Criteria and Methodology

• Criteria used must be objective, reasonable, and must disclose all known flaws in methodology used.
• Payer performance programs should incorporate the use of non-claims based data when available, such as national registry data and physician recognition programs, that rely on practice-collected all-payer data. Current examples include NCQA Provider Recognition Programs and Maintenance of Certification Part IV practice improvement modules. Soon, Health Information Exchange has the potential to provide this sort of clinical data for performance measurement purposes. Economic profiling unrelated to quality should not occur; however any supplemental data used must be clearly defined and explained.
• Established criteria and methodology must be evidence-based and nationally recognized by the National Quality Forum, the Ambulatory Care Quality Alliance or the National Committee on Quality Assurance.
• Basis for criteria and methodology should be made available to the public in an understandable manner, providing a disclaimer that economic efficiencies as determined by the third party payer may not equate to inefficiencies in practitioner quality.
• Measures must be risk adjusted when necessary and specialty-specific severity adjustments must be made when appropriate.
• Methodology for determining and addressing outlier scenarios must be clearly explained by a third party payer prior to measuring practitioners.
• Methodology used to attribute episodes of care to specific practitioners must be fully explained by a payer and and look-back period specifically defined.

Certification of Data

• The data and methodologies used in a third party payer’s performance measurement program should be audited and certified by an independent quality assessment organization.
• The North Carolina Department of Insurance must hold the authority and responsibility for ensuring that performance measurement programs adequately protect practitioners and patients.
• Any penalties imposed on a practitioner for failure to report on measures, or for other violations of a performance measurement program agreement or policy must be reasonable and clearly identified by the third party payer.
  Implementation

• Practitioners must be given proper notice of a performance measurement program prior to its implementation, ample time to review data to be analyzed, and the opportunity to appeal prior to publication of any designation.
• A practitioner must be allowed to discuss details of his/her assessment with a peer clinician representative of the third party payer. The peer clinician should have access to the practitioner’s data, applicable metrics, the assessment, and should hold the authority to make appropriate adjustment to the practitioner’s assessment.
• An appeal process must be clearly defined and available to all practitioners.
• All costs associated with the creation and certification of data in a performance measurement program must be the sole responsibility of the third party payer.
• Any contract provision requiring a practitioner to submit data to a third party payer for performance measurement must also allow for adequate payment to the practitioner for that data reporting.
• Practitioners must be clearly informed regarding how their information will be used and how designations will be made available to patients or the public.
• Third party payers must avoid performance measurement programs that may adversely impact a patient’s ability to access primary care or specialty care in their geographic area, which may occur through limitations on coverage or increased co-pays or co-insurance.