Value-based care systems largely rely on quality metrics and benchmarks to measure physician performance and determine payment. Understanding how insurers or other entities calculate performance — including how they attribute your patients to quality metrics and what factors would exclude patients from certain metrics — is vital for your success within these payment models.

THREE PARTS TO EVERY METRIC SCORE

Quality metric calculations include the following:

• Numerator (the subset of patients in the denominator for whom a particular service has been provided or a particular outcome has been achieved),

• Denominator (the total eligible patient population),

• Exclusions (patients with characteristics that remove them from the calculation).

For example, a common quality metric is the percentage of women age 50–74 who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. In this case, the numerator is the number of women age 50–74 who had a mammogram in the measurement period. The denominator is the total eligible population (women 50–74 years of age). The exclusions are patients who should be removed from the calculation (women who have had a bilateral mastectomy, use hospice services, etc.).