and attempt to establish a routine of regular follow up appointments for those patients with results above the targets for A1c and BP control.
  • Take a 2nd blood pressure if the 1st is 140/90 or greater.
  • Encourage your patient to obtain a home blood pressure monitor. Blood pressures taken at home tend to be more reflective of a patient’s true BP
  • Record home blood pressure readings in the medical record. Patient reported blood pressures may be submitted to the payers during settlement as long as the medical record reflects the date and actual systolic/diastolic reading, as well as the use of a digital BP monitor.

Please contact anyone on the Quality Team with questions about the Diabetes outcomes or other Quality measures.