Your session is about to expire

Your session will automatically expire in  seconds.

   
Skip Navigation Links

Physician Quality Measurement (PQM)  Program Description

The Physician Quality Measurement (PQM) program displays physician performance measures to assist members in selecting a provider. The PQM program displays nationally endorsed and evidence-based physician quality performance measures along with supporting data, local comparison norms, and educational consumer information.

The Blues® believe that care improvement comes from a combination of measuring what can be measured, promoting ongoing practice improvement, and recognizing the champions of care delivery.  PQM is the Blue program that supports making measured performance information available to consumers. 

The Healthcare Effectiveness Data and Information Set (HEDIS) is a National Committee for Quality Assurance (NCQA) tool widely used by health plans to measure performance on important dimensions of care. Results for specific HEDIS® physician performance measures are  be displayed for Primary Care Physicians (PCPs) for whom Blue Cross and Blue Shield of Montana (BCBSMT) has a valid member sample available

Many doctors work in group medical practices or clinics. Clinic or group level measurement is done to create a team approach to improving care within the group and to make sure that there are enough patients to calculate meaningful results.  The performance data is aggregated for all physicians in the physicians practice group for each measure.

 Patient Condition  Quality Measures 
 Breast Cancer  Breast cancer screening is used to find cancers before they start to cause symptoms in a person.  Early detection has saved thousands of lives every year because it allows doctors to make a diagnosis when the cancer tends to be smaller, has not spread, and there is a greater likelihood of a good outcome.  Breast Cancer Screen Rate is the number of women members, aged 42 to 69 years, who had a mammogram done during the measurement year or the year prior to the measurement year, expressed as a percentage of the total number of women members, aged 42 to 69 years at the end of the measurement period.  It excludes women who had a bilateral mastectomy or two unilateral mastectomies on different service dates any time prior to or during the measurement period, based on claims included in the database.  This measure is based on results returned by the Rules Engine for the Breast Cancer Screen measure that includes continuous enrollment criteria.  Sources: NQF (endorser); NCQA (owner) 2011
 Cervical Cancer  Cervical cancer screening is done to find cell changes (cancer) in the lower end of a woman's womb (cervix). Doctors screen for early cervical cancers before cell changes cause symptoms and when successful treatment is likely. Early detection has helped save thousands of lives every year.  Cervical Cancer Screen Rate is the number of women members, aged 24 to 64 years, who had a Pap test done during the measurement year or in the two years prior to the measurement year, expressed as a percentage of the total number of women members aged 24 to 64 years.  It excludes women who had a hysterectomy with no residual cervix any time prior to or during the measurement period, based on claims included in the database.  This measure is based on results returned by the Rules Engine for the Cervical Cancer Screen measure that includes continuous enrollment criteria.  Sources: NQF (endorser); NCQA (owner) 2011
 Diabetes  Diabetes is a disease that keeps the body from making or using insulin, a hormone that helps cells absorb blood sugar (glucose), so it can be available for your body to use as energy. When blood sugar is too high, it can lead to other problems such as heart disease, kidney disease, blindness, and loss of limbs. People who have diabetes have at least two times greater risk of heart disease and stroke than those who do not. 

People with diabetes need to keep both their blood sugar (glucose) levels and cholesterol levels within a healthy range.

The HbA1C
test is used to measure blood sugar control over several months. Overall, the closer HbA1C is to normal, the lower the risk for complications such as eye disease, heart disease, kidney disease, nerve damage, and stroke. Doctors are measured on the percentage of patients with diabetes whose blood sugar (glucose) was appropriately monitored using HbA1C testing.

Lipid tests are more commonly called cholesterol tests, lipid profiles or lipid panels, as well as coronary risk panels. They are a set of blood tests designed to measure the amount of fatty substances, specifically cholesterol and triglycerides, within the human body. Since high levels of the two organic compounds usually produce no symptoms, lipid tests are essential for detecting the presence or likelihood of the heart disease they can eventually cause.
 Diabetes HbA1c Test Rate is the number of patients with type 1 or type 2 diabetes, aged 18 to 75 years, who had an HbA1c test done, expressed as a percentage of the total number of patients, aged 18 to 75 years, with type 1 or type 2 diabetes.  It excludes patients with a diagnosis of gestational diabetes or steroid-induced diabetes any time prior to or during the measurement period, based on claims included in the database.  This measure is based on results returned by the Rules Engine for the Diabetes HbA1c Test measure that includes continuous enrollment criteria.  Sources: NQF (endorser); NCQA (owner) 2011

