Quality of care and patient experience program, Oxford Commercial Supplement - 2022 UnitedHealthcare Administrative Guide

Quality of care

The health care provider group must maintain a quality-of-care program. As part of this program, the practice is expected to meet quality standards for the population enrolled in the capitated product. The quality standards include a suite of current Healthcare Effectiveness Data and Information Set (HEDIS) metrics as developed and maintained by the National Committee for Quality Assurance (NCQA). The quality program will include standardized metrics and measurement methodology that is consistent with UnitedHealthcare value-based care programs. The provider is expected to meet quality requirements and improve performance each measurement year.

Quality metric standards

  • The quality suite includes 18 HEDIS quality measures, which will be reviewed and updated by UnitedHealthcare annually.
  • The health care provider group is expected to reach a minimum 70% aggregate closure rate of all 18 HEDIS quality measures. Performance is expected to improve year-over-year by 2%, up to 80% aggregate closure rate. The aggregate rate looks at all potential open gaps as the denominator and the total of all closed gaps as the numerator in order to create 1 total score representing 18 measures.
  • For the calculation of the aggregated closure rate, one metric may be removed if closure rate is low and population prevalence rate is below 1.5%.

Providers should work to improve patient care and outreach workflows to ensure continuous improvement of care delivery. Goals for performance should be set to move beyond the minimum necessary percentage closure of the listed measures. It is recommended that the practice set a minimum goal per measure of meeting the NCQA Quality Compass 50th percentile on individual measures.

Performance review

The provider group performance is available monthly through the HEDIS quality data summary. There will also be an annual review of practice performance as indicated by aggregate closure rate of the 18 HEDIS measures included in the quality suite.

If the practice fails to meet the target aggregate closure rate of 70%+, as indicated at the beginning of the year, a corrective action plan will be created in conjunction with a UnitedHealthcare consultant. The practice will be required to carry out the corrective actions included in the corrective action plan.


The provider group is responsible for quality metrics of the attributed/assigned population.


  • The Patient Care Opportunity Report (PCOR) provides actionable information for physician groups and organizations to use to identify their patients’ adherence to preventive screenings, treatments and medications that may be included in the suite of quality standards.
  • UnitedHealthcare Point of Care Assist Tool (POCA) can be used by providers to identify actionable patient opportunities at the time of care to improve the quality of care the patient population receives.
  • HEDIS Quality Data Summary will be delivered to the practice monthly to inform on progress towards meeting quality goals.

HEDIS quality suite

Performance Measure Performance Measure Description
Breast Cancer Screening Female patients 50–74 years of age who had a mammogram to screen for breast cancer in the past 2 years.
Cervical Cancer Screening Female patients who were screened for cervical cancer using either of the following criteria: age 21–64 who had cervical cytology performed every 3 years or age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
Colorectal Cancer Screening Patients who had appropriate screening for colorectal cancer.
Comprehensive Diabetes Care Patients with diabetes (type 1 or type 2) who had an HbA1c test.
Comprehensive Diabetes Care Patients with diabetes (type 1 or type 2) who had eye screening for diabetic retinal disease.
Kidney Health Evaluation for Patient with Diabetes The percentage of patients with diabetes (type 1 and type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR), during measurement year.
Comprehensive Diabetes Care Patients with diabetes (type 1 or type 2) with most recent HbA1c result value less than 8.0%.
Bronchitis, Acute, Avoidance of Antibiotic Treatment in Adults

Patients with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or 3 days after the visit date.

Childhood Immunization Status Combination 2: DTaP, IPV, MMR, HiB, Hepatitis B, VZV.
Use of Imaging Studies for Low Back Pain

Patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.

Persistence of Beta-Blocker Treatment After a Heart Attack Patients who were hospitalized and discharged from July 1 of the year prior to the measurement period to June 30 of the current measurement period with a diagnosis of AMI and who received persistent beta-blocker treatment for 6 months after discharge.
Appropriate Testing for Children with Pharyngitis Patients who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
Appropriate Treatment for Children with Upper Respiratory Infection Patients who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or 3 days after the event.
Well-Child Visits in the First 30 Months of Life

The percentage of patients who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:

  • Well-child visits in the first 15 months. Children who turned 15 months old during the measurement year: 6 or more well-child visits.
  • Well-child visits for age 15 months–30 months. Children who turned 30 months old during the measurement year: 2 or more well-child visits.
Child and Adolescent Well-Care Visits

Patients 3–11 years of age who had at least 1 comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year.

Chlamydia Screening in Women Female patients who were identified as sexually active and who had at least 1 test for chlamydia.
AMR Asthma Medication Ratio Total - Commercial (5-85 years) Provider assesses adults and children 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
UOD: Use of Opioids at High Dosage Provider assesses potentially high-risk opioid analgesic prescribing practices: The proportion of members 18 years and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose >120 mg) for 15 or more days during the measurement year.

Patient experience

NCQA sets national quality standards called Quality Compass that providers can be measured against. Provider groups will be measured on patient experience through use of the Health Plan (HP) CAHPS survey. This survey is designed to measure patient experience with their health plan, health care and personal doctor/specialist. For purposes of this capitated product, survey results relative to patient experience with their personal doctor/specialist will be assessed.

Patient experience standards

  • HP CAHPS surveys fielded annually, February–May
  • Asks health plan members about their experiences with care received over the last 12 months
  • Patient experience measures for provider assessment:
    • Rating of personal doctor seen most often
    • Getting needed care
    • Getting care quickly
  • The provider group is expected to reach the NCQA benchmark equal to or better than 50th percentile for each score.

Monitoring and improving HP CAHPS aligns with the value-based care objectives of improving member experience. UnitedHealthcare will provide the baseline results with the 2022 CAHPS survey.

UnitedHealthcare support

A UnitedHealthcare consultant assigned to the practice will monitor quality performance, patient experience results and consult on opportunities to improve patient outcomes and quality performance and discuss opportunities to implement UnitedHealthcare tools and reports.