Selected quality measures include: Specialty Measure Descriptin Allergy / Immunlgy Asthma Drug Mgt Vaccine Pneumnia Vaccine High Perfrmance Netwrk Quality Criteria fr Designatin AvMed has selected certain Natinal Quality Frum apprved measures t determine HPN designatin. Thrugh the cmbined effrts f Medical Management and Quality Imprvement departments, AvMed determined that certain apprved quality measures were relevant fr particular HPN selected specialties. Fr the upcming year's HPN designatin, AvMed has selected t use quality measure data received frm the prir calendar year thrugh the first quarter f the current year. This ensures that an apprpriate number f care pprtunities is assigned t the prvider grups being measured. Prvider grups are assigned care pprtunities if they encunter an AvMed member that falls int the ppulatin fr a particular quality measure (i.e. denminatr ppulatin). Prvider grups are marked as achieving care pprtunities fr that ppulatin if they fulfill the care pprtunity particular t that measure (i.e. numeratr ppulatin). Asthma Drug Mgt {QM} is the number f patients with persistent asthma, aged 5 t 56 years, wh were prescribed an inhaled crticsterid r an acceptable alternative primary therapy asthma medicatin, expressed as a percentage f the ttal number f patients, aged 5 t 56 years, with persistent asthma. It excludes patients with a diagnsis f emphysema r chrnic bstructive pulmnary disease (COPD) any time prir t r during the measurement perid, based n claims included in the database. Vaccine {QM} is the number f members, aged 50 years and lder, wh received an influenza vaccinatin, expressed as a percentage f the ttal number f members aged 50 years and lder. Pneumnia Vaccine {QM} is the number f members, aged 65 years and lder, wh received a pneumnia vaccinatin, expressed as a percentage f the ttal number f members aged 65 years and lder. Cardilgy Annual Mnitring f Digxin CAD ACE Inhib r ARB CAD Antiplatelet Tx Annual Mnitring f Digxin {QM} indicates whether a patient, aged 18 years and lder, wh received at least 180 days f digxin medicatin therapy during the measurement year, had at least ne therapeutic mnitring event (lab tests) during that same perid. This excludes patients wh had an inpatient stay during the measurement year. This measure is based n the HEDIS measure Annual Mnitring fr Patients n Persistent Medicatins (MPM). CAD ACE Inhib r ARB {QM} is the number f patients with crnary artery disease tgether with diabetes and/r left ventricular systlic dysfunctin (LVSD), aged 18 years and lder, wh were prescribed ACE inhibitr r ARB therapy, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with crnary artery disease tgether with diabetes and/r left ventricular systlic dysfunctin (LVSD). CAD Antiplatelet Tx {QM} is the number f patients with crnary artery disease, aged 18 years and lder, wh were prescribed antiplatelet therapy, expressed as a percentage f the ttal number f patients, age 18 years and lder, with crnary artery disease. HPN Quality Criteria V01012016 Page 1 f 6
Cardilgy (cntinued) Endcrinlgy CAD Beta Blk 6 M Pst MI CAD Event LDL LT 100 CAD LDL Lwering Drug HF ACE Inhib r ARB HF Atrial Fib Warfarin HF Beta Blcker Tx HF LVF Assessment Vaccine Pneumnia Vaccine CAD LDL Lwering Drug Therapy Diabetes Eye Exam CAD Beta Blk 6MPstMI{QM}isthenumberf patients hspitalized and discharged alive with a diagnsis f acute mycardial infarctin (MI), aged 18 years and lder, wh received treatment with beta-blcker drugs fr six mnths fllwing discharge, expressed as a percentage f the ttal number f patients, aged 18 years and lder, hspitalized and discharged alive with a diagnsis f acute mycardial infarctin (MI). CAD LDL LT 100 {QM} is the number f patients with a cardivascular event r diagnsis f ischemic vascular disease, aged 18 t 75 years, wh had at least ne nn-zer lw density lipprtein chlesterl (LDL-C) lab result recrd in the database during the measurement year and the mst recent result value was less than 100 mg/dl, expressed as a percentage f the ttal number f patients, aged 18 t 75 years, with a cardivascular event r diagnsis f ischemic vascular disease and at least ne nn-zer LDL-C lab result recrd in the database during the measurement year. CAD LDL Lwering Drug {QM} is the number f patients with crnary artery disease, aged 18 years and lder, wh were prescribed a lipid-lwering drug, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with crnary artery disease. It excludes patients with an allergy r intlerance t lipid-lwering drugs, as well thse with a dcumented reasn (e.g., medical, patient chice, system) fr nt having lipid-lwering therapy prescribed. HF ACE Inhib r ARB {QM} is the number f patients with heart failure tgether with left ventricular systlic dysfunctin (LVSD), aged 18 years and lder, wh were prescribed ACE inhibitr r ARB therapy, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with heart failure alng with left ventricular systlic dysfunctin (LVSD). HF AtrialFib Warfarin {QM} is the number f patients with heart failure tgether with parxysmal r chrnic atrial fibrillatin, aged 18 years and lder, wh were prescribed warfarin therapy, expressed as a percentage f the ttal number