Coming in 2011 - The New BlueCompare Physician Designation Program
Continued escalation of health care costs has driven premiums and medical expenses to
higher and higher levels each year. This, in turn, has motivated employers and consumers to
search for information about the value (quality and cost) they receive for their health care
dollars. These stakeholders are asking Blue Cross and Blue Shield of Texas (BCBSTX) to
support their purchasing decisions by identifying the providers who offer the best value
(quality and cost). BCBSTX must pay attention to the needs of its employers and members.
BCBSTX understands the complexities of measuring provider quality and cost performance,
both historical and current. Fortunately, we now have available both state and national
published guidelines and requirements for provider transparency methodologies and
programs. We have taken care to incorporate these guidelines and requirements into a
redesigned BlueCompare Physician Designation program as we strive to meet the demand
for information on provider performance. See Appendix A for more information on national
guidelines.
Our redesigned BlueCompare Physician Designation program will measure physicians on
both quality related performance and cost efficiency:

The quality related assessment will utilize Evidence Based Measures (EBMs) from
nationally recognized entities such as the National Quality Forum (NQF), the Ambulatory
Care Quality Alliance (AQA), and the National Committee for Quality Assurance (NCQA).

We have implemented a Bridges to Excellence® program to recognize and reward health
care providers who demonstrate implementation of sound management of complex
patients and deliver safe, timely, effective and efficient patient-centered care. Therefore,
physicians in the BlueCompare measured Working Specialties that are currently
recognized by the Bridges to Excellence® organization in their Diabetes Care Link or
Cardiac Care Link programs will be recognized and display a BlueCompare Blue Ribbon.

The cost efficiency assessment will be based on an ‘Episodes of Care’ methodology.

Both the quality related and cost efficiency performance measurement will utilize two
years of BCBSTX PPO incurred claims data.

The BlueCompare program will adhere to nationally recognized transparency
methodology and program standards and guidelines (NCQA Standards and Guidelines for
the Certification of Physician and Hospital Quality) and will comply with Texas Insurance
Code Chapter 1460.
This document contains detailed descriptions of the BCBSTX methodologies for assessment
of both quality related performance on EBMs and cost efficiency.
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Measured Specialties and Eligibility
The new BlueCompare Physician Designation Program will apply to the Working Specialties
for which both quality related performance and cost efficiency can be measured. Physicians
must practice in one of the measurable Working Specialties and be a contracted physician in
good standing with the BCBSTX BlueChoice® provider network to be eligible for participation
in the BlueCompare Physician Designation Program.
There are a select number of available EBMs for quality related measurement that meet
nationally recognized standards (e.g. NQF, AQA and NCQA), and methodology adherence
for quality measurement. BCBSTX will only measure cost efficiency on those Working
Specialties where it can also measure quality related performance.
Thus, BCBSTX will apply quality related measurement, and in turn the cost efficiency
assessment, to the following fourteen Working Specialties:
Allergy-Immunology
Cardiovascular Disease-Non-Interventional
Cardiovascular Disease-Interventional
Endocrinology
Family Practice
Geriatric Medicine
Internal Medicine
Nephrology
Neurology
Obstetrics-Gynecology
Pediatric Allergy-Immunology
Pediatric Pulmonary Disease
Pediatrics
Pulmonary Disease
BlueCompare EBM Assessment
BCBSTX will use claims and enrollment data to assess a physician’s adherence to nationally
recognized EBMs when treating his/her qualifying patients. These measures cover
significant areas of preventive care such as diabetes, cardiovascular disease, and other
health care services. A complete list of the EBMs used in the evaluation, along with the
clinical intent and sponsoring organizations, is contained in Appendix B of this document.
Physicians will be evaluated using only the EBMs that are considered relevant to their
Working Specialty and relative to their specialty peers in Texas. All physicians within a
common Practice Evaluation ID (typically the Tax Identification Number) and Working
Specialty will be evaluated together, regardless of the level of individual physician
contribution, and will be given the same BlueCompare EBM designation. For example, a
group of physicians practicing under a common Tax Identification Number that is comprised
of Internal Medicine, Family Practice, and Obstetrics-Gynecology specialties would receive
three distinct evaluations and BlueCompare designations. A physician who practices under
multiple Tax Identification Numbers can achieve different EBM evaluation results for each
group and Working Specialty in which the physician is evaluated.
