Commercial Business Medical Cost
Target Measurement Period HandbookFor Enhanced Personal Health Care
Measurement Period beginning:
01/01/17
CBMCT Version 01/01/17V1
Introduction:
Welcome to your Commercial Business Medical Cost Target Model Measurement Period Handbook. This
handbook applies to those Providers who are contracted for the Enhanced Personal Health Care Medical
Cost Target Program. As explained in the Program Description, the Incentive Program gives you the
opportunity to share in savings achieved by your Medical Panel duri ng a given Measurement Period. If you
meet both quality and cost performance targets, your provider organization could share in the cost
savings.
To determine whether or how much of a shared savings payment you are eligible for, we measure your
performance against quality, utilization and cost targets. In this handbook, you’ll have the chance to learn
more about those targets and how you can learn more about your performance. Below you will see
definitions of some of the most important terms used in this handbook and the details of your Incentive
Program:

Medical Cost Target Report. Prior to the start of your Measurement Period, or as soon thereafter
as practicable, you will be able to access your provider organization’s Medical Cost Target (MCT)
report via our secure website. The Medical Cost Target report shows medical costs incurred by
your Attributed Patients over the course of the Baseline Period. This information is used as the
starting point for the projected medical trends used to establish the Medical Cost Targets (MCTs)
for the Incentive Program. You are eligible to earn shared savings when the Medical Cost
Performance (MCP) during the Measurement Period comes in below the MCT (with consideration
to the Risk Corridor), and your measured performance on quality metrics and outcomes meets or
exceeds the Program’s Quality Gate.

Measurement Period Start Date. The first day of the twelve (12) month period during which we measure
Medical Cost Performance (MCP) and quality and utilization performance for purposes of calculating shared
savings between Anthem Blue Cross and the Medical Panel.

Quality Gate. The minimum clinical quality scores that your provider organization must deliver in order to
earn any shared savings under the Incentive Program. Your quality gate will be set at 10th percentile.
Further information about the Quality Gate is reviewed in the shared savings section, on page 10.

Upside Shared Savings Potential. The maximum percentage of savings under the Incentive Program that you
may be entitled to share, as long as your provider organization meets the Quality Gate and other Non-Cost
Program Targets.

Minimum Risk Corridor. (MRC) the percentage of MCT that Anthem retains before sharing any savings with
the Medical Panel. This percentage is determined by Anthem and is designed to limit savings payouts that are
driven by random variation.

Upside Cap The maximum Incentive Program shared savings that you can earn through the Incentive
Program. As is the case with the Gross Savings, the Upside Cap is adjusted by the Paid/Allowed Ratio as
defined in the Program Description.

Performance Scorecard Report. In addition to the MCT report, you will also be able to access
your provider organization’s Performance Scorecard via our secure website (www.Availity.com).
The Performance Scorecard shows your performance on the selected clinical, quality and
utilization measures listed in this handbook. The Performance Scorecard is a tool to help you
assess your quality and utilization performance on a quarterly basis.
The information included in this handbook is designed to help you understand your Medical Cost Target
report, your Performance Scorecard and the scoring methodology. After reviewing, if you have any
questions, please send an email to our dedicated Enhanced Personal Health Care mailbox .
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Table of Contents
Introduction: ............................................................................................................................................... 2
Section 1: Medical Cost Target .................................................................................................................. 4
Where to Find Your MCT Report and Supporting Materials................................................................... 4
Section 2: Performance Scorecard & Your Measures ............................................................................... 5
Overview................................................................................................................................................ 5
Scorecard Report Example .................................................................................................................... 5
Quality Measures for Your Measurement Period ................................................................................... 6
Section 3: Calculating Your Shared Savings ........................................................................................... 11
Overview.............................................................................................................................................. 11
Quality Gate – Did you pass the Quality Gate? ................................................................................... 11
Weighting Composites ......................................................................................................................... 13
Calculating Composite Scores ............................................................................................................. 15
Summary of your scoring ..................................................................................................................... 22
INDEX – Scorecard Measure Specifications ........................................................................................... 24
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Section 1: Medical Cost Target
Overview
As part of our Enhanced Personal Health Care Program, we track overall medical costs incurred by our
members, and under the incentive portion of the Program, we reward participating providers who are able
to provide appropriate care in a cost-effective manner while maintaining or improving performance against
nationally recognized quality measures.
The Medical Cost Target Report shows medical costs incurred by a given Medical Panel’s Attributed
Members over the course of the Baseline Period. This information is used to establish the Medical Cost
Targets (MCTs) for the Incentive Program.
The Medical Cost Target Report lists supporting member months, average risk scores and claims
expenditures incurred by Attributed Members over the course of the Baseline Period.
You are eligible to earn shared savings if your performance during the Measurement Period creates “Net
Savings” (i.e., costs in the Measurement Period come in lower than projected) and if you meet or exceed
the Program’s quality benchmarks. The better the quality score, the higher the potential shared savings
payment.
The Medical Cost Target Report is meant to give you a sense of the baseline cost trend from which you are
starting. This level-set helps you hit the ground running at the beginning of the Measurement Period for the
Incentive Program. This report is produced at the start of each annual Measurement Period. You will
receive periodic reports that show your Medical Cost Performance (MCP) over the course of the year.
Where to Find Your MCT Report and Supporting Materials
Your MCT report will be available within 45 days following the start of your Measurement Period or
as soon thereafter as practicable. To view your MCT report or to view a useful Quick Reference
Guide for MCT, select the “Provider Online Reporting” link on Availity.com.
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Section 2: Performance Scorecard & Your Measures
Overview
The performance scorecard is comprised of Clinical Quality and Utilization Measures. In addition to serving
as a basis for Incentive Program savings calculations, these measures are used to establish a minimum
level of performance expected of you under the Program, and to encourage improvement through sharing
of information.
The performance scorecard allows you to monitor your progress in these measures throughout the year. It
will identify:

Historic measure rate during the Baseline Period

Rolling measure rate

Rolling measure numerator and denominator

Benchmarks for your Measurement Period
Scorecard Report Example
The Performance Scorecard report
includes information for providers on:
Earned Contribution:
The proportion of the Shared Savings
Potential earned for each Scorecard
category and for the overall Program.
Maximum Possible Shared Savings:
The maximum percentage (out of
100%) of Shared Savings to which the
provider is entitled under the Incentive
Program.
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Total Shared Savings-Example
The PCMS Scorecard shows the Total Shared Savings Percentage on the Summary tab. The % Shared
Savings (in this example, 23.20%) is calculated by multiplying the total earned percentage (in this example,
66.29% as shown on the previous page) to the Upside Shared Savings Potential (in this example, 35%).
Quality Measures for Your Measurement Period
Clinical Quality Measures
The clinical quality measures for the Program are grouped into two categories: (1) Acute and Chronic Care
Management and (2) Preventive Care. These categories are then further broken out into six subcomposites. These measures cover care for both the adult and pediatric populations. Nationally
standardized specifications are used to construct the quality measures in conjunction with Plan data.
 Acute and Chronic Care Management Measures
6
o
Medication Adherence
- Proportion of Days Covered (PDC): Oral Diabetes
- Proportion of Days Covered (PDC): Hypertension (ACE or ARB)
- Proportion of Days Covered (PDC): Cholesterol (Statins)
o
Diabetes Care
- Diabetes: Urine Protein Screening
- Diabetes: HbA1c Testing
- Diabetes: Eye Exam
o
Annual Monitoring for Persistent Medications
- Annual Monitoring for Patients on Persistent Medications: Digoxin
- Annual Monitoring for Patients on Persistent Medications: ACE/ARB
- Annual Monitoring for Patients on Persistent Medications: Diuretics
o
Other Acute and Chronic Care Measurement
- Appropriate Testing for Children with Pharyngitis
- Appropriate Treatment for Children with Upper Respiratory Infection
- Osteoporosis Management in Women Who Had a Fracture
- Persistence of Beta-Blocker Treatment After a Heart Attack
- Arthritis: Disease Modifying Anti-rheumatic Drug (DMARD) Therapy in
Rheumatoid Arthritis
- Medication Management for People with Asthma
- New Episode of Depression: Effective Acute Phase Treatment
- New Episode of Depression: Effective Continuation Phase Treatment
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Preventive Measures
o
o
Pediatric Prevention
- Childhood Immunization Status: MMR
- Childhood Immunization Status: VZV
- Well-Child Visits Ages 0-15 Months
- Well-Child Visits Ages 3-6 Years Old
- Well-Child Visits Ages 12-21 Years Old
Adult Prevention
- Breast Cancer Screening
- Cervical Cancer Screening
Utilization Measures
Three different utilization measures are included in the Program scorecard. The measures focus on
appropriate emergency room (ER) utilization, management of ambulatory-sensitive care conditions as
measured by hospital admissions, and generic dispensing rates for a select set of drug classifications. As
with the clinical metrics, administrative data are used to construct the utilization measures.
 Potentially Avoidable ER Visits
This measure was developed using research that determines ER visits that were potentially avoidable
by identifying visits that could have been treatable in an ambulatory care setting. Visits for treatment of
conditions, such as the following, are considered potentially avoidable:
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Conjunctivitis
Otitis media
Sinusitis
Bronchitis
Sinusitis
Gastritis
Constipation
Urinary tract infection
Menstrual disorders
Cellulitis
Dermatitis
Sun burn
Osteoarthrosis
Joint pain
Backache
Cramps
Insomnia
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Malaise and fatigue
Throat pain
Cough
Nausea or vomiting alone
Diarrhea
Sprains
Abrasions
Contusions
First degree burns
Strep throat
Vaccinations
Routine child
Prenatal
Gynecological and adult exams
Change of wound dressings
Radiology and laboratory exams
Health screenings.
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 Adult and Pediatric, Ambulatory Sensitive Care Hospital Admissions
The Agency for Healthcare Research and Quality (AHRQ) has developed a Prevention Quality
Indicators (PQI) composite measure of 11 potentially avoidable hospitalizations for ambulatory care
sensitive conditions that are the basis of this measure. They are:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Diabetes short-term complications
Diabetes long-term complications
Chronic obstructive pulmonary disease or asthma in older adults
Hypertension
Heart Failure
Dehydration
Bacterial pneumonia
Urinary tract infection
Angina without procedure
Uncontrolled diabetes
Asthma in younger adults
 Generic Dispensing Rate
We assess the generic dispensing rate for five classes of medication:
1.
2.
3.
4.
5.
Statins
ADHD Medications
ARBs and ARB Combinations
Beta Blockers and Beta Blocker Combinations
Serotonin Agonists and Serotonin Agonist Combinations (Migraine Medications)
Quality Improvement Measures
In addition to assessing performance against thresholds, a subset of the clinical measures (listed below)
will be scored for improvement. The selection of these measures is a subset of the current set of
performance measures. These improvement measures will be assessed at your provider organization level
and will be weighted equally for each measure that has a denominator greater than or equal to 30. If the
denominator for each of the improvement measures is less than 30, then we will not use a score for that
category.
1. Breast Cancer Screening
2. Medication Adherences: Statins
3. Diabetes: HbA1c Testing
4. Well Child Visits ages 3-6 Years Old
5. Appropriate Testing for Children with Pharyngitis
Note: In some instances, pharmacy information may not be available for certain membership. Membership
that is lacking pharmacy detail will be excluded from the measures that require pharmacy information. Once
pharmacy information becomes available to Anthem, the data will be phased into the measures.
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Composite Overview
Scorecard points are divided into five categories, or composites. Several of the composites are based upon
sub-composites. Then, within some of the sub-composites there are specific care measures. Performance
on the clinical measures listed above will be calculated at the sub-composite level. The sub-composites are
scored as the sum of the numerators for the measures within the sub-composite divided by the sum of the
denominators. Scoring of the clinical measure sub-composites occurs at the provider organization level. If
all of the clinical sub-composites have a denominator less than 30, or if the Annual Monitoring for Persistent
Medications is the only clinical sub-composite with a denominator of at least 30, then scoring will occur at
the Medical Panel-level. The Utilization Measures will always be scored at your Medical Panel-level to
achieve sufficient denominator sizes for meaningful measurement. The five major composites are:
1.
2.
3.
4.
5.
Acute and Chronic Care Management
Preventive Care
Utilization
Clinical Quality Improvement
Patient-Centered Medical Home (PCMH) Recognition from the National Committee for Quality
Assurance (NCQA)
*Is an optional category; full shared savings can be earned without PCMH Recognition.
Composite Details
1. The Acute and Chronic Care Management Composite has four sub-composites. Each of the
sub-composites has multiple care measures that contribute to the Acute and Chronic Care
Management calculation:
 Medication Adherence
 Diabetes Care
 Annual Monitoring for Persistent Medications
 Other Acute and Chronic Care Management
2. The Preventive Care Composite has two sub-composites, with five individual care measures:


