Quality metrics are an essential consideration in shared-savings or shared-risk contracts. Information about these metrics typically is located in an appendix, addendum, or exhibit. The provider organization should be familiar with and understand the specific measures. For each metric, organizations should ask:
- How is this metric calculated?
- What data are used? (Are claims data used?)
- What time periods are used?
- Are the data normalized?
- What data are excluded?
- If codes are used (e.g., ICD10, HCPCS, CPT), how are code updates handled? When are code changes made?
- Are the data auditable?
- Is there an appeal mechanism if the payer’s data report is inconsistent with the provider’s data?
- When calculating the quality scores, are the scores derived from the payer’s entire patient population or just those segments covered under the specific agreement?
It also is important for the organization to ask whether metrics are negotiable. The organization should request that metrics be changed only as mutually agreed upon and in advance of adoption and use (exceptions may be government programs or measures such as HEDIS).