EBM performance will be attributed to physicians based upon their involvement in treating the
BCBSTX PPO members who qualify for the measures, according to HEDIS standards. The
number of members who qualify for the EBMs (denominator) will be compared to the number
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of members who were provided services satisfying the EBM criteria (numerator). A minimum
of thirty denominator events must be attributed to the physician or specialty group to qualify
for an evaluation. Although two calendar years of PPO claims data will be commonly used,
some EBMs will use five years of claims data. The methods for determining the specific
denominators and numerators differ by measure.
These details are available at
www.bcbstx.com/provider/ebi_2010.htm
EBM Performance Scoring Details
A physician group's performance score is derived from the following factors:
• A count of qualifying events, which defines a denominator. An example is the
continuously enrolled diabetic patients for whom a specified test or other service is
expected.
• A count of the clinical responses to the qualifying events, which defines the numerator.
An example is the number of diabetic patients in the denominator who receive the
expected test or service.
• The weighting associated with the applicable indicator. This is determined by the
statistical reliability of a measure, as determined by its variance.
The composite performance score for a physician group is derived by applying and
aggregating the above factors. This score is used to assess the group’s performance relative
to its peers. The composite score will be considered valid only if a physician group has a
minimum of thirty denominator events across all indicators.
Performance will be aggregated across all relevant EBMs. Each EBM will be weighted by the
inverse of the variance of the measure, resulting in a weighted average that reflects both the
total number of denominator events and the variability of performance by peers. This
methodology decreases the impact of differences in the number of denominators that occur
from practice to practice, and summarizes performance on individual measures into a single
EBM score.
The practice EBM scores are distributed for a specialty wide comparison of performance. A
system based on statistical methods is used to identify a performance threshold within this
distribution. Practices with scores that are at or above the performance threshold will be
recognized. Practices with a score more than two standard deviations from the mean,
compared to the peer average, are considered outliers.
An external statistician, with extensive experience in biostatistics, reviewed and validated the
EBM scoring methodology for appropriateness. A more detailed explanation of the scoring
methodology can be found in Appendix C of this document.
Where there are no measures present for a specialty, insufficient data is available, or
threshold performance on the EBMs is not met, an appropriate designation will be assigned
to the physician. For more information on designations, see BlueCompare Designation
section contained later in this document.
This EBM measurement is the quality related component of the BlueCompare Physician
Designation Program. It must be satisfied for a physician to be eligible for the cost efficiency
evaluation.
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BlueCompare Physician Cost Assessment (PCA)
Consistent with national guidelines (NCQA PHQ), BCBSTX will first assess a physician for
performance on quality related measures. Pending that outcome, BCBSTX will review the
physician for cost efficiency. A cost-efficiency assessment will only be performed if the
specialty-specific quality related criteria are met. BCBSTX engaged physicians currently in
clinical practice to assist us in building this new PCA methodology as described below.
To assess a physician’s cost efficiency, BCBSTX will analyze claims based on the Episodes
of Care that are attributable to the physician. Thompson Reuters MEG (Medical Episode
Grouper) software will be utilized for the Episode of Care analysis.
PCAs will be performed using two incurred years of outlier trimmed claims data. Similar to
the BlueCompare quality related assessment, the PCA will be performed at the Practice
Evaluation ID/Working Specialty level. PCA Peer Comparisons will also take into account the
disparate costs in the geographic area in which the physician practices. BCBSTX has
twenty-two different Peer Comparison areas for which physician cost efficiency can be
assessed as depicted below.
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Episodes of Care
An Episode of Care will be built by linking sets of health care services provided to a patient
over time to treat a specific disease or health status, and can be composed of one or more
encounters or visits, procedures or inpatient admissions. The episode continues as long as
there is relatively continuous contact with the health care system for the same basic
diagnosis, disease or health status.
Episode Grouping Logic example:
The example above demonstrates how a complete episode ranges in time between the lab
test and the final office visit. A lab or X-ray cannot initiate an episode; however, the lookback period can incorporate such services.
Physician Episode of Care Attribution
Only one physician per episode will be considered to be the “responsible physician.” The
responsible physician is assigned as follows:



Physician who performs procedures with the highest total RVUs billed; if none, then
Physician with the greatest number of E&M services billed; if none, then
Physician with the highest allowed dollars.
This logic helps to ensure that primary care physicians are not inappropriately attributed high
cost cases for which they are not primarily responsible. The responsible physician will be
determined without regard to the physician’s contract status with BCBSTX. Episodes
attributed to non-contracted physicians will be removed from the analysis during the data
trimming process.
