Quality Score

Your Quality Score is calculated by comparing your compliance with a series of quality measures to that of peer providers practicing in your specialty, adjusting for measure, patient, and sample size effects.  The highest-quality providers have quality scores closest to one. 

See the RHI Statistical Model doc format of Summary_of_Advanced_Statistical_Approach_in_GIC_CPII_Ev
for an explanation of the statistical model RHI used to assess practice quality for FY17.

See the  RHI quality measures docx format of January_2016_quality_measures.docx
used for the FY17 assessment, along with citations from the literature supporting these measures.

Efficiency Score

Your use of health care services (office visits, labs, medications, etc.) in treating patients with particular clinical conditions is compared to the resource use of other physicians in your specialty treating patients for similar conditions.  Individual episodes are assigned to physicians based on an evaluation of the claims data to determine which physician provided the overall management of the care of the patient during the course of his or her treatment for a particular clinical condition

The efficiency score is created by comparing the consumption of resources (using a proxy cost) in treating your patients to the resource use of your peers treating patients with similar clinical conditions, adjusted for the severity of your patient case mix.  The most efficient providers have low efficiency scores; less-efficient providers have higher scores.

  • Cost-efficiency scores are developed by VIPS using ETGs, a product of Symmetry that is well known and widely used by health insurers and physician groups
  • Claims are bundled into Episode Treatment Groups (ETGs) and contract-neutral prices (proxy prices) are applied

See the Symmetry Episode Treatment Groups document doc format of symmetry_episode_treatment_groups_wp_06_2012.doc
for technical details

Tiering Method by Health Plan

For details on each GIC health plan’s tiering assignments,  see the CPI Section of their website:

Fallon Health – Clinical Performance Improvement Initiative details

Harvard Pilgrim Health Care – Clinical Performance Improvement Initiative details:

Health New England – Clinical Performance Improvement Initiative details

Neighborhood Health Plan – Clinical Performance Improvement Initiative details

Tufts Health Plan – Clinical Performance Improvement Initiative details

UniCare State Indemnity Plan – Clinical Performance Improvement Initiative details

This information provided by the Group Insurance Commission.