This report shows performance of the primary care providers of members/patients represented in the population of records in the database, at a detailed level, as compared to their specialty group overall.




Target Audience for this Report

Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, Utilization Management, and Sales and Client Relations.


Business Processes Impacted by this Report

Filtering by PCP provides information that supports a targeted approach to provider outreach, education and network management.


Physician specific data in a format that allows comparison of like specialties and member populations are increasingly used as the basis for quality improvement efforts, contracting decisions, and financial incentives.


Public and private health plan purchases are demanding more information about physicians and this can aid in presenting that information to clients or potential clients as well as supporting bids with Medicaid and Medicare Advantage plans.


Individual physicians as well as physician groups are interested in data which they believe represents their performance in a comparative manner.  Using this report with physicians allows them an opportunity to validate and learn about the metrics in order to modify aspects of their practice.



Detail and Definitions

The Provider’s Specialty is driven by the taxonomy associated with the provider in the NPI database.


The overall score for the provider is within their Specialty and panel range.



  • ProviderName
  • Avg Patient Risk
  • Score - The overall calculated score is the average percentile ranking of each of the five categories: Cost, Utilization, Quality, Prevention, and Pharmacy.
  • Overall Ranking - Example: 10 / 50 – The provider group selected is ranked 10th out of the 50 other provider groups.
  • Percentile (ranking)
  • Panel Size
  • Specialty
  • Avg Specialty Score
  • Avg Specialty Risk (member)


Performance Score (Graph) – shows the relative performance increase or decrease (by percentage) of the selected provider’s performance, by category (Cost, Utilization, Quality, Prevention, Rx) vs all other provider peers.  Bars/numbers above the axis indicate the provider/group is “