NY Manual
SHP Manual

New York Provider Manual
14.5 Quality Improvement – Medicare | 15.1 Provider Notice Requirements – Medicare

14.6 Quality Evaluation of Providers

Healthfirst uses standardized and evidence-based tools to evaluate the quality of providers acting as Primary Care Physicians for our members.  Healthfirst evaluates the quality of providers using their Overall Quality Rating (OQR), a numerical score on a scale of 1.0 to 5.0 that summarizes the provider’s weighted average performance on select quality measures.  The quality measures used to determine OQR (as well as their cut points and target rates) are informed by Medicare STARS and the New York State Department of Health Medicaid Incentive Program which are updated on a yearly basis. Healthfirst’s detailed methodology for calculating OQR is available upon request.  A list of the quality measures commonly used for OQR calculation(s) is available in Appendix XVII.

Providers are evaluated on the following domains for quality:

·         Adult and Pediatric Preventive Care, including measures related to well-care visits, screenings and immunizations 

·         Chronic Care Management, including measures related to asthma, diabetes and HIV treatment

·         Acute Care Management, including measures related to pharyngitis and bronchitis

·         Efficiency of Care, including measures related to hospital utilization rates and medication adherence

·         Enrollee Experience and Satisfaction with Care

Providers’ OQRs are calculated by line of business.  Providers will have access to their quality data and OQRs through Healthfirst reporting tools.  Healthfirst will review Providers’ OQRs throughout the calendar year (January-December).  Healthfirst will calculate and share Final OQRs with Providers included in the evaluation by late Q2 or early Q3 of the following year. 

Healthfirst will engage Providers falling at or below the Minimum Quality Rating (MQR) for the Provider network.  Each MQR will be no higher than 3.0 and Providers will only be evaluated against the MQR if they have at least ten valid quality measures they can be evaluated on.  Providers will be notified if they are at or below the MQR throughout the year via engagement with Network Management or Clinical Quality Managers.  Providers whose Final OQR is at or below the MQR will receive a formal notification letter from Healthfirst. This letter will include an offer to furnish Providers with additional support and resources to improve their OQRs.

For Providers consistently falling below the MQR, Healthfirst may take other actions deemed necessary, including but not limited to:

·         Suppression of the Provider's information from the Healthfirst Directory

·         Reduction or discontinuation of quality incentive bonus payments/deductions

·         Suppression from Healthfirst's Enrollee/PCP auto-assignment pro​cess

·         Removal from the Healthfirst network

Providers can appeal their Overall Quality Rating.  Providers may appeal by following the guidelines briefly described in Section 16.3 of this Provider Manual.  Healthfirst reserves the right to deny or disqualify appeals as applicable.

For additional information, please em​ail HQIP@Healthfirst.org