f patients, age 18 years and lder, with heart failure alng with parxysmal r chrnic atrial fibrillatin. HF Beta Blcker Tx {QM}isthenumberf patients with heart failure tgether with left ventricular systlic dysfunctin (LVSD), aged 18 years and lder, wh were prescribed beta blcker therapy, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with heart failure alng with left ventricular systlic dysfunctin (LVSD). HF LVF Assessment {QM} is the number f patients with heart failure, aged 18 years and lder, wh had a left ventricular functin (LVF) assessment dne, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with heart failure. Vaccine {QM} is the number f members, aged 50 years and lder, wh received an influenza vaccinatin, expressed as a percentage f the ttal number f members aged 50 years and lder. Pneumnia Vaccine {QM} is the number members, a ed 65 years and lder, wh received a pneumnia vaccinatin, expressed as a percentage f the ttal number f members aged 65 years and lder. CAD LDL Lwering Drug Therapy {QM} indicates whether a patient with crnary artery disease (CAD), aged 18 years and lder, was prescribed a lipid-lwering drug. This excludes patients with an allergy r intlerance t lipid-lwering drugs, as well as thse with a dcumented reasn (e.g., medical, patient chice, system) fr nt having lipid-lwering therapy prescribed. This measure is based n AMA PCPI's measure Chrnic Stable Crnary Artery Disease Perfrmance Measure Set, Lipid Cntrl. Diabetes Eye Exam {QM} is the number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had an eye exam dne, expressed as a percentage f the ttal number f patients, aged 18 t 75 years, with type 1 r type 2 diabetes. HPN Quality Criteria V01012016 Page 2 f 6
Diabetes HbA1c LT 8% Diabetes HbA1c LT 8% {QM} is the number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer HbA1c lab result recrd in the database during the measurement year and the mst recent result value was less than 8%, expressed as a percentage f the ttal number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer HbA1c lab result recrd in the database during the measurement year. Endcrinlgy (cntinued) OB/GYN Diabetes HbA1c LT 9% Diabetes HbA1c Test Diabetes LDL LT 100 Diabetes Micralbumin Vaccine Pneumnia Vaccine Breast Cancer Screen Vaccine Osteprsis Pst Fx Mgt Diabetes HbA1c LT 9% {QM} is the number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer HbA1c lab result recrd in the database during the measurement year and the mst recent result value was less than r equal t 9%, expressed as a percentage f the ttal number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer HbA1c lab result recrd in the database during the measurement year. Diabetes HbA1c Test {QM} indicates whether a patient with type 1 r type 2 diabetes, aged 18 t 75 years, had a hemglbin A1c test perfrmed. This excludes patients with a previus diagnsis f plycystic varies, gestatinal diabetes, r sterid-induced diabetes. This measure is based n the HEDIS measure Cmprehensive Adult Diabetes (CDC). Diabetes LDL LT 100 {QM} is the number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer lw density lipprtein chlesterl (LDL-C) lab result recrd in the database during the measurement year and the mst recent result value was less than 100 mg/dl, expressed as a percentage f the ttal number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had at least ne nn-zer LDL-C lab result recrd in the database during the measurement year. Diabetes Micralbumin {QM} is the number f patients with type 1 r type 2 diabetes, aged 18 t 75 years, wh had a micralbumin test dne r had evidence f treatment fr nephrpathy, expressed as a percentage f the ttal number f patients, aged 18 t 75 years, with type 1 r type 2 diabetes. Vaccine {QM} is the number f members, aged 50 years and lder, wh received an influenza vaccinatin, expressed as a percentage f the ttal number f members aged 50 years and lder. Pneumnia Vaccine {QM} is the number f members, aged 65 years and lder, wh received a pneumnia vaccinatin, expressed as a percentage f the ttal number f members aged 65 years and lder. Breast Cancer Screen {QM} is the number f wmen members, aged 42 t 69 years, wh had a mammgram dne during the measurement year r the year prir t the measurement year, expressed as a percentage f the ttal number f wmen members, aged 42 t 69 years at the end f the measurement perid. Vaccine {QM} is the number f members, aged 50 years and lder, wh received an influenza vaccinatin, expressed as a percentage f the ttal number f members aged 50 years and lder. Osteprsis Pst Fx Mgt {QM} is the number f wmen wh suffered a fracture, aged 67 years and lder, and received either a bne mineral density test (BMD) r a prescriptin fr a drug t treat r prevent steprsis within 6 mnths f the fracture, expressed as a percentage f the ttal number f wmen, aged 67 years and lder, wh suffered a fracture. HPN Quality Criteria V01012016 Page 3 f 6