Episode of Care Data Trims
A trim is an exclusion to the data set done prior to calculation of the PCA. BCBSTX will make
several data trims to the base episode of care data to help ensure that the results are not
influenced by patient Severity, case mix or burden of illness. BCBSTX will use only complete
episodes of care that are risk and Severity adjusted. Listed below are the trims that will be
made to the data before the PCA calculation is performed.
Episodes will be removed if they:
 are incomplete
 are high or low cost outliers
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





are attributed to members with fewer than nine member months for the time period of the
episode
belong to a MEG/Sub stage with low volume
represent an episode where the responsible physician has less than 80% of the RVUs
driving utilization
contain Emergency Room revenue codes or place of service
are for preventive care
are in MEG categories not typically provided by a particular Working Specialty
After these data trims are done, the result is a set of qualified episodes. Only qualified
episodes will be used in calculating the PCA.
Physician Cost Assessment Calculation
The PCA will be calculated based on the average cost of qualified episodes partitioned by:
 episode group
 Severity of illness for the episode
 relative risk of the patient
 time period of the episode
 Working Specialty of the physician
 geographic area of the physician
The PCA will be calculated by comparing the Actual Allowed Cost of the physician’s Episodes
of Care to an Expected Allowed Cost for the physician’s episodes of care in their Working
Specialty.
Determination of Physician Cost Efficiency Performance Level
Consistent with national guidelines, BCBSTX will use a Confidence Interval methodology to
determine if physicians meet cost efficiency performance thresholds for a Working Specialty
within a geographic market. Specifically:

PCA results will be cited at the physician/practice, Working Specialty level in conjunction
with a 90% Confidence Interval relative to 1.00.

If the lower bound of the Confidence Interval is higher than 1.00, then the
physician/practice will be determined to have costs that are higher than their peers and
will therefore not have met the cost efficiency designation performance threshold.

If a physician/practice’s Confidence Interval contains 1.00, then the physician/practice will
not be determined to have costs that are either higher or lower than their peers.
Therefore, costs are similar to their peers and the physician will have met the cost
efficiency designation performance threshold.
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In the example below, the PCA is 1.16 with a confidence interval from .92 to 1.41. Because
the lower bound of the confidence interval is below 1.00, the physician in this example would
meet the cost efficiency performance threshold.
PCA = 1.16
Upper bound of 90% PCA
confidence interval: 1.41
Lower bound of 90% PCA
confidence interval: 0.92
PCA 90% Confidence Interval
5%
0.5
5%
1.0
1.5
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BlueCompare Designations
Results of the BlueCompare Physician Designation Program will be displayed by using the
online Provider Finder® tool at bcbstx.com. When members search for providers in the
BlueChoice network, search results will include one of the following symbols/designations
next to the physician’s name:
Meets or exceeds expected quality related performance
compared to other doctors.
Meets or exceeds expected quality related and cost efficiency
performance compared to other doctors.
Performance measures are not available for this specialty.
There is not enough data to measure performance or this doctor
is new to the network. Re-evaluations are conducted
periodically.
Meets or exceeds expected quality related performance
compared to other doctors, but there is not enough BCBSTX
claims data to measure cost efficiency performance.
This doctor requested to not participate in the BlueCompare
program.
Physicians that are in a measured Working Specialty but do not meet the required quality
related and cost efficiency recognition threshold will not have a symbol in Provider Finder.
The BlueCompare tool is provided for informational purposes only. Physician selection is a
personal choice, and consumers are informed that they should not base decisions solely on
information displayed in BlueCompare. BlueCompare designations are based on claims from
BCBSTX PPO membership records and may not be indicative of the physician’s overall
practice.
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The Review Process
Affected physicians who are dissatisfied with their BlueCompare results have the right to
request a review in writing. In addition to the written fair review reconsideration process,
BCBSTX also provides a fair reconsideration proceeding as described below:
• When a physician requests a review, BCBSTX will provide a fair reconsideration
proceeding. This proceeding will be conducted by teleconference or in person, at the
physician’s option.
• A physician requesting a review has the right to provide information, to have a
representative participate, and to submit a written statement at the conclusion of the
reconsideration proceeding.
• BCBSTX will communicate the outcome of the reconsideration proceeding in writing,
including the specific reason(s) for the final determination.
