quality reports : Clinical Quality : Technical Appendix


Quality Insights: Clinical Quality in Primary Care

Technical Appendix

The clinical performance measures contained in this report are drawn from a group of measures known as the HEDIS® Measure Set, which have been thoroughly tested and generally accepted as accurate indicators of high quality healthcare. The HEDIS® Measure Set has been developed by the National Committee for Quality Assurance (NCQA), a private, non-profit, accrediting organization. NCQA requires that these measures must be independently audited by an NCQA-accredited auditing agency according to standard auditing specifications. All of the health plans that submitted the HEDIS® 2009 measures contained in this report had successfully completed the NCQA-mandated audits for each measurement year.

Reporting Methods

This report provides information on the 2008 performance of Massachusetts Medical Groups on the selected HEDIS® Measure Set.

To be in this report, medical groups must have at least 3 doctors and 2 measures with enough patients to report on. Medical groups may be composed of several doctors' offices where each doctor practices alone or with just 1 other doctor. However, the clinical quality information on doctors who are not associated with any medical group is only included in statewide scores.

The physicians included in this report are those who were listed as a primary care physician (PCP) by at least one of the five participating health plans (see the list of health plans below). These physicians include internists, family practitioners, and pediatricians, but also specialists who serve as a PCP for some patients.

While we receive HEDIS measure data from each health plan at the level of the individual PCPs, we do not report measure results for individual PCPs. This is because even if we combine the data from all five plans, the total resulting numbers are insufficient to produce a reliable estimate of the performance of individual PCPs for the vast majority of measures reported here. This is due to the small number of an individual PCP's patients that are eligible to be included in each measure.

Population

All measures have been calculated for commercially insured enrollees in Health Maintenance Organization (HMO) and Point of Service (POS) products in the five participating MHQP-member health plans:

  • Blue Cross Blue Shield of Massachusetts
  • Fallon Community Health Plan
  • Harvard Pilgrim Health Care
  • Health New England
  • Tufts Health Plan

Over 50 percent of Massachusetts' commercially insured residents were enrolled in the HMO and POS products of these five health plans during the period covered by this report.

HEDIS® 2009 measures report on the health plan population that was enrolled as of December 31st of 2008, and that met the enrollment, demographic, and clinical specifications required for each measure.

Period

The measurement periods vary somewhat by measure, but in general, HEDIS® 2009 measures report on performance during calendar year 2008.

Performance Measures

Each performance measure is calculated based on a "numerator" that represents the number of people who actually received a recommended healthcare service divided by a "denominator" that represents the number of people who should have received that healthcare service.

A brief description and a high-level definition of the denominator population and numerator events for each measure are provided in this report.

Additional detail on these measures can be found through the National Quality Measures Clearinghouse maintained by the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services.

Specific measures in this report are:

  • Adult Diagnostic and Preventive Care:
    • Colorectal Cancer Screening Tests (Ages 50 to 80)
    • High Blood Pressure Control *
    • Using Image Testing for Lower Back Pain Only When Appropriate
    • Spirometry Test for COPD (Chronic Obstructive Pulmonary Disease)

  • Depression:
    • Short-term Medication
    • Long-term Medication

  • Medication Management:
    • Correct Use of Antibiotics for Acute Bronchitis **
    • Yearly Follow-up to Monitor Patients on Long-Term ACE Inhibitors or ARBs
    • Yearly Follow-up to Monitor Patients on Long-Term Anticonvulsant Medication
    • Yearly Follow-up to Monitor Patients on Long-Term Diuretics
    • Yearly Follow-up to Monitor Patients on Long-Term Medication

  • Asthma Care:
    • Medications for Children (Ages 5 to 17)
    • Medications for Adults (Ages 18 to 56)

  • Heart Disease and Cholesterol Management:
    • Cholesterol Screening Test for Cardiovascular Disease
    • Cholesterol (LDL-C) Good Control *