OB/GYN (cntinued) Pneumnia Vaccine Pneumnia Vaccine {QM} is the number f members, aged 65 years and lder, wh received a pneumnia vaccinatin, expressed as a percentage f the ttal number f members aged 65 years and lder. Pulmnlgy Rheumatlgy Asthma Drug Mgt COPD Inhal Brnchdilate COPD Spirmetry Eval Vaccine Pneumnia Vaccine Rheum Arthritis DMARD Asthma Drug Mgt {QM} is the number f patients with persistent asthma, aged 5 t 56 years, wh were prescribed an inhaled crticsterid r an acceptable alternative primary therapy asthma medicatin, expressed as a percentage f the ttal number f patients, aged 5 t 56 years, with persistent asthma. It excludes patients with a diagnsis f emphysema r chrnic bstructive pulmnary disease (COPD) anytime prir t r during the measurement perid, based n claims included in the database. COPD Inhal Brnchdilat {QM} is the number f patients with chrnic bstructive pulmnary disease (COPD), aged 18 years and lder, wh were prescribed an inhaled brnchdilatr, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with chrnic bstructive pulmnary disease (COPD). COPD Spirmetry Eval {QM} is the number f patients with chrnic bstructive pulmnary disease (COPD), aged 18 years and lder, wh had a spirmetry evaluatin dne, expressed as a percentage f the ttal number f patients, aged 18 years and lder, with chrnic bstructive pulmnary disease (COPD). Vaccine {QM} is the number f members, aged 50 years and lder, wh received an influenza vaccinatin, expressed as a percentage f the ttal number f members aged 50 years and lder. Pneumnia Vaccine {QM} is the number f members, aged 65 years and lder, wh received a pneumnia vaccinatin, expressed as a percentage f the ttal number f members aged 65 years and lder. Rheum Arthritis DMARD {QM} is the number f patients with rheumatid arthritis, aged 18 years and lder, wh had at least ne ambulatry prescriptin dispensed fr a disease-mdifying antirheumatic drug (DMARD), expressed as a percentage f the ttal number f patients, aged 18 years and lder, with rheumatid arthritis. HPN Quality Criteria V01012016 Page 4 f 6
Criteria fr Vlume Requirements, Scring Criteria, and Prvider Grup Definitins Calculating HPN Perfrmance fr selected quality measures A prvider grup s perfrmance n quality is based n the number f achieved care pprtunities they received cmpared t the number achieved by the verall peer grup. The peer grup is defined as like specialists fr all cmbined prducts. Example Quality Measure Calculatin: Per Specialty - Cmbined Prducts Quality Measure # 1 Quality Measure # 2 Quality Measure # 3 Ttal Ttal Ttal Peer Grup 100 40 40.0% 530 250 47.2% 1000 600 60.0% Results Ttal Quality Measure # 1 Quality Measure # 2 Quality Measure # 3 QM Cmbined Ttal Ttal Prvider Grup # 1 23 10 9 75 23 35 323 125 194 158 238 Prvider Grup # 2 15 7 6 60 31 28 221 135 133 173 167 Prvider Grup # 1 s achieved care pprtunities were belw the peer grup average s they did nt met the HPN criteria Prvider Grup # 2 s achieved care pprtunities were abve the peer grup average s they met the HPN criteria pprtunities met ( ) is calculated as the peer grup rate fr that particular quality measure multiplied against the ttal care pprtunities fr that particular prvider grup. Fr Quality Measure #1 being applied t Prvider Grup #1 abve, this wuld be calculated as 40% * 23 = 9 The final QM scre sums the ttal expected care pprtunities met and cmpares against the actual care pprtunities met fr that particular prvider grup fr the relevant quality measures. A prvider grup must have at least 20 ttal care pprtunities t be cnsideredfr measurement. HPN Quality Criteria V01012016 Page 5 f 6
Quality was measured fr sl practitiners, single specialty grup practices, and multi-specialty grup practices. In general, t meet the HPN quality criteria, a prvider grup must have: Ttal Opprtunities = 20 r greater Have a care pprtunities met equal t r greater than the expected care pprtunities met Sl Practitiners Defined as ne physician, wh will meet the quality criteria when the physician has 20 r mre ttal care pprtunities and has care pprtunities met that are equal t r greater than the expected care pprtunities met during the measuring perid. Single specialty grups Defined as having mre than ne physician practicing in the same specialty and billing with the same tax id number. The practice receives designatin in the High Perfrmance Netwrk when the grup has 20 r mre ttal care pprtunities, and has care pprtunities met that are equal t r greater than the expected care pprtunities met during the measuring perid. If the grup practice has fewer than 20 ttal care pprtunities r has care pprtunities met that are belw the expected pprtunities met, the grup will nt receive the High Perfrmance Netwrk designatin based n that measuring perid. Multi-specialty grups Defined as having mre than ne physician practicing in mre than ne HPN selected specialty and billing with the same tax id. Each specialty is evaluated separately and will receive designatin in the High Perfrmance Netwrk when that particular specialty has 20 r mre ttal care pprtunities, and has care pprtunities met that are equal t r greater than the expected care pprtunities met during the measuring perid. If the specialty grup has fewer than 20 ttal care pprtunities r has care pprtunities met that are belw the expected pprtunities met, the grup will nt receive the High Perfrmance Netwrk designatin based n that measuring perid. HPN Quality Criteria V01012016 Page 6 f 6