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Appendix A - National Guidelines
1. NCQA Standards and Guidelines for the Certification of Physician and Hospital
Quality: http://www.ncqa.org/tabid/740/Default.aspx
2. Ambulatory Care Quality Alliance http://www.aqaalliance.org/performancewg.htm
3. National Quality Forum
http://www.qualityforum.org/Measuring_Performance/Measuring_Performance.aspx
4. Patient Charter for Physician Performance Measurement, Reporting and Tiering
Programs: Ensuring Transparency, Fairness and Independent Review
http://healthcaredisclosure.org/docs/files/PatientCharter040108.pdf
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Appendix B - Evidence Based Measures
The following Evidence Based Measures will be used in the BlueCompare quality related
assessment.
Evidence
Based Measure
Cervical Cancer
Screening
Colorectal
Cancer
Screening
Clinical Intent
To ensure that
all women ages
21-64 receive a
cervical cancer
screening test
during the
measurement
year or the 2
years prior.
Guideline
U.S. Preventive Services
Task Force (USPSTF),
Screening for Cervical
Cancer, 2003
http://www.ahrq.gov/clinic/us
pstf/uspscerv.htm
To ensure that
members 50–80
years of age
received
appropriate
screening for
colorectal
cancer.
ASGE Guideline: Colorectal
Cancer Screening and
Surveillance. 2006
http://www.guideline.gov/su
mmary/summary.aspx?ss=1
5&doc_id=10162&nbr=5347
#s24
Sponsoring Organization(s)
United States Preventive Services
Task Force (USPSTF), American
Cancer Society, American
Academy of Family Physicians
(AAFP), American College of
Obstetricians and Gynecologists
(ACOG), American College of
Preventive Medicine, American
Medical Assn. (AMA), Canadian
Task Force on Preventive Health
Care, American Academy of
Pediatrics, NCQA (HEDIS 2009
Technical Specification), National
Quality Forum (NQF) endorsed
measure, AMA Physician
Consortium for Performance
Improvement (PCPI) endorsed;
AQA Alliance endorsed
NCQA (HEDIS 2009 Technical
Specification), United States
Preventive Services Task Force
(USPSTF), American Cancer
Society, American College of
Obstetricians and Gynecologists
(ACOG), American Academy of
Family Physicians (AAFP),
American Gastroenterological
Association, National Quality
Forum (NQF) endorsed measure,
AMA Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
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Strength of
Evidence1
A
Specialty
Attribution
Family Practice,
Internal
Medicine,
ObstetricsGynecology
A
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
ObstetricsGynecology
Evidence
Based Measure
Diabetic Retinal
Exam (Annual)
Clinical Intent
To ensure that
all diabetic
members ages
18-75 receive at
least 1 retinal or
dilated eye exam
during the
measurement
year.
Glycosylated
Hemoglobin
(HbA1c) Test for
Diabetics
(Annual)
To ensure that
all diabetic
members ages
18-75 receive at
least 1
glycosylated
hemoglobin test
during the
measurement
year.
Appropriate
Treatment for
Children with
Upper
Respiratory
Infection (URI)
To ensure that
children, ages 3
months to 18
years old as of
the end of the
measurement
year, diagnosed
with nonspecific
upper respiratory
infections are
not being
inappropriately
treated with
antibiotics.
Guideline
American Diabetes
Association, Texas
Department of State Health
Services-Minimum Practice
Recommendations for
Diabetes. Revised 1/8/09
http://www.dshs.state.tx.us/d
iabetes/hcstand.shtm
The National Quality
Measures Clearinghouse™
(NQMC), sponsored by the
Agency for Healthcare
Research and Quality
(AHRQ), U.S. Department of
Health and Human Services
http://www.qualitymeasures.
ahrq.gov/summary/summary.