  • Diabetes Care for Adults:
    • HbA1c Test
    • HbA1c -- Poor Blood Sugar Control (Lower score is better) *
    • Blood Pressure Control *
    • Cholesterol (LDL-C) Screening Test
    • Cholesterol (LDL-C) Good Control *
    • Tests to Monitor Kidney Disease

  • Pediatric Care:
    • Well Visits for Children 0 to 15 Months of Age
    • Well Visits for Children Ages 3 to 6
    • Well Visits for Adolescents Ages 12 to 21
    • Correct Antibiotic Use for Upper Respiratory Infections
    • Follow-up with Children Starting Medication for ADHD

  • Women's Health:
    • Breast Cancer Screening (Ages 40 to 69)
    • Cervical Cancer Screening (Ages 21 to 64)
    • Chlamydia Screening (Ages 16 to 20)
    • Chlamydia Screening (Ages 21 to 24)

* For these measures, only statewide rates are reported as they are based on sample chart reviews performed by the health plans. There are not enough cases to validly report these measures for individual medical groups.

** MHQP will not be reporting results for this measure this year due to concerns about how it is calculated. However, important information about the appropriate use of antibiotics is included in this report.

Data Sources and Measurement Methods

The five participating health plans provided the HEDIS® data used to compile the measures in this report. The health plans aggregated their data at the individual physician level prior to submission to MHQP. All measurements were attributed to the enrollee's primary care physician (PCP) as of December 31st of the performance year. If a numerator event was delivered by another healthcare provider, that event was credited to the enrollee's PCP.

The participating health plans have reported the HEDIS measures included in this report using a combination of claims/billing information provided to the health plan by clinicians, laboratories, and pharmacies that provide services to the health plan's members; and enrollment information provided to the health plan by employers and members. We refer to these information sources collectively as "Administrative Data."

In some health plans and for some measures, administrative data are known to produce results that underestimate true performance. To address this, MHQP has worked with the health plans and the MHQP Physicians Council to define an adjustment methodology that helps to account for differences in the rates obtained using administrative data to measure performance and the rates that are obtained when medical records are reviewed. We applied this adjustment methodology to all measures known to have discrepancies between these two data sources, in order to increase the measured rates and better approximate true performance.

Each health plan also provided MHQP with a file containing a directory of all physicians in their network who were eligible to serve as a PCP as of December 31st of the performance year. We linked these files across health plans to create a Massachusetts Provider Database of PCPs, which we then used to link the individual PCP-level HEDIS® data supplied by the health plans.

MHQP developed a detailed multi-step process for assigning each physician to the appropriate physician group and network in its Massachusetts Provider Database, in order to report measure results accurately. In the first years of reporting, we used information provided by the five health plans on groupings of physicians in each of their contracts as of December 31st of the performance year. We then created groups using an MHQP algorithm. Physician networks and medical groups with 3 or more physicians were asked to review the list of physicians that MHQP attributed to their group and make changes if needed. A majority of groups reviewed and modified their list over the past several years. The final group assignments for the current report were based on the most recent information from the groups on where physicians were practicing in the year ending December 31, 2008. For those few groups that did not review their physician lists, the group assignment based on the MHQP algorithm continues to be used.

Statistical Comparisons

Ninety-five percent confidence intervals were calculated for each measured rate. Three benchmarks were used:

  1. The national average performance rate for the measure by all health plans reporting the measure to NCQA
  2. The national 90th percentile performance rate for the measure by all health plans reporting the measure to NCQA
  3. The Massachusetts statewide rate for all physicians for whom the participating health plans reported the measure to MHQP

Scoring Performance

For each measure where a medical group has a sufficient number of eligible patients (at least 30) the group received one star. For each measure where a group's performance was better than one or more benchmarks, the group was awarded additional stars. If a medical group performed better than the State and National benchmarks, that medical group received four stars.

 

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