Adult Preventive
Pediatric Preventive
3. The Utilization Composite is made up of three sub-composites:
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Potentially avoidable ER visits
Admissions for ambulatory sensitive care
Generic drug dispensing rate for five classifications
4. The Clinical Quality Improvement Composite has five measures, and was outlined previously.
5. Patient-Centered Medical Home NCQA Recognition
In addition to the opportunity to earn shared savings based on quality and cost, provider
organizations that have obtained NCQA PCMH Levels 2 and 3 recognition can earn credit for that
achievement. Your provider organization will not be penalized if you do not have NCQA PCMH
recognition.
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A score of 75% is awarded if a provider organization receives Levels 2 or 3 recognition for
20% to 50% of provider organization locations.
A score of 100% is awarded for Levels 2 or 3 recognition if received for 50% or more of
provider organization locations.
Groups that have not obtained this recognition are not penalized. The overall Shared
Savings Potential percentage remains the same
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Section 3: Calculating Your Shared Savings
Overview
The opportunity to share in savings that are realized for your Attributed Members is a key characteristic of
the Program. After savings are determined, the proportion of shared savings that you can earn depends on
your organization’s performance on a scorecard. Your Scorecard serves two functions: (1) it will let you
know if you met the Quality Gate, and (2) it will show you the overall percentage of the shared savings you
earn. Below, we review the four major steps to determine your shared savings:
1. Savings Pool
Funded
2. Quality Gate
Passed
3. Earned
Contribution
Calculated for
each Composite
4. Overall
Shared Savings
Potential
Calculated
Savings Pool Funded – Was the savings pool funded?
In order to participate in shared savings, the Savings Pool must be funded. For that to happen, your
Medical Panel’s Attributed Member population must demonstrate savings over the course of your
Measurement Period. As described more fully in the Program Description, Anthem will calculate the
Savings Pool by comparing the “Medical Cost Performance” (MCP) for your Attributed Member
population for a specified 12 month “Measurement Period” to the established “Medical Cost Target”
(MCT). In the event that the MCP is less than the MCT, the Savings Pool is funded. After the pool is
funded, the Minimum Risk Corridor (MRC) is calculated by multiplying the MCT by the MRC, and then
multiplying the result with the Paid/Allowed Ratio (as outlined further in the Program Description).
Ultimately, the Savings Pool is multiplied by your Shared Savings Percentage earned to calculate your
shared savings payout.
Quality Gate – Did you pass the Quality Gate?
Your provider organization must meet a minimum threshold of performance on clinical quality
measures in order for you to share a portion of the savings pool. That threshold, referred to as the
Quality Gate, is based on an overall clinical quality score, which is computed by aggregating your
scores across the scorecard’s clinical sub-composites. We calculate that score for the Measurement
Period and compare it to the distribution of performance across the market for the same time period.
The market distribution of performance includes provider organizations (including primary care and
specialist providers, whether participating in the Program or not) that have at least one of the 6 quality
sub-composites with a denominator of 30 or more. Your provider organization’s clinical quality score
must meet or exceed the market 10th percentile to pass the Quality Gate.
For provider organizations with denominators of at least 30 in all 6 clinical sub-composites, the subcomposite rates are proportionally weighted by the assigned Shared Savings Potential to arrive at the
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overall clinical quality score. When provider organizations have one to five sub-composites with
denominators of 30 or more, the weights are redistributed accordingly and then a final overall quality
composite score is calculated. If your overall quality composite score is greater than the Quality Gate,
you are eligible to earn shared savings. Examples follow in the tables below:
Table 1: Clinical Sub-Composites and Weights for Calculating the Overall Quality Composite: In this example the
group had sufficient denominators to be scored in all categories. The Quality Gate, using the 10 th percentile, equates to a
22% performance rate across all sub-composites. When the sub-composite scores are aggregated proportional to the
weights, the group has an overall score of 42%. Since the Quality Gate was set at 22%, this group would pass the Quality
Gate.
Example One
Clinical Sub-Composites
Denominator
Numerator
Performance
Rate
Medication Adherence
Diabetes Care
Annual Monitoring for Persist Meds
Other Acute and Chronic Care Management
Pediatric Preventive
Adult Preventive
138
280
63
71
89
250
62
69
52
51
18
68
45%
25%
83%
72%
20%
27%
Overall
Contribution
Percentage
Weight
25.0%
12.5%
5.0%
20.0%
12.5%
25.0%
100%
11%
3%
4%
14%
3%
7%
QUALITY GATE
42%
Table 2: Clinical Sub-Composites and Weights for Calculating the Overall Quality Composite : In this example the
group did not have sufficient denominators to be scored in all categories, so the weights were proportionally redistributed
accordingly, producing an overall quality composite score of 45%. Since the Quality Gate was set at 22%, this group would
pass the Quality Gate.
Example Two
Clinical Sub-Composites
Denominator
Numerator
Performance
Rate
Weight
Overall Contribution
Percentage
Medication Adherence
Diabetes Care
Annual Monitoring for Persist Meds
Other Acute and Chronic Care
Management
Pediatric Preventive
Adult Preventive
138
280
63
62
69
52
45%
25%
83%
28.6%
14.3%
5.7%
13%
4%
5%
71
51
72%
22.9%
16%
18
250
15
68
NA
27%
NA
28.6%
100%
NA
8%
QUALITY GATE
12
45%
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Weighting Composites
The composite, sub-composites, and care measures do not contribute equally to the Scorecard’s results –
they are weighted more heavily toward Clinical Measures:
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The clinical composites (Acute and Chronic Care Management, Preventive Care and
Improvement) are weighted to account for 50% or 60% of the scorecard points depending on
the presence of NCQA PCMH Recognition. The weighting for recognition is explained further in
a separate section below.
The Acute and Chronic Care composite is weighted more heavily than preventive care.
Utilization measures account for 40% of the scorecard points.
Table 3: Composite Weights - Example
Allocation of Shared Savings Potential
With NCQA Recognition Without NCQA Recognition
Clinical: Acute and Chronic Care Management
Medication Adherence
10
12
Diabetes Care
5
6
Annual Monitoring for Persist Meds
2
2.4
Other Acute and Chronic Care Management
8
9.6
Clinical: Preventive
Pediatric
5
6
Adult
10
12
Clinical: Improvement
10
12
Utilization
40
40
NCQA PCMH Recognition
10
N/A
TOTAL
100%
100%
Category
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Table 4: Shared Savings Potential per Composite in Absolute Terms - Example
Percentage of Shared Savings
Category
With NCQA Recognition Without NCQA Recognition
Clinical: Acute and Chronic Care Management
Medication Adherence
Diabetes Care
Annual Monitoring for Persist Meds
Other Acute and Chronic Care Management
Clinical: Preventive
Pediatric
Adult
Clinical: Improvement
Utilization
NCQA PCMH Recognition
TOTAL
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3.50%
1.75%
0.70%
2.80%
4.20%
2.10%
0.84%
3.36%
1.75%
3.50%
3.50%
14.00%
3.50%
35%
2.10%
4.20%
4.20%
14.00%
NA
35%
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Calculating Composite Scores
As mentioned above, there are five composites that are calculated for the scorecard. Each area is
explained in detail below.
Composites 1 & 2: Acute and Chronic Care Management and Preventive Care Measures
We use four steps to determine the proportion of shared savings earned for the acute and chronic
care management and preventive care. The table below is a visual representation of the process.
Table 5: The Four Steps That Are Used to Calculate for Preventive Care Measures - Example
Level 4 - 80th Percentile
Earned Shared Savings 100%
52%
60%
65%
72%
Step 1
Step 2
Shared Savings Percentage
Level 3 - 60th Percentile
Earned Shared Savings 70%
62%
Upside Shared Savings Potential
Level 2 - 40th Percentile
Earned Shared Savings 50%
2049
Earned Contribution
Level 1 - 20th percentile
Earned Shared Savings = 30%
3303
Measurement Level
Rate
Shared Savings
Compliant with
Measure
Market Thresholds
Eligible Population
Adult Preventive Sub-composite
Organizations Current
Performance
Group 50% 4.20% 2.1%
Step 3
Step 4
Step 1. Calculate sub-composite rate
Sub-composite rates are calculated by summing- the numerators (the number compliant with
measure) across each of the measures within the sub-composite, and then dividing by the sum
of the denominators (eligible population).
Step 2. Compare performance to market thresholds
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Market thresholds are established for each of the sub-composites at the <20th, 20th,
40th, 60th and 80th percentiles for the year prior to the Program Measurement Period.
Performance thresholds will be provided soon after the start of the Measurement
Period
The thresholds are set jointly for all lines of business included in the Program using
performance of all providers within the market.
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
Provider organizations with a sub-composite denominator less than 30 are excluded
from the calculation of the relevant sub-composite thresholds.
Step 3. Assign percentage of the category earned
The four levels of market thresholds are used to categorize four (4) tiers of performance.
After passing the lowest market threshold, each performance tier is associated with a
greater proportion of earned shared savings:
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
(0 - < 20th percentile) = 0% of shared savings earned
Level 1 (20th-<40th percentile) = 30% of shared savings earned
Level 2 (40th-<60th percentile) = 50% of shared savings earned
Level 3 (60th-<80th percentile) = 70% of shared savings earned
Level 4 (80th -<100th percentile) = 100% of shared savings earned
Step 4. Calculate shared savings earned
After the percentage of the category earned is determined, that value is multiplied by the
group’s Upside Shared Savings Potential for the Sub-composite. This yields the earned
shared savings for the sub-composite.
Composite 3: Utilization Measures Calculated
We use five steps to determine the proportion of shared savings earned for each utilization
sub-composite. Table 6 uses sample data to show hypothetical calculations.
Table 6: The Five Steps That Are Used to Calculate Utilization Measures - Example
Current Performance
176.00
0.77
18,076
54.00
1.02
Level
4
98,043
Earned
Contribution
Shared
Savings
%
27.90 37.71 27.61 21.91 17.65
2.96%
30.00%
0.89%
35.00 26.12 22.15 17.96 12.27
0.54%
00.00%
0.00%
3.50%
25.33%
0.89%
Step 3
Step 4
Weighted Subcomposite Total:
Step 1
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Shared Savings
Upside
Shared
Savings
Potential
Risk
Adj.
Rate
Step 2
Level
3
Visits
Risk Adj.
Factor
Level
2
Commercial
Adult
Commercial
< 18
Member
Months
Level
1
Measures
Market Benchmark
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Step 5
Step 1 Calculate utilization rates for the Medical Panel for distinct line of business and age
categories.
Ambulatory Sensitive Admits and Potentially Avoidable ER measures:
o To control for variation in patient mix and associated variable utilization between
Medical Panels, utilization rates are calculated separately for:
 Commercial members at least 18 years of age
 Commercial members less than 18 years of age
o The numerator is the count of qualifying events during the Measurement Period.
o The denominator is the sum of Member Months for members attributed to the
Medical Panel during the Measurement Period.
o The unadjusted rate is computed as (numerator/denominator)*12,000.
o This rate is risk-adjusted by dividing the actual raw rate for the provider panel by
the relative risk score.
o The Medical Panel risk score is calculated as the sum of weighted retrospective
diagnostic cost grouping risk scores for members attributed to the Medical Panel,
divided by number of Attributed Members with a risk score. That rate is then
divided by the average Risk Score of all members within the line of business/age
group (excluding BlueCard).
Generic Dispensing Rates
o To control for variation in patient mix and associated variable utilization between
Medical Panels, utilization rates are calculated separately for:
 Commercial members at least 18 years of age
 Commercial members less than 18 years of age
o The Generic Dispensing Rate is calculated separately for each of the five therapeutic
classes.
o Denominator = count of all prescriptions for the Medical Panel’s attributed patient
population within each of the five generic classes.
o Numerator = count of generic prescriptions during Measurement Period within each of
the five generic classes.
o The rate is computed as (numerator/denominator) percentage for each line of
business/age group within each of the five generic classes separately.
Step 2 Compare performance to market thresholds.
o Market Thresholds are established for each of the utilization measures for three
distinct line of business/age groups (commercial adult, commercial <18).
o Four levels of thresholds are calculated based on the overall market: <20th, 20th, 40th,
60th and 80th percentiles for the year prior to the Program Measurement Period.
o We will provide performance thresholds soon after the start of the Measurement
Period. Note: Market thresholds exclude BlueCard.
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Step 3 Determine Shared Savings Potential for each line of business/age group.
Upside shared savings -Potential for the utilization measures:
Potentially avoidable emergency room visits = 3.5%
Generic dispensing rate (GDR) = 7%
Ambulatory sensitive care admissions = 3.5%
Since these measures are assessed by line of business/age groups, the shared
savings opportunity for each of these groups must be determined.
o Upside shared savings opportunity for each GDR drug class is determined by
distributing the overall Upside Shared Savings Potential for GDR (7%) based on the
proportion of prescriptions within that drug class compared to the overall (total) GDR
prescription count.
o Within each drug class, the shared savings opportunity is determined for each line of
business age/group based on the proportion of prescriptions within that line of
business/age group.
o
o
o
o
o
Step 4 Assign the earned contribution percentage.
The four levels of market thresholds are used to categorize four tiers of performance. After
passing the lowest market threshold, each performance tier is associated with a greater
proportion of earned shared savings:
o
(0 - < 20th percentile) = 0% of shared savings earned
o Level 1 (20th-<40th percentile) = 30% of shared savings earned
o Level 2 (40th-<60th percentile) = 50% of shared savings earned
o Level 3 (60th-<80th percentile) = 70% of shared savings earned
o Level 4 (80th -<100th percentile) = 100% of shared savings earned
Step 5 Calculate earned shared savings for each utilization measure and the overall
category.