aspx?doc_id=4078
American Diabetes
Association, Texas
Department of State Health
Services-Minimum Practice
Recommendations for
Diabetes. Revised 1/8/09
http://www.dshs.state.tx.us/d
iabetes/hcstand.shtm
CDC - Get Smart: Know
When Antibiotics Work
http://www.cdc.gov/getsmart/
specific-groups/healthcareproviders.html
Sponsoring Organization(s)
NCQA (HEDIS 2009 Technical
Specifications), American
Diabetes Association, American
Academy of Ophthalmology,
American College of Physicians,
National Quality Forum (NQF)
endorsed measure, AMA
Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
American Diabetes Association,
American Association of Clinical
Endocrinologists, American
College of Endocrinology,
Centers for Disease Control and
Prevention, Veterans Affairs
Administration, NCQA (HEDIS
2009 Technical Specifications),
National Quality Forum (NQF)
endorsed measure, AMA
Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
Centers for Disease Control and
Prevention, American College of
Physicians, American Society of
Internal Medicine, American
Academy of Family Physicians,
American Academy of Pediatrics,
Infectious Diseases Society of
America, NCQA (HEDIS 2009
Technical Specifications),
National Quality Forum (NQF)
endorsed measure, AMA
Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
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Strength of
Evidence1
B
Specialty
Attribution
Endocrinology,
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Nephrology
B
Endocrinology,
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Nephrology
B
AllergyImmunology,
Family Practice,
Pediatrics,
Pediatric Allergy
and Immunology
Evidence
Based Measure
Clinical Intent
To ensure that
all members age
18-75 years old
with diabetes
receive LDL
monitoring
during the
measurement
year.
Guideline
American Diabetes
Association, Texas
Department of State Health
Services-Minimum Practice
Recommendations for
Diabetes. Revised 1/8/09
http://www.dshs.state.tx.us/d
iabetes/hcstand.shtm
Sponsoring Organization(s)
American Diabetes Association,
NCEP-ATP-III Guidelines, NCQA
(HEDIS 2009 Technical
Specifications), National Quality
Forum (NQF) endorsed measure,
AMA Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
Mammography
Screening
To ensure that
all eligible
women age 4069 receive a
mammography
screening test
during the
measurement
year or year
prior.
Screening Mammography for
Breast Cancer: American
College of Preventive
Medicine Practice Policy
Statement, 1996.
http://www.acpm.org/breast.
htm
Treatment of
Cardiovascular
Conditions:
Monitoring Lipid
Levels (Annual)
To ensure that
members with
cardiovascular
conditions
receive lipid
level monitoring
at a clinically
appropriate
frequency.
AHA/ACC Guidelines for
Secondary Prevention for
Patients With Coronary and
Other Atherosclerotic
Vascular Disease: 2006
Update
http://guidelines.gov/summar
y/summary.aspx?doc_id=93
73
United States Preventive Services
Task Force (USPSTF), Canadian
Task Force on Preventive Health
Care, American Academy of
Family Physicians (AAFP),
American College of Preventive
Medicine, American Medical
Assn. (AMA), American College
of Obstetricians and
Gynecologists (ACOG), American
College of Radiology, American
Cancer Society, NCQA (HEDIS
2009 Technical Specifications),
National Quality Forum (NQF)
endorsed measure, AMA
Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
NCQA (HEDIS 2009 Technical
Specifications), Third Report of
the National Cholesterol
Education Program (NCEP)
Expert Panel on Detection,
Evaluation and Treatment of High
Blood Cholesterol in Adults (Adult
Treatment Panel III, or ATP III),
American College of Cardiology,
American Heart Association,
National Cholesterol Education
Program, National Quality Forum
(NQF) endorsed measure, AMA
Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
LDL Monitoring
for Diabetes
(Annual)
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Strength of
Evidence1
B (for most adults
with diabetes)
C (for adults with
low-risk lipid
values [LDL <
100mg/dl, HDL >
50mg/dl, and
triglycerides <
150mg/dl])
Specialty
Attribution
Cardiovascular
Disease - NonInterventional,
Cardiovascular
Disease Interventional,
Endocrinology,
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Nephrology
A (50 to 69)
B (40 to 49)
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
ObstetricsGynecology
A
Cardiovascular
Disease – Non Interventional,
Cardiovascular
Disease Interventional,
Family Practice,
Geriatric
Medicine,
Internal
Medicine
Evidence
Based Measure
Appropriate Use
of Imaging in
Low Back Pain
Assessment
Follow-up After
Initial Diagnosis
and Treatment
of Colorectal
Cancer: CEA
X-ray Prior to
MRI/CAT Scan
in the
Evaluation of
Lower Back
Pain
Use of LongTerm Control
Drugs for
Persistent
Asthma
Clinical Intent
To ensure that
all members
diagnosed with
lower back pain
did not receive a
clinically
inappropriate
imaging study.
Guideline
National Committee for
Quality Assurance (NCQA).
