![]() The incentive under FFS is productivity: the more billed charges, the greater potential for financial success. Medications for cancer treatment, for example, are always expensive yet usually clinically appropriate. Keep in mind higher cost is not always avoidable or inappropriate. Identification of higher-cost areas of health care spending. High-cost specialists, facilities, or pharmaceuticals The total cost of care for all patients, frequently reported as a PMPM value that is compared to a benchmark (or target) value. Often reported as all-cause readmissions during the 30 days following discharge PMPM divided by 1,000. Often reported as all-cause admissions PMPM divided by 1,000. ![]() Often reported as ED visits per member per month (PMPM) divided by 1,000. ![]() National CRCS guidelines changed in 2021, 1 but most payers have not yet changed their quality metrics to reflect this. Metric exclusions include: hospice, end-stage renal disease, rhabdomyolysis, myopathy, pregnancy, lactation, fertility, liver disease, pre-diabetes, or polycystic ovary syndrome.įor value-based care metrics, CRCS is generally defined as fecal occult blood test during the previous year, flexible sigmoidoscopy during the previous five years, colonoscopy during the previous 10 years, computed tomography colonography during the previous five years, or fecal immunochemical DNA test during the previous three years. Statin use should usually be considered for patients with diabetes between ages 40 and 75. Sometimes this metric is reported in the inverse (A1C < 9%, or well-controlled diabetes). Generally, A1C > 9% is a marker of poorly controlled diabetes.
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