The earned shared savings for each measure/group combination is calculated by
multiplying the percentage of the category earned for each line of business/age group for
each of the utilization measures by the Medical Panel’s Maximum Upside Shared Savings
Potential.
These scores are summed to determine the overall percentage of shared savings for each
of the Utilization Metrics, and then summed for an overall utilization shared savings
earned.
Overall Scoring Summary for Utilization Components
The chart below demonstrates how steps 3, 4 and 5, described above, are used to
calculate the overall score for the utilization subcomponents.
18
CBMCT Version 010117V1
3. Determine Upside Shared Savings Potential for each line of business/age
group.
4. Assign the earned contribution percentage.
5. Calculate earned shared savings for each utilization measure and the overall
category.
Table 7: Overall scoring for Utilization Measures - Example
Step 4
Step 3
Composite 4: Clinical Quality Improvement Components Calculated
There are five clinical improvement measures selected from the clinical quality measures as
follows:
1. Breast cancer screening
2. Medication adherence: statins
3. Diabetes: HbA1c Testing
4. Well child visits for ages 3-6 Years old
5. Appropriate testing for children with pharyngitis
Scoring of this scorecard component is performed only at the individual provider organization level.
19
CBMCT Version 010117V1
Step 5
Performance is measured as follows:

Rates are calculated for each of the five clinical improvement measures where the
denominator size is 30 or more for both Measurement Periods.

Weights for measures with a denominator less than 30 are reallocated to the remaining
improvement measures.

A target rate is set for each of the improvement measures.

This target represents an improvement of 20% in closing the quality gap.

(1-Group Baseline Rate)*.20)+group baseline rate

If the target is achieved, you will receive full credit for that measure.

Additionally, if the current rate is 90% or higher, full credit is received.

Scoring for improvement measures will always take place at the group level.

Each of the five improvement measures will be weighted equally at 20%.

If your denominator less than 30 for any measure, that measure will not be scored but the
weighting will be redistributed to the remaining measures with sufficient denominator size.