HEDIS 2009 American
College of Radiology (ACR)
http://www.guideline.gov/su
mmary/summary.aspx?view_
id=1&doc_id=13671
To ensure that
all eligible
members with
colorectal cancer
who are status
post colon
resection receive
follow up CEA
test at least
every 6 months
to monitor for
cancer
reoccurrence.
To ensure that
an x-ray is
conducted prior
to an MRI for
eligible members
diagnosed with
lower back pain.
NCCN National
Comprehensive Cancer
Network, Clinical Practice
Guidelines in Oncology Colon Cancer, 2007
http://www.nccn.org/professi
onals/physician_gls/PDF/col
on.pdf
American College of
Physicians, American Pain
Society
http://www.annals.org/cgi/rep
rint/147/7/478.pdf
To ensure that
members with
persistent
asthma receive
medication
appropriate for
long term control
of asthma.
National Heart, Blood and
Lung Institute, National
Asthma Education and
Prevention Program, Expert
Panel Report 3 (EPR 3):
Guidelines for the Diagnosis
and Management of Asthma,
Section 3 & 4, 2007
http://www.nhlbi.nih.gov/guid
elines/asthma/asthgdln.htm
Strength of
Evidence1
A
Specialty
Attribution
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Neurology
B
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Agency for Healthcare Policy and
Research, American Academy of
Family Physicians, American
Academy of Neurology, American
College of Physicians, American
Pain Society, Institute for Clinical
Systems Improvement.
B
Family Practice,
Internal
Medicine,
Geriatric
Medicine,
Neurology
The National Asthma Education
and Prevention Program, The
Joint Council of Allergy, Asthma
and Immunology, National Heart,
Lung and Blood Institute, NCQA
(HEDIS 2009 Technical
Specifications), National Quality
Forum (NQF) endorsed measure,
AMA Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
A (inhaled
corticosteroid or
inhaled
corticosteroid
combos)
B (other classes of
medication [i.e.,
mast cell
stabilizers,
leukotriene
modifiers,
methylxanthines])
Allergy –
Immunology,
Family Practice,
Geriatric
Medicine,
Internal
Medicine,
Pediatrics,
Pediatric Allergy
and
Immunology,
Pediatric
Pulmonary
Disease,
Pulmonary
Disease
Sponsoring Organization(s)
Agency for Healthcare Research
and Quality, Institute for Clinical
Systems Improvement, American
Academy of Family Physicians,
American College of Physicians,
American College of Radiology,
American Pain Society, NCQA
(HEDIS 2009 Technical
Specifications), National Quality
Forum (NQF) endorsed measure,
AMA Physician Consortium for
Performance Improvement (PCPI)
endorsed; AQA Alliance endorsed
American Society of Clinical
Oncology, National
Comprehensive Cancer Network
Page 14 of 17
Evidence
Based Measure
Chlamydia
Screening for
Women
Monitoring for
Diabetic
Nephropathy
Clinical Intent
To ensure that
sexually active
women 16-25
years of age had
at least one
screening test
for chlamydia
during the
measurement
year.
To ensure
diabetic
members ages
18-75 receive a
diabetic
nephropathy
screening test
during the
measurement
year.
Guideline
U.S. Preventive Services
Task Force (USPSTF),
Screening for Chlamydia,
2007
http://www.ahrq.gov/clinic/us
pstf/uspschlm.htm
Sponsoring Organization(s)
American Academy of Family
Physicians, Centers for Disease
Control and Prevention and U.S.
Preventive Services Task Force
(USPSTF), NCQA (HEDIS 2009
Technical Specification), National
Quality Forum (NQF) endorsed
measure
American Diabetes
Association, Texas
Department of State Health
Services-Minimum Practice
Recommendations for
Diabetes. Revised 1/8/09
http://www.dshs.state.tx.us/d
iabetes/hcstand.shtm
American Diabetes Association,
NCQA (HEDIS 2009 Technical
Specifications), National Quality
Forum (NQF) endorsed measure,
AMA Physician Consortium for
Performance Improvement (PCPI)
endorsed
Strength of
Evidence1
A (for women 24
years and
younger)
C (for women 25
years)
Specialty
Attribution
Educational:
Family Practice,
Internal
Medicine,
ObstetricsGynecology
B
Educational:
Endocrinology,
Family Practice,
Geriatric
Medicine,
Internal
Medicine
1Strength
of Evidence Definitions:
A. Recommendation based on consistent and good-quality patient-oriented evidence.
B. Recommendation based on inconsistent or limited-quality patient-oriented evidence.
C. Recommendation based on consensus, usual practice, disease-oriented evidence, case series for
studies of treatment or screening, and/or opinion.
Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to Grading Evidence in the
Medical Literature http://www.aafp.org/afp/20040201/548.html
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Appendix C – Details on Calculating EBM Scores
For each relevant EBM indicator category, a physician p-score is calculated as the ratio of the
number of occasions on which the indicated service was provided by the physician to the
number of eligible patient encounters.
The aggregate p-score for a physician is the weighted average over all relevant indicators of
the physician’s p-scores. Before summing, each p-score is multiplied by the inverse of its
approximate variance. This weighting factor explicitly takes into account the number of
eligible patient encounters within each indicator for the physician so that p-scores based on a
large number of encounters are more influential in determining the aggregate score than pscores based on a smaller number of encounters.
The statewide p-score for the indicator is the ratio of the total number of occasions in the
state on which the indicated service was provided to the total number of eligible patient
encounters, all within the indicator category. The same inverse-variance weighting factors are
used, so the numbers of eligible patient encounters within each indicator category are again
taken into account. The expected p-score for the physician is the weighted sum over all
relevant indicators of the statewide p-scores.
The physician EBM score is the ratio of the physician’s aggregate p-score to the
corresponding statewide p-score, divided by the approximate standard deviation of the ratio.
The EBM score may be positive or negative, indicating that the physician’s overall rate of
performance of indicated services falls above or below statewide rate.
To determine the practice group EBM score, each member physician’s EBM score is
weighted by the inverse of its variance, and then aggregated across the relevant indicators.
This results in a weighted average that reflects both the total number of patient encounters
for each physician and the variability of the EBM score. EBM scores based on many patient
encounters are weighted more heavily than those based on fewer encounters. This
methodology takes into account differences in the numbers of patient encounters for both
individual physicians and for practice groups.
The specialty ratio for a practice group is the ratio of the number of occasions on which the
indicated service was provided to the number of eligible patient encounters, aggregated over
all physicians in the group. A physician group is evaluated using only those indicators which
are considered relevant to the specialty. Thirty or more patient encounters across all
indicators must be attributed to the physician group to be included in the assessment. A
group's performance is assessed relative to other physicians in the same specialty within the
BCBSTX network.
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Definitions
Actual Allowed Cost: This is the allowed cost (physician payment and patient liability) for all
services provided by all physicians, ancillary providers and facilities related to the episodes of
care attributed to the physician.
Confidence Interval: The probability at a 90% level of confidence that a PCA lies within a
specified range.
Expected Allowed Cost: This is based on the average allowed cost of qualified episodes
partitioned by MEG, severity, comorbidity group, and time period for a specialty in a
geographic region.
Episode of Care: An episode of care is composed of one or more encounters or visits,
procedures or inpatient admissions. It is built by linking sets of health care services provided
to a patient over time to treat a specific disease or health status. It continues as long as there
is relatively continuous contact with the health care system for the same basic diagnosis,
disease or health status.
MEG (Medical Episode Group): The Thomson Reuters Medical Episode Group numeric
code identifying a clinically homogenous episode of care.
PCA: Total cost of all qualified episodes attributed to the Practice Evaluation ID (for a
Working Specialty) divided by the total expected cost for those episodes.
Peer Comparison: All comparisons are made to specialty peers in the same geographic
area on episodes in the same Medical Episode Group (MEG) at the same level of severity, in
the same Comorbidity Group and during the same time period.
Practice Evaluation ID: The Tax Identification Number for group providers or other unique
identifier for solo providers.
Severity: Indicates the level of severity observed in episodes of a specific clinical condition
(Medical Episode Group). Subdivisions (x.xx) indicate more precise classification. For some
Medical Episode Groups, severity is further classified using age, gender and type of episode.
0
1
2
3
History of a significant predisposing factor for the disease, but no current pathology,
e.g. history of carcinoma or neonate born to mother suspected of infection at time of
delivery
Conditions with no complications or problems with minimal severity
Problems limited to a single organ or system; significantly increased risk of
complications than Stage 1
Multiple site involvement; generalized systemic involvement; poor prognosis
Working Specialty: A specialty designation derived by utilizing the physician’s primary,
secondary and tertiary specialties on record, practice limitations, physician type, and in
certain cases, primary place of service.
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