How we score physicians and facilities
Every provider is compared with true peers using national medical and pharmacy claims, risk adjustment and cost standardization. The result is one Overall Quality score, built from three component scores.
One overall score, three components
Our scores identify high-value providers with a blend of population-based effectiveness, cost and appropriateness metrics. A higher Overall Quality rating shows which providers are most likely to follow best practices and achieve better outcomes at lower cost than their peers.
Effectiveness
Evidence-based measures of quality, patient safety and outcomes, such as recommended treatment and 30-day readmissions. Referral-based measures add the value of the facilities and specialists a physician works with.
Cost
Standardized costs of visits, tests, procedures and prescription medications, so providers are compared on the resources they use rather than the prices they negotiated.
Appropriateness
Tests, procedures and medications that are prone to overuse and add little value, such as routine low back imaging, pre-op chest X-rays and opioid prescribing.
Fair comparisons, step by step
Group true peers
Providers are grouped by specialty and subspecialty from the services they bill, within their Hospital Referral Region. Spine surgeons are compared with spine surgeons. If a region has too few peers, the comparison goes national.
Measure from claims
Metrics come from national medical and pharmacy claims, using standard measures from CMS, AHRQ and NQF plus measures we build from clinical guidelines.
Adjust for risk
Patient-level risk adjustment based on CMS HHS-HCC risk factors, with condition, age and sex adjustments where they fit better, so doctors with sicker patients are compared fairly.
Standardize cost
Care is priced with standard units for each setting (MS-DRGs, APCs, RVUs and AWP), which removes differences in contract rates between payers and providers.
Score and rank
Each metric is ranked into quintiles against the peer group, then combined into the three component scores and one Overall Quality score.
The differences between peers are large
Physicians in the same specialty and region practice very differently. These comparisons of the lowest and highest scorers come from our methodology document.
more days of acid suppressants for patients of the lowest-scoring general gastroenterologists.
more large joint aspirations performed by the lowest-scoring knee surgeons.
higher 30-day readmission rates among the lowest-scoring cardiac surgeons.
more of the drug spend going to brand-name drugs among the lowest-scoring primary care physicians.
Built on published evidence, checked in the field
Clinical evidence and measure standards
How we check our work
- Subspecialty assignments are tested and verified with client clinicians and practice managers.
- Metric values are compared with expected results from CMS, client reports and all-payer claims databases.
- Outliers are reviewed openly with provider practices, including joint data checks.
Read the full methodology
The methodology document covers each score, the clinical evidence behind every measure, and the safeguards in detail, with example charts by region.