Diabetes Lipid Test Rate is the number of patients with type 1 or type 2 diabetes, aged 18 to 75 years, who had a lipid test done, expressed as a percentage of the total number of patients, aged 18 to 75 years, with type 1 or type 2 diabetes.  It excludes patients with a diagnosis of gestational diabetes or steroid-induced diabetes any time prior to or during the measurement period, based on claims included in the database.  This measure is based on results returned by the Rules Engine for the Diabetes Lipid Test measure that includes continuous enrollment criteria.  Source: NCQA (owner) 2011
 Heart Disease (Coronary Artery Disease)  Heart disease, also known as cardiovascular disease or coronary artery disease, is one of the leading causes of death.  It reduces the ability of your heart and blood vessels to work correctly. When this happens, your heart or brain does not receive needed oxygen and nutrients which can cause a heart attack (acute myocardial infarction) or a stroke (cerebral vascular accident). Patients who have one heart attack or stroke have a higher risk for another heart attack or stroke.  These patients need to be checked regularly by a doctor to reduce their risk of a repeat occurrence.  This measurement category contains two of the individual performance measures for screening and medicating patients with heart disease.

Lipid tests are more commonly called cholesterol tests, lipid profiles or lipid panels, as well as coronary risk panels. They are a set of blood tests designed to measure the amount of fatty substances, specifically cholesterol and triglycerides, within the human body. Since high levels of the two organic compounds usually produce no symptoms, lipid tests are essential for detecting the presence or likelihood of the heart disease they can eventually cause.  
 CAD Lipid Test Rate is the number of patients with coronary artery disease, aged 18 years and older, who had at least one lipid profile or all component tests done, expressed as a percentage of the total number of patients, aged 18 years and older, with coronary artery disease.  This measure is based on results returned by the Rules Engine for the CAD Lipid Test measure that includes continuous enrollment criteria.  Source: AMA PCPI/ACC/AHA (owner) 2007

Physician Quality Measures Calculation Methodology

Blue Cross and Blue Shield of Montana used Thomson Reuters’ Rules Engine methodology to derive the scoring methodologies used in the Physician Quality Measurement (PQM) ratings, based on select HEDIS® physician performance measures.  Below is a description of that methodology and the details of the specific HEDIS measures included in the PQM rating calculations:     

The Rules Engine
• Has measures that are directed to patient conditions and their expected care
• Verifies each patient condition against criteria for that condition, including any relevant exclusion criteria
• Identifies the provider responsible for the care of the condition
• Checks whether the care was received
• Applies continuous enrollment to each measure as defined in each measure specification

The score is calculated as the number of patients in the physician practice who received the recommended treatment (numerator or n) divided by the number of patients in the practice who should have received the treatment (denominator or d) and converted to a percentage (n/d100).  This tells you the percentage of patients who received care for an individual measure according to the clinical guidelines.

Physician Quality Ratings

Ratings indicate whether the doctor or group/clinic performance was above, at, or below the local average. 

Scoring Details
• Measurement was done for five individual measures
• Measurement was calculated at the individual primary care physician level and calculated as an aggregate at the Physician Tax ID level for the physician group.
• Criteria of 30 instances as a minimum number of observations to display a “star” designation for physicians

Thresholds are the two measurement points that classify provider performance into three levels as compared to a local norm.  Performance results above the upper threshold are classified as Above the Average.  Results that fall below the lower threshold are considered Below Average.  All other results are classified as Average.

The “star” designations of the results are as follows:

Percentile 
 
Number of Stars
 Above the 75th percentile  ***
 Between the 25th and 75th percentile  **
 Below the 25th percentile  *
 Not Enough Data to Report  ND

Performance information for physicians, group practices and/or clinics in Montana is published as of 7/9/12 for the measurement period from 1/1/11 through 12/31/11.  Note that the claims period may vary by individual measure and may include claims with dates of service prior to the measurement period to ensure accuracy and statistical validity.

 
 
Linked In
Follow us on TwitterFind us on Facebook     A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
     Association.   © Copyright 2013 Health Care Service Corporation. All Rights Reserved
PhysicianQualityMeasures PhysicianQualityMeasures