PCP Profile
The PCP Profile Index is a measure of the utilization of the entire health care resources by the PCP’s panel of patients (actual expenses in dollars Per Member Per Month or “PMPM”). It is compared to the average utilization of the health care resources by all other members in the health plan (expected expenses in dollars PMPM), controlled for age, sex, and principle diagnoses of the PCP’s specific panel of patients. An index or a comparative measure of 1.00 denotes overall utilization performance equal to the average of all peers. An index of greater than 1.00 indicates how much more resources were used compared with peers for the same type of patients. An index of less than 1.00 measures the level of utilization less than peers for the same type of patients. To be eligible for the PCP Profile portion, the practice must have an average of 150 members each month, or at least 450 member months for the quarter reviewed must be maintained in conjunction with a profile index of less than or equal to 1.00.
Member Satisfaction
The Plan utilizes its member complaint data to produce the Provider Recognition Program PCP member satisfaction reports. Data is compiled twice annually, reflecting a six-month period. PCP groups are stratified by panel size for statistically appropriate peer group comparisons. Peer group one includes panel sizes of greater than 259 members, peer group two includes panel sizes of 110 up to 259 members, and peer group three includes panel sizes of less than 110 members. The rate is calculated by dividing the total number of member complaints against the PCP group by the total number of PCP panel member months during reporting period, multiplying the quotient times 1000. Results of each PCP group are then compared against one another in like peer groups. Qualifying PCP groups will score at or below the mean.
Total # member complaints against the PCP group |
= |
Y |
Total # PCP panel member months during reporting period |
Y x 1000 = group rate
Health Outcomes
Please note that methodology for reimbursement rewards excellence and improvement. Passport Health Plan has selected to utilize the National Committee for Quality Assurance’s (NCQA) methodology for achieving statistically significant improvement.
- Breast Cancer Rates
The breast cancer screening rate is a new measure performed in accordance with HEDIS®. It is based on the percentage of women ages 40 to 69 who received a mammogram either during the measurement year or during the year prior to the measurement year.
- Cervical Cancer Rates
The cervical cancer screening rate is a new measure performed in accordance with HEDIS®. It is based on the percentage of women ages 21 to 64 who received one or more pap tests either during the measurement year or during the two years prior to the measurement year.
- Chlamydia Screening Rates
The chlamydia screening rate is a new measure performed in accordance with HEDIS®. It is based on the percentage of women ages 16 to 25 who were identified as sexually active and who obtained at least one test for chlamydia during the measurement year.
- EPSDT Screening and Participation Rates
The EPSDT screening rate is calculated using the current CMS 416 logic. This rate indicates the extent to which EPSDT eligibles receive the number of initial and periodic screening services required by the Plan’s periodicity schedule, adjusted by the proportion of the year for which they are eligible for Medicaid.
The EPSDT participation rate is also calculated using the current CMS 416 logic. This rate indicates the number of unduplicated count of members who received at least one documented initial or periodic screening service during the year, in accordance with the Plan’s periodicity schedule and the average period of eligibility.
Access to Care
- Emergency Room Utilization
Emergency room utilization is a new measure performed in accordance with HEDIS®. It is based on the total number of ER visits within the reporting period by the total member months. Total plan data is reported in a per 1000 member month rate. Member months are obtained from members included in the annual HEDIS® report and assigned to the provider by individual month. Any ER visits would be attributed to the provider the member was assigned to on the date of service.
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