If none of the five measures have a denominator of 30 or more, no points will be awarded
or reallocated for the improvement component.
Note: The Baseline Period for determining both the improvement and quality metrics’ benchmarks
is the 12 month period of incurred service dates which precedes both a 3 month paid claims run
out period and a period of time needed to calculate and report benchmarks. The period needed for
calculation and reporting of the benchmarks for improvement metrics is approximately 1 month
while the quality metrics take 3 months. As a result, the improvement metrics are based on data
which is two months more current than the data used to set the quality metrics’ benchmarks.
20
CBMCT Version 010117V1
Composite 5: NCQA PCMH Level 2 and 3 Recognition Component
Groups that have obtained NCQA PCMH Levels 2 and 3 recognition can receive credit for that
achievement. Groups that do not have recognition ARE NOT penalized. The section bellow
explains how PCMH recognition is calculated into the scorecard.
21

Provider organizations with 20% or more of their locations having achieved NCQA PCMH
Level 2 or 3 Recognition during the Measurement Period will receive up to 10% of the
upside shared savings payout automatically as part of this scorecard component.

10% of the upside shared savings payout will be awarded to provider organizations that
have Level 2 or Level 3 recognition for 50% or more of their locations. In absolute terms
10% x 35% maximum payout equals a guaranteed 3.5% payout.

7.5% of the upside shared savings payout will be awarded to provider organizations that
have Levels 2 or Level 3 recognition for between 20% and 50% of its provider organization
locations. In absolute terms 75% x 35% maximum payout equals a guaranteed 2.63%
payout of shared savings. The remaining 2.5% of the possible payout for NCQA PCMH
Recognition shall not be reallocated to the other clinical quality and improvement
components. Instead, provider organizations receiving partial credit for the NCQA PCMH
recognition shall have their clinical quality and improvement components measured using
both the “with” and “without” NCQA PCMH weights and shall be awarded the result with
the greatest payout amount.

The maximum payout level (3.5% of the total 35% maximum shared savings payout
assigned to this component) is subtracted from the total possible payout levels available in
the clinical quality and improvement components. For example, a provider organization
with no NCQA PCMH recognition has a maximum payout opportunity from clinical quality
and improvement components of 21%, whereas this provider organization with all of its
locations having achieved NCQA PCMH level 3 recognition would be guaranteed a 3.5%
payout from NCQA PCMH recognition and an opportunity to earn up to 17.5% (21% 3.5%) from performance in the clinical quality and improvement measures.

Provider Organizations that have not obtained this recognition are not penalized. The
overall shared savings percentage remains the same and can be earned entirely from the
utilization, clinical quality and improvement components.

Information about your NCQA PCMH status by location must be communicated to Anthem
no later than 30 days after the close of any Measurement Period for which recognition was
in effect by completing the electronic attestation form.
CBMCT Version 010117V1
Summary of your scoring
The tables below pull together all of the scoring that is described in this Measurement Period Handbook.
The performance of your Medical Panel is used to calculate a score (0-100%) for each scorecard
component. Your shared savings for each scorecard component is calculated by multiplying the Upside
Shared Savings Potential (shown above in table 4) by the category score. The sum of your earned shared
savings for each scoring components yields your overall earned shared savings – examples of this
calculation are shown in Tables 8 and 9 below.
The tables below, which you will receive with your scorecard posted to Availity, will show:


Whether you passed the Quality Gate, and
The overall percentage of shared savings that you have earned for the Measurement Period.
Table 8: In this example, the provider organization does not have NCQA PCMH recognition and would earn 20.76 % of a Shared
Savings Pool.
Summary one - Without NCQA PCMH Recognition Example
Category
Savings
Potential
Category %
Earned
Passed Quality Gate (10th percentile) ------>
(1) Clinical: Acute and Chronic Care Mgmt.
Savings
Earned
YES
10.50%
Medication Adherence
4.20%
70%
2.94%
Diabetes Care
2.10%
50%
1.05%
Annual Monitoring for Persistent Medications
0.84%
0%
0.00%
Other Acute and Chronic Care
3.36%
100%
3.36%
(2) Clinical: Preventive
6.30%
Pediatric Preventive
2.10%
15%
0.32%
Adult Preventive
4.20%
70%
2.94%
(3) Clinical: Improvement
4.20%
75%
3.15%
(4) Utilization
14.00%
50%
7.00%
OVERALL SAVINGS POTENTIAL
35%
EARNED SHARED SAVINGS
22
20.76%
CBMCT Version 010117V1
Table 9: In this example, the provider organization does have NCQA PCMH recognition and would earn 21.10% of a Shared
Savings Pool.
Summary two - With NCQA PCMH Recognition
Category
Savings
Potential
Category %
Earned
Passed Quality Gate (10th percentile) -------------------------------------->
Savings
Earned
YES
(1) Clinical: Acute and Chronic Care Mgmt.
Medication Adherence
3.50%
70%
2.45%
Diabetes Care
1.75%
50%
0.88%
Annual Monitoring for Persistent Medications
0.70%
0%
0.00%
Other Acute and Chronic Care
2.80%
100%
2.80%
Pediatric Preventive
1.75%
15%
0.26%
Adult Preventive
3.50%
70%
2.45%
(3) Clinical: Improvement
3.50%
75%
2.63%
(4) Utilization
14.00%
50%
7.00%
(5) NCQA PCMH Recognition
3.50%
75%
2.63%
OVERALL SAVINGS POTENTIAL
35%
(2) Clinical: Preventive
EARNED SHARED SAVINGS
23
21.10 %
CBMCT Version 010117V1
INDEX – Scorecard Measure Specifications
*Note: The term “patient(s),” as used throughout the Index, shall mean and refer only to Attributed Member(s).
Acute and Chronic Care Management Measures
Sub-composite: Medication Adherence
Measure
Description
Numerator/Denominator
Technical Specifications
Proportion of
Days
Covered
(PDC): Oral
Diabetes
This measure identifies
patients with at least
two prescriptions for
diabetic oral agents in
the measurement year
who have at least 80%
days covered (PDC)
since the first
prescription of an oral
diabetic agent during
the year.
Numerator
Patients in the denominator
with at least 80% days
covered for an oral diabetic
Rx since the first prescription
for the drug during the last
365 days.
Numerator
>=80% days covered (PDC) for Diabetic Oral
Agents (removing overlapping days for Rx) from
index event to end of measurement year.
This measure identifies
Patients with at least
two prescriptions for an
ACE/ARB in the
measurement year who
have at least 80% days
covered (PDC) since
the first prescription of
an ACE/ARB during the
year.
Numerator
Patients in the denominator
with at least 80% days
covered for an ACE/ARB
since the first prescription for
the drug during the last 365
days.
This measure identifies
patients with at least
two prescriptions for a
Statin in the
measurement year who
have at least 80% days
covered (PDC) since
the first prescription of a
Statin during the year.
Numerator
Patients in the denominator
with at least 80% days
covered for a Statin since the
first prescription for the drug
during the last 365 days.
Proportion of
Days
Covered
(PDC):
Hypertension
(ACE or
ARB)
Proportion of
Days
Covered
(PDC):
Cholesterol
(Statins)
24
Denominator
Patients who have at least
two prescriptions for an oral
diabetic drug during the last
365 days.
Denominator
Patients who have at least
two prescriptions for an
ACE/ARB during the last 365
days.
Denominator
Patients who have at least
two prescriptions for a Statin
during the last 365 days.
Measure
Citation
CMS Part D
Specifications
2014
Denominator
>=2 Rx claims for diabetic oral agents from end
of measurement year-365 to end of
measurement year, saving earliest instance as
index event (IE);
Rx eligibility from index event to end of
measurement year using HEDIS gap method,
<=1 gap <=45 days max;
>=18yo
No Rx claims for 'Insulin' from index event to end
of measurement year.
Numerator
>=80 days covered (PDC) for ACE/ ARB
(removing overlapping days) from index event to
end of measurement year.
CMS Part D
Specifications
2014
Denominator
>=2 Rx claims for ACE/ ARB from end of
measurement year-365 to end of measurement
year, saving earliest instance as index event (IE);
Rx eligibility from index event to end of
measurement year , using HEDIS gap method,
<=1 gap <=45 days max;
>=18yo.
Numerator
>=80% days covered (PDC) for Statins
(removing overlapping days) from index event to
end of measurement year.
CMS Part D
Specifications
2014
Denominator
>=2 Rx claims for Statins from end of
measurement year-365 to end of measurement
year, saving earliest instance as index event (IE);
Rx eligibility from index event to end of
measurement year using HEDIS gap method,
<=1 gap <=45 days max;
>=18yo.
CBMCT Version 010117V1
Sub-composite: Diabetes Care
Measure
Description
Numerator/Denominator
Technical Specifications
Diabetes:
Urine
Protein
Screening
This measure identifies
diabetic patients with a
nephropathy screening
test or evidence of
nephropathy during the
measurement year.
Numerator
Patients in the denominator
with claims for urine protein
tests, nephropathy
treatment, ESRD, stage 4
CKD, kidney transplant, ACE
inhibitors, ARBs, or an
outpatient visit with a
nephrologist.
Numerator
Any one of the following during the measurement
year:

At least 1 procedure in any position for
urine protein tests

OR at least 1 lab LOINC claim for
urine protein tests

OR at least 1 procedure or diagnosis
in any position for treatment for
nephropathy

OR at least 1 procedure or diagnosis
in any position for ESRD

OR at least 1 diagnosis in any position
for CKD stage 4

OR at least 1 procedure or diagnosis
in any position for kidney transplant

OR at least 1 prescription claim for
ACE inhibitors or ARBs

OR at least 1 outpatient visit defined
by outpatient with a nephrologist
specialist.
Denominator
Patients between the ages of
18 and 75 years old who
have diabetes.
Measure
Citation
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Denominator

Age between 18 and 75 years old

AND service eligibility during the
measurement year with no more than
1 gap of no more than 45 days

AND member eligibility with no gaps
on analysis date

AND identified by the following criteria:
o
Any one of the following

At least 2 claims at least
one day apart with a
diagnosis of diabetes in
any position from an
outpatient, observation,
acute inpatient ED, or
nonacute inpatient
setting in the 2 years
before the analysis date

At least 1 prescription
claim for insulin or oral
hypoglycemic
medication dispensed in
the 2 years before the
analysis date
o
Exclude patients with claims for
diabetes exclusions
Deviation from HEDIS 2016 specs: Added
requirement to look for at least 2 diabetes
diagnoses from an inpatient setting.
25
CBMCT Version 010117V1
Measures
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Diabetes:
HbA1c
Testing
This measure identifies
patients with diabetes
who have had a HbA1c
test over the past year.
Numerator
Patients in the denominator
who had an HbA1c test
during the measurement
year.
Denominator

Age between 18 and 75 years as of
analysis date

Patients identified by the following
criteria:
o
Any one of the following

At least 2 claims at least
one day apart with a
diagnosis of diabetes in
any position from an
outpatient, observation,
acute inpatient ED, or
nonacute inpatient
setting in the 2 years
before the analysis date

At least 1 prescription
claim for insulin or oral
hypoglycemic
medication dispensed in
the 2 years before the
analysis date
o
Exclude patients with claims for
diabetes exclusions.
o
Deviation from HEDIS 2016 specs:
Added requirement to look for at
least 2 diabetes diagnoses from an
inpatient setting.
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Denominator
Patients between the ages of
18 and 75 who have
diabetes.


Continuous member eligibility during
the measurement year with maximum 1
gap of no more than 45 days.
Member eligibility with no gaps on
analysis date.
Numerator
Either one of the following:

At least 1 procedure claim for an HbA1c
test during the measurement year
OR at least 1 lab result for a HbA1c test during
the measurement year.
26
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specifications
Diabetes:
Eye Exam
This measure identifies
patients between 18 and
75 years old who have
diabetes and who had a
retinal eye exam from an
eye care professional in
the last 2 years.
Numerator
Patients in the denominator
who had a retinal eye exam
from an eye care
professional in the last 2
years.
Denominator

Age between 18 and 75 years as of
analysis date

Patients identified by the following
criteria:
o
Any one of the following

At least 2 claims at least
one day apart with a
diagnosis of diabetes in
any position from an
outpatient, observation,
acute inpatient ED, or
nonacute inpatient
setting in the 2 years
before the analysis date

At least 1 prescription
claim for insulin or oral
hypoglycemic medication
dispensed in the 2 years
before the analysis date
o
Exclude patients with claims for
diabetes exclusions
o
Deviation from HEDIS 2016 specs:
Added requirement to look for at
least 2 diabetes diagnoses from an
inpatient setting.
Denominator
Patients between the ages of
18 and 75 who have
diabetes.


Continuous member eligibility during the
measurement year with maximum 1 gap
of no more than 45 days.
Member eligibility with no gaps on
analysis date.
Numerator

At least 1 claim for an eye exam as
specified by HEDIS in the last 730 days

Exe exams are defined either as
o
non-specific office visits with
an ophthalmologist or
optometrist.
o
specific eye care code sets for
a diabetic retinal screening

OR At least 1 claim for an eye exam as
specified by HEDIS in the last 365 days.
Note that HEDIS specifications only count retinal
eye exams from the previous year if the results
were negative, but due to data limitations this
measure was loosened to accept all eye exams
from the previous year regardless of result.
27
CBMCT Version 010117V1
Measure
Citation
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol
2, 2015.
Sub-composite: Annual Monitoring for Persistent Medications
Measure
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Annual
Monitoring for
Patients on
Persistent
Medications:
Digoxin
The percentage of
patients 18 years of age
and older who received at
least 180 treatment days
of ambulatory medication
therapy for digoxin during
the measurement year
and at least one
therapeutic monitoring
event for the therapeutic
agent in the measurement
year.
Numerator
Patients in the denominator
who had at least one serum
potassium test and one
serum creatinine test and
one serum digoxin test
during the measurement
year.
Numerator
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2,
2015.
The percentage of
patients 18 years of age
and older who received at
least 180 treatment days
of ambulatory medication
therapy for an ACE
inhibitor or ARB during the
measurement year and at
least one serum
potassium and one serum
creatinine test during the
measurement year.
Numerator
Patients in the denominator
who had at least one serum
potassium test and one
serum creatinine test during
the measurement year.
Denominator
Patients who had at least
180 ambulatory treatment
days for ACE inhibitors or
ARBs during the
measurement year.
Annual
Monitoring for
Patients on
Persistent
Medications:
ACE/ARB
Denominator
Patients who had at least
180 ambulatory treatment
days for digoxin during the
measurement year.


At least 1 claim for a lab panel test AND
≥1 claims for a serum digoxin test during
the measurement year
OR at least 1 claim for a serum
potassium test AND ≥1 claims for serum
creatinine test AND at least 1 claim for a
serum digoxin test during the
measurement year
Denominator

Age >18 years on analysis date

Has member and prescription eligibility
during the measurement year, no more
than 1 gap of no more than 45 days

Has member and prescription eligibility
with no gaps on analysis date

Has at least a 180-day supply for digoxin
during the measurement year, translating
claims forward, including prescription
filled prior to the beginning of the
measurement year the days’ supply
overlaps with the measurement year

Has no claims from acute inpatient place
of service during the measurement year
OR has no claims from non-acute inpatient place of
service during the measurement year
Numerator

At least 1 claim for a lab panel during the
measurement year

OR at least 1 claim for serum potassium
and serum creatinine tests during the
measurement year.
Denominator

Age >18 years on analysis date

Has member and prescription eligibility
during the measurement year, no more
than 1 gap of no more than 45 days

Has member and prescription eligibility
with no gaps on analysis date

Has 180-day supply of ACE inhibitors or
ARBs during the measurement year,
translating claims forward, including
prescription filled prior to the
measurement year if the days supply
overlaps with the measurement year

Has no claims from acute inpatient place
of service during the measurement year

OR has no claims from Non-Acute
Inpatient place of service during the
measurement year
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2,
2015.
Latest Date of Service: Preserve the latest day of
service for the lab tests for all patients in
denominator.
28
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator Technical Specifications
Measure Citation
Annual
Monitoring
for Patients
on Persistent
Medications:
Diuretics
This measure identifies
patients age 18 or older
who had at 180
ambulatory treatment
days for diuretics during
the measurement year
who had at least 1 serum
potassium and 1 serum
creatinine therapeutic
monitoring test during the
measurement year.
Numerator
Patients in the denominator
who had at least one serum
potassium test and one
serum creatinine therapeutic
monitoring test during the
measurement year.
Denominator
Patients who had at least
180 ambulatory treatment
days for diuretics during the
measurement year.
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Numerator

At least 1 claim for a lab panel during the
measurement year

OR at least 1 claim for serum potassium
and serum creatinine tests during the
measurement year.
Denominator

Age >18 years on analysis date

Has member and prescription during the
measurement year, no more than 1 gap
of no more than 45 days

Has member and prescription eligibility
with no gaps on analysis date

Has 180-day supply of diuretics during
the measurement year, translating claims
forward, including prescription filled prior
to the measuremet year if the days
supply overlaps with the measurement
year

Has no claims from acute inpatient place
of service during the measurement year

OR has no claims from non-acute
inpatient place of service during the
measurement year
Latest Date of Service: Preserve the latest day of
service for the lab tests for all patients in
denominator.
29
CBMCT Version 010117V1
Sub-composite: Other Acute and Chronic Care Measurement
Measure
Description
Numerator/Denominator
Appropriate
Testing for
Children with
Pharyngitis
This measure identifies
children 2–18 years of age
who were diagnosed with
pharyngitis prior to or
during the measurement
year, dispensed an
antibiotic, and had a test
for group A streptococcus
for the episode. A higher
rate represents better
performance (i.e.,
appropriate testing).
Numerator
Numerator
Patients in the denominator

At least 1 claim for a group A strep test
who had a test for group A
within 3 days before or after the
streptococcus (strep) for the
pharyngitis onset date
episode of pharyngitis.
Denominator
Denominator

Age between 3 years 6 months and 18
years 6 months
Children age 2 to 18 who

AND at least 1 medical claim for
were diagnosed with
pharyngitis as a solitary primary diagnosis
pharyngitis and dispensed
between 30 and 365 days before the end
an antibiotic within 6
of the measurement year
months prior to the
o
Exclude claims from acute
measurement year or
inpatient or an outpatient facility
during the first 6 months of
that is followed by an ER visit
the measurement year.
within 2 days.

AND have active prescription for an
antibiotic from 0 to 3 days after
pharyngitis onset date

AND no prescription for antibiotic
medications dispensed from in the 30
days before the pharyngitis onset date

No prescription claims for antibiotic
medications occurring 30 days before the
onset date that were active on the onset
date (done by checking for MPR at least
80% on the onset date)

AND member eligibility in the month
before and 3 days after pharyngitis onset
date, with no gaps

AND prescription eligibility in the month
before and 3 days after pharyngitis onset
date, with no gaps
30
Technical Specifications
Measure Citation
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2,
2015.
CBMCT Version 010117V1
Measures
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Appropriate
Treatment for
Children with
Upper
Respiratory
Infection
This measure identifies
children age 3 months to
18 years who were
diagnosed with an upper
respiratory infection (URI)
who did not receive an
antibiotic prescription
within 3 days after
diagnosis.
Numerator
Patients in the denominator
who did not receive an
antibiotic prescription within
3 days after the diagnosis.
Numerator

No prescription claims for antibiotic
medications in the 3 days after the URI
diagnosis.
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2,
2015.
31
Denominator
Children age 3 months old
as of 18 months prior to the
end of the measurement
year to 18 years old 6
months prior to the end of
the measurement year who
were diagnosed with URI
between 545 and 180 days
prior to the end of the
measurement year.
Denominator

Age between 1 year 9 months and 18
years 6 months

At least1 claim for upper respiratory
infection, solitary diagnosis, 548 to 184
days before the analysis date from an
outpatient, observation, or ED setting
o
Exclude claims that are
followed by an acute inpatient
stay within 2 days to exclude
ER admissions that resulted in
an inpatient admission

No prescription claims for antibiotic
medications dispensed in the 30 days
after the URI diagnosis

No prescription claims for antibiotic
medications with an active days supply
on the date of URI diagnosis (done by
checking for medication possession ratio
of at least 80% on diagnosis date)

No claim for pharyngitis or competing
diagnosis in the 3 days after the URI
diagnosis

Member eligibility in the 30 days before
and 3 days after URI diagnosis, with no
gaps
Prescription eligibility in the 30 days before and 3
days after URI diagnosis, with no gaps
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator Technical Specifications
Measure Citation
Osteoporosis
Management
in Women
Who Had a
Fracture
This measure identifies
female patients 67 to 85
years of age who suffered
a fracture and had either
a BMD test or prescription
for a drug to treat or
prevent osteoporosis in
the six 6 after the fracture.
Numerator
Patients in the denominator
who had either a bone
mineral density test or a
prescription for a drug to
treat or prevent osteoporosis
in the 6 months after the
date of fracture.
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Denominator
Women who are 67 years or
older who suffered a bone
fracture during the 6 months
prior to the measurement
year or during the first 6
months of the measurement
year.
32
Numerator
Any one of the following within 180 days of OD:

At least 1 claim for bone mineral density
tests

OR at least 1 prescription claim for
osteoporosis medication
Denominator

Age between 67 and 85 years old on
analysis date

AND female

AND either of the following, saving
earliest claim as onset date (OD):
o
at least 1 discharge for
fractures from 548 to 184 days
before the analysis date in an
inpatient stay setting,
combining inpatient claims
connected by a transfer
o
OR at least 1 claim for
fractures from 548 to 184 days
before the analysis date, in an
outpatient, ED, or observation
setting

AND member eligibility from 365 days
before OD through 180 days after OD,
with no more than 1 gap of no more than
45 days.

AND prescription eligibility from 365 days
before OD through 180 days after OD,
with no more than 1 gap of no more than
45 days.

AND member and prescription eligibility
with no gaps on analysis date

AND no claim for fractures in the 60 days
before OD, in an outpatient, ED, inpatient
stay, or observation setting

AND no claims for bone mineral density
tests in the 2 years before OD, use
enddate

AND no claims for osteoporosis
medications in the year before OD, use
enddate
AND no prescription supply for osteoporosis
prescriptions in the year before OD, use end date
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Persistence of
Beta-Blocker
Treatment
After a Heart
Attack
This measure identifies patients
18 years of age and older
during the measurement year
who were hospitalized from 6
months prior to the
measurement year to 6 months
before the end of the
measurement year with a
diagnosis of acute myocardial
infarction (AMI) and who
received persistent beta-blocker
treatment for 6 months after
discharge.
Numerator
Patients in the denominator who
received persistent beta blocker
treatment for 6 months after
discharge.
Numerator

At least 135 days’ supply for a
beta blocker medication in the
179 days after being
discharged.
Denominator
Patients age 18 years or older
who were hospitalized with an
AMI 548 to 184 days before the
analysis date.
Denominator

Age at least 18 at analysis
date

Discharged from an acute
inpatient setting with an AMI
548 to 184 days before the
analysis date, saving the
earliest discharge date.*

Member and prescription
eligibility from discharge date
to 179 days after discharge
date, with no more than 1 gap
of no more than 45 days

Member and prescription
eligibility with no gaps on
discharge date
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Exclude

Hospitalizations in which the
member was transferred
directly to a nonacute inpatient
care setting for any diagnosis

Patients with a diagnostic
code from asthma, COPD,
obstructive chronic bronchitis,
chronic respiratory conditions
due to fumes or vapors, beta
blocker contraindications, or
asthma medications.
Departure from HEDIS specifications
It was not possible to exclude from the
denominator patients with intolerance or
allergy to beta blocker therapy , as this
information is not available from claims
data.
33
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Arthritis:
Disease
Modifying
Antirheumatic
Drug
(DMARD)
Therapy in
RA
This measure identifies
patients with a diagnosis
of rheumatoid arthritis
(RA) and who were
dispensed at least one
ambulatory prescription
for a disease-modifying
anti-rheumatic drug
(DMARD) during the
measurement year.
Numerator
Patients in the denominator who were
dispensed at least one ambulatory
prescription for a DMARD during the
measurement year.
Numerator
Either of the following during the
measurement year:

>=1 prescription claim
for DMARDs

OR >=1 procedure for
DMARD
National Committee
for Quality Assurance.
HEDIS 2016.
Washington, DC:
National Committee
for Quality Assurance.
Technical
Specifications Vol 2,
2015.
34
Denominator
Patients ≥18 years old with 2 face-to-face
physician encounters with different dates of
service in an outpatient or non-acute inpatient
setting during the first 11 months of the
measurement year with any diagnosis of RA.
Excludes patients diagnosed with HIV or who
were pregnant during the measurement year.
Denominator

Age at least18 years old
as of analysis date

At least 2 diagnoses of
RA in any position from
an inpatient stay or
outpatient settings
separated by at least 1
day in the 11 months
before the analysis date
(count nonacute
inpatient discharge*
date)

Medical and
prescription eligibility
during the
measurement year, with
no more than 1 gap of
no more than 45 days

Medical and Rx
eligibility with no gaps
on analysis date

No claims with a
diagnosis for HIV
anytime in the past

No claims with a
diagnosis for pregnancy
during the
measurement year
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specification
Measure Citation
Medication
Management
for People
with Asthma
The measure
identifies
patients
between 5 and
85 years old
during the
measurement
year who have
persistent
asthma and
were
appropriately
prescribed
medication
during the
measurement
year who
remained on
an asthma
controller
medication for
at least 75%
of their
treatment
period.
Numerator
Patients in the denominator
with a medication
possession ratio of at least
0.75 from the earliest
dispensing event to the
analysis date.
Numerator

Medication posession ratio at least 0.75 from earliest
dispensing event for preferred asthma medications to
analysis date.
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2,
2015.
35
Denominator
Patients between the age of
5 and 85 who have asthma.
Denominator

Age between 5 and 85 years as of the analysis date

AND by the following criteria:
o
Meets the following criteria

Claims for a diagnosis of asthma
during the measurement year
from an inpatient setting or from
an ED setting

OR at least 4 claims for a
diagnosis of asthma during the
measurement year from an
Outpatient setting or Observation
AND at least 2 prescription
claims for leukotrine antagonists,
asthma inhalers, or oral asthma
meds

OR at least 4 four claims for any
combination of leukotrine
antagonists, asthma inhalers, or
oral asthma meds during the
measurement year AND, if all 4
claims were for leukotriene
antagonists, a claim for an
asthma diagnosis
o
AND meets the following criteria:

Claims for a diagnosis of asthma
in the year before the
measurement year from an
inpatient setting or from an ED
setting

OR at least 4 claims for a
diagnosis of asthma in the year
before the measurement year
from an Outpatient setting or
Observation AND at least 2
prescription claims for leukotrine
antagonists, asthma inhalers, or
oral asthma meds

OR at least 4 four claims for any
combination of leukotrine
antagonists, asthma inhalers, or
oral asthma meds in the year
before the measurement year
AND, if all 4 claims were for
leukotriene antagonists, a claim
for an asthma diagnosis

AND medical eligibility in the measurement year and
the year before the measurement year, with no more
than 1 gap of no more than 45 days during each year
of the 2-year period

AND prescription eligibility during the measurement
year

Medical and prescription eligibility without gaps on
analysis date

Exclude patients with emphysemal, COPD, chronic
respiratory conditions due to fumes/vapors, acute
respirtatory failure, cystic fibrosis, or obstructive
chronic bronchitis.
Exclude patients with no claims for preferred asthma
medications during the measurement year
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specification
Measure Citation
New
Episode of
Depression:
Effective
Acute Phase
Treatment
The
percentage of
patients 18
years of age
and older with
a diagnosis of
major
depression
and were
treated with
antidepressant
medication,
and who
remained on
an
antidepressant
medication
treatment for
at least 84
days (12
weeks).
Numerator
Patients in the denominator with a
medication possession ratio of at
least 0.73 for their antidepressant
medication.
OD: The date of the earliest dispensing
event for an antidepressant medication
during the intake period. The intake period
is the 12-month window starting on May 1
(609 days before analysis date) of the
year prior to the measurement year and
ending on April 30 (245 days before
analysis date) of the measurement year.
National Committee for Quality
Assurance. HEDIS 2016.
Washington, DC: National
Committee for Quality Assurance.
Technical Specifications Vol 2, 2015.
36
Denominator
Patients age at least 18 years and
8 months who were diagnosed with
major depression and treated with
antidepressant medication.
Numerator

Days supply for antidepressant
medications in the 114 days
following OD with a medication
possession ratio of at least 0.73
Denominator

Age at least 18 years and 8
months as of analysis date

AND member eligibility from
105 days before to 231 days
after the OD, with no more than
1 gap of no more than 45 days

AND prescription eligibility from
from 105 days before to 231
days after OD, with no more
than 1 gap of no more than 45
days

AND member and prescription
eligibility with no gaps on OD

AND prescription dispensed for
antidepressant medications
during the intake period, save
earliest as OD

AND no prescription dispensed
for antidepressant medications
in the 105 days before OD

AND discharge for major
depression concurrent with
inpatient stay 60 days before or
after OD

OR claims for major depression
in any diagnosis position 60
days before or after OD
concurrent WITH ANY of the
following:
o
Claims for AMM
Stand Alone Visits
o
OR claims for ED
OR claims for AMM visits with point of
service roll-up of major depression
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specification
Measure Citation
New
Episode of
Depression:
Effective
Continuation
Phase
Treatment
This measure
identifies
patients 18
years of age
and older with
a diagnosis of
major
depression
and were
treated with
antidepressant
medication,
and who
remained on
an
antidepressant
medication
treatment for
at least 180
days (6
months).
Numerator
Patients in the denominator who
were maintained on antidepressant
therapy for at least 180 days in the
231-day period following the
earliest dispensing event.
OD: The date of the earliest dispensing
event for an antidepressant medication
during the intake period. The intake period
is the 12-month window starting on May 1
(609 days before analysis date) of the
year prior to the measurement year and
ending on April 30 (245 days before
analysis date) of the measurement year.
National Committee for Quality
Assurance. HEDIS 2016.
Washington, DC: National
Committee for Quality Assurance.
Technical Specifications Vol 2, 2015.
37
Denominator
Patients with at least one
dispensing event for an
antidepressant medication during
the 12-month window starting on
May 1 of the year prior to the
measurement year and ending on
April 30 of the measurement year,
with a diagnosis of major
depression within 60 days from the
earliest dispensing event.
Numerator

Days supply for antidepressant
medications in the 231 days
after OD with a medication
posession ratio of at least 0.78
Denominator

Age at least 18 years and 8
months as of analysis date

AND member eligibility from
105 days before to 231 days
after the OD, with no more than
1 gap of no more than 45 days

AND prescription eligibility from
from 105 days before to 231
days after OD, with no more
than 1 gap of no more than 45
days

AND member and prescription
eligibility with no gaps on OD

AND prescription dispensed for
antidepressant medications
during the intake period, save
earliest as OD

AND no prescription dispensed
for antidepressant medications
in the 105 days before OD

AND discharge for major
depression concurrent with
inpatient stay 60 days before or
after OD

OR claims for major depression
in any diagnosis position 60
days before or after OD
concurrent with any of the
following:
o
Claims for AMM
Stand Alone Visits
o
OR claims for ED
OR claims for AMM visits with point of
service roll-up of major depression
CBMCT Version 010117V1
Preventive Measures
Sub-composite: Pediatric Prevention
Measure
Description
Numerator/Denominator
Technical Specifications
Childhood
Immunization
Status: MMR
The percentage of
children 2 years of
age during the
measurement year
who had one
measles, mumps and
rubella (MMR) by
their second birthday.
Numerator
Patients in the denominator
who have had at least one
MMR vaccination on or before
the child’s second birthday.
Numerator
One of the following within 730 days of birth:

At least 1 claim for measles, mumps, or
rubella

OR at least 1 claim for MMR vaccine
administered in any procedure position

OR at least 1 claim for each of
o
Measles vaccine administered
in any position OR a measles
diagnosis
o
Mumps vaccine administered
in any position OR a mumps
diagnosis
o
Rubella vaccine administered
in any position OR a rubella
diagnosis

OR at least 1 claim for each of
o
Measles/rubella vaccine
administered in any procedure
position
o
AND mumps vaccine
administered in any procedure
position OR a mumps
diagnosis
Denominator
Enrolled children who turn 2
years of age during the
measurement year, excluding
children with history of
anaphylactic reaction to
immunizations, malignant
neoplasm of lymphatic tissue,
HIV or other disorders of the
immune system.
Denominator

Between 2 years and 3 years old as of
analysis date

AND have medical eligibility between the
ages of 1 and 2 (i.e., 365-730 days after
birth), with no more than 1 gap of no
more than 45 days

AND have medical eligibility with no gaps
on (730 days after birth)

AND no claims for anaphylactic reaction
due to vaccine within 730 days of birth

AND no claims for malignant neoplasm
of lymphatic tissue, disorders of the
immune system, or HIV anytime within
730 days of birth (before the child's
second birthday)
Deviation from HEDIS specification
Numerator criterion looking for "A seropositive test
result for each antigen" not implemented. Code
sets not provided by NCQA.
Exclusion Step “Anaphylactic reaction to neomycin”
unable to implement due to unavailability of the
EMR data.
38
CBMCT Version 010117V1
Measure
Citation
National
Committee for
Quality Assurance.
HEDIS 2016.
Washington, DC:
National
Committee for
Quality Assurance.
Technical
Specifications Vol
2, 2015.
Measures
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Childhood
Immunization
Status: VZV
This measure
identifies patients 2
years of age who had
chicken pox (VZV)
shot by their second
birthday.
Numerator
Patients in the denominator
who have had at least one VZV
vaccination on or before the
child’s second birthday.
Numerator

At least 1 claim for varicella zoster or
varicella zoster vacaccine administered
from date of birth (DOB) to DOB + 731, all
procedure positions
Denominator
Enrolled children who turn 2
years of age during the
measurement year, excluding
children with history of
anaphylactic reaction to
immunizations, malignant
neoplasm of lymphatic tissue,
HIV or other disorders of the
immune system.
Denominator

Age between 2 and 3 years as of analysis
date (save DOB as start date)

AND Have medical eligibility between
DOB +365 and DOB + 730 with no more
than 1 gap of no more than 45 days.

AND Have med eligibility with no gaps on
Anchor Date (DOB + 730)

AND no claims for anaphylactic reaction
due to vaccine from DOB to DOB + 730

AND No claims for malignant neoplasm of
lymphatic tissue or disorders of the
immune system or HIV anytime from DOB
to DOB + 730 (before the child's second
birthday)
National Committee
for Quality
Assurance. HEDIS
2016. Washington,
DC: National
Committee for
Quality Assurance.
Technical
Specifications Vol 2,
2015.
Deviation from HEDIS specifications
Numerator criterion looking for a seropositive test
result for each antigen not implemented. Code sets
not provided by NCQA. Exclusion Step
“Anaphylactic reaction to neomycin” unable to
implement due to unavailability of the EMR data.
39
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Well-Child
Visits Ages 015 Months
The percentage of patients
who turned 15 months old
during the measurement
year and who had 6 wellchild visits during their first
15 months of life
Numerator
Numerator
Patients in the denominator who

At least 6 claims for
have had at least 6 office visits during
well-care visits during
their first 15 months of life.
their first 15 months
of life.
Denominator
Denominator
Children who turned who turned 15

Children who turned
months old during the measurement
15 months old during
year.
the measurement
year.
AND have medical service
eligibility between 31 days and
15 months of age.
Well-Child
Visits Ages 36 Years Old
The percentage of patients
3–6 years of age who had
one or more well-child visits
with during the
measurement year.
Numerator
Patients in the denominator who
have had at least one well-child visit
during the measurement year.
Denominator
Children who are 3–6 years as of the
end of the measurement year.
Technical Specifications
Numerator

At least 1 claim for a
well-care visit during
the measurement
year.
Measure Citation
National Committee for Quality
Assurance. HEDIS 2016.
Washington, DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2, 2015.
National Committee for Quality
Assurance. HEDIS 2016.
Washington, DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2, 2015.
Denominator

Children who are 3–6
years of age as of the
end of the
measurement year.
AND have service eligibility
during the entire measurement
year.
Well-Child
Visits Ages
12-21 Years
Old
40
The percentage of patients
12–21 years of age who
had at least one well-child
visits during the
measurement year.
Numerator
Patients in the denominator who
have had at least one well-child visit
during the measurement year.
Denominator
Children who are 12–21years of age
as of the end of the measurement
year.
Numerator

At least 1 claim for a
well-care visit during
the measurement
year.
National Committee for Quality
Assurance. HEDIS 2016.
Washington, DC: National
Committee for Quality
Assurance. Technical
Specifications Vol 2, 2015.
Denominator

Children who are 12–
21 years of age as of
the end of the
measurement year.
AND have service eligibility
during the entire measurement
year.
CBMCT Version 010117V1
Sub-composite: Adult Prevention
Measures
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Breast Cancer
Screening
The percentage of women
50-74 of age who had a
mammogram to screen for
breast cancer.
Numerator
Patients in the denominator who
had a mammogram in the 2 years
and 3 months before the analysis
date.
Numerator

At least 1 procedure
claim for mammography
in the 2 years and 3
months prior to the
analysis date
National Committee for
Quality Assurance. HEDIS
2016. Washington, DC:
National Committee for
Quality Assurance. Technical
Specifications Vol 2, 2015.
Denominator
Female patients between the age
of 52 and 74 with no claims for a
bilateral or unilateral mastectomy
or breast cancer.
Denominator

Female

Age between 52 and 74
years old

AND member eligibility
from in the year before
the measuremen year
with no more than 1 gap
of no more than 45 days

AND member eligibility in
the measuremen year
with no more than 1 gap
of no more than 45 days

AND member eligibility
with no gaps on analysis
date
Exclusions
Any of the following

At least 1 claim for
bilateral mastectomy at
any time in the past

At least 2 claims for
unilateral mastectomy
separated by at least 14
days at any time in the
past

At least 1 claim for
unilateral mastectomy
with bilateral modifier

Identified by the following
criteria:

At least 18 years old

AND at least 2 claims for
breast cancer in any
position coming from
office visit with activity
gap of 30 days

OR have at least 1 claim
for breast cancer in any
position from a hospital or
ER

At least 1 claim for history
of bilateral mastectomy at
any time in the past

At least 1 claim for
unilateral mastectomy
with modifier code right
modifier at any time in the
past and at least 1 claim
for unilateral mastectomy
with modifier code left
modifier at any time in the
past

At least 1 claim for
absence of left breast at
any time in the past

AND at least 1 claim for
absence of right breast at
any time in the past
CONTINUED NEXT PAGE
41
CBMCT Version 010117V1
Sub-composite: Adult Prevention
Measures
Description
Numerator/Denominator
Technical Specifications
Measure Citation
(Continued)

At least 1 claim for
unilateral mastectomy left
at any time in the past

AND at least 1 claim for
unilateral mastectomy
right at any time in the
past
Note: The breast cancer
exclusion is a deviation from
the HEDIS 2016
specifications. This has been
implemented after discussing
with the PC2 group, since the
follow up for breast cancer
patients is typically performed
by oncologists (PCPs are less
involved). Sustained member
eligibility was defined as 2
years prior to analysis date as
opposed to 2 years and 3
months prior to analysis date,
as defined by HEDIS. This
was done to limit the impact on
the denominator count.
Cervical
Cancer
Screening
This measure identifies
women between 21 and 64
years of age who had a
cervical cancer screening
during the measurement
year or the two years prior
to the measurement year
or who had cervical
cytology/ HPV co-testing
performed in the last 5
years.
Numerator
Patients in the denominator who
had at least 1 claim for cervical
cytology in the past three years or,
for those age 30-64, at least 1
claim for cervical cytology and at
least 1 claim for an HPV test in the
past 5 years.
Denominator
Female patients between the ages
of 24 and 65.
Numerator
For women 24-64 years of
age:
• at least 1 claim for cervical
cytology in the past 3 years.
National Committee for
Quality Assurance. HEDIS
2016. Washington, DC:
National Committee for
Quality Assurance. Technical
Specifications Vol. 2, 2015.
For women 30-64 years of age
on the service date of both:
• at least 1 claim for cervical
cytology AND at least 1 claim
for HPV Tests less than 4 days
apart* in last 5 years.
Denominator
• Age between 24 and 65 as of
the analysis date
• Female gender
• Member eligibility from 2
years prior to the
measurement year, with no
more than 1 gap of no more
than 45 days
• Member eligibility in the year
before the measurement year,
with no more than 1 gap of no
more than 45 days
• Member eligibility in the
measurement year, with no
more than 1 gap of no more
than 45 days
• Member eligibility with no
gaps on analysis date
Exclusion
• Patients who had any
diagnosis of Absence of Cervix
at any time in the past
.
42
CBMCT Version 010117V1
Utilization Measures
Utilization Measures
Measure
Description
Numerator/Denominator
Ambulatory
Care Sensitive
Admissions
The composite Ambulatory
Care Sensitive Admissions
rate per 1,000 patients age
18 and older during the
measurement period.
Numerator
The composite count of Ambulatory
Care Sensitive Admissions during
the reporting period.
Denominator
Total Member Months for the
eligible population for the
designated time period
Rate
(Numerator  Denominator) x
12,000
Technical
Specifications
Numerator
The composite count of
admissions for patients age
18 and older for the
following conditions:
Angina ;
Asthma/Bronchitis
Chronic Obstructive
Pulmonary Disease (COPD)
Dehydration
Diabetes
Heart Failure
Hypertension
Pneumonia
Urinary Tract Infection
Measure Citation
Internally developed.
Informed by the Agency for
Healthcare Research and
Quality (AHRQ) Prevention
Quality Indicators. AHRQ
Quality Indicators, Version
4.4, March 2012.
Denominator
The count of eligible
patients (age 18 and older)
for each month of eligibility
for the designated time
period
Exclusions
patients under the age of
18
Sub-acute admissions to
Skilled Nursing Facility
(SNF)
43
CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Pediatric
Ambulatory
Care Sensitive
Admissions
(continued on
next page)
The composite Ambulatory
Care Sensitive Admissions
rate per 1,000 pediatric
patients under 18 years.
Note: this measure only
applies to Pediatricians.
Numerator
The composite count of Pediatric
Ambulatory Care Sensitive
Admissions during the reporting
period.
Separate Numerator and
Denominators are calculated
for the two Pediatric
Ambulatory Care Sensitive
Admissions – Asthma and
Gastroenteritis.
Internally developed.
Informed by the Agency for
Healthcare Research and
Quality (AHRQ) Pediatric
Quality Indicators. AHRQ
Quality Indicators, Version
4.4, March 2012.
Denominator
Total Member Months for the eligible
population for the designated time
period
Rate
(Numerator  Denominator) x 12,000
Pediatric Asthma
Numerator
Discharge ages 2 through
17years during the
measurement period with a
primary diagnosis of asthma.
Exclusions
Transfers to sub-acute facilities
Any admission with any
diagnosis for cystic fibrosis and
anomalies of the respiratory
system.
Denominator
The count of eligible patients
(ages 2 through 17 years) for
each month of eligibility for the
designated time period.
(continued on next page)
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CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Technical Specifications
Measure Citation
Pediatric
Ambulatory
Care Sensitive
Admissions
(continued)
The composite Ambulatory
Care Sensitive Admissions
rate per 1,000 pediatric
patients under 18 years.
Note: this measure only
applies to Pediatricians.
Numerator
The composite count of Pediatric
Ambulatory Care Sensitive
Admissions during the reporting
period.
Separate Numerator and
Denominators are calculated for the
two Pediatric Ambulatory Care
Sensitive Admissions – Asthma and
Gastroenteritis.
Denominator
Total Member Months for the
eligible population for the
designated time period
Rate
(Numerator  Denominator) x
12,000.
Pediatric Gastroenteritis
Numerator
Discharge ages 3 months through
17 years during the measurement
period with a primary diagnosis code
of gastroenteritis OR a secondary
diagnosis code of gastroenteritis and
a primary diagnosis of dehydration.
Primary
Exclusions
Transfers to sub-acute facilities
Any admission with any diagnosis
code of gastrointestinal
abnormalities or bacterial
gastroenteritis.
Internally developed.
Informed by the Agency
for Healthcare Research
and Quality (AHRQ)
Pediatric Quality
Indicators. AHRQ Quality
Indicators, Version 4.4,
March 2012.
Denominator
The count of eligible patients (ages
2 months through 17 years) for each
month of eligibility for the designated
time period
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CBMCT Version 010117V1
Measure
Description
Numerator/Denominator
Generic
Dispensing
Rate for
Specific
Therapeutic
Classes
(GDR)
The percentage of
prescriptions filled as
generics in five selected
therapeutic classes where
opportunity for therapeutic
substitution is deemed to
be high. The five
therapeutic classes are:
Statins
ADHD Medications
ARBs and ARB
Combinations
Beta Blockers and Beta
Blocker Combinations
Serotonin Agonists and
Serotonin Agonist
Combinations(Migraine
Medications)
Numerator
The number of generic prescriptions
filled in five therapeutic classes for the
eligible population for the designated
time period.
Technical Specifications
Numerator
The total number of denominator
prescribing events that are
dispensed for a generic drug
(defined by NDC code drug
brand/generic indicator).
Denominator
.
Total number of total prescriptions filled Denominator
in five therapeutic classes for the
Total number of prescriptions with
eligible population for the designated
fill dates in the measurement period
time period
for the following five specified
Rate
therapeutic classes :
Statins
(Numerator  Denominator) *100
ADHD Medications
ARBs and ARB combos
Beta Blockers and Beta Blocker
Combinations
Serotonin Agonists and Serotonin
Agonist Combinations(Migraine
Medications)
Measure Citation
Internally developed.
Note: HEDIS definition of a
dispensing event used—each 30
day supply of drug counts as one
denominator event.
Potentially
Avoidable
Emergency
Room Visits
The rate of Potentially
Avoidable Emergency
Room visits per
1,000patients.
Numerator
The number of potentially avoidable
emergency room visits for the eligible
population for the designated time
period.
Denominator
Total Member Months for the eligible
population for the designated time
period
Rate
(Numerator  Denominator) x 12,000
Numerator
Emergency room visits identified by
the presence of UB revenue codes.
Potentially avoidable emergency
room visits are identified by primary
ICD-10 diagnosis codes.
Internally developed.
Informed by research
conducted by The NYU
Center for Health and
Public Service Research
and the United Hospital
Fund of New York
Denominator
The count of eligible patients for
each month of eligibility for the
designated time period
Exclusions
Emergency room visits that resulted
in 1) an inpatient admission or 2) a
surgical procedure
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of the Anthem Insurance Companies, Inc. ® The Blue
Cross name and symbol are registered marks of the Blue Cross Association
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CBMCT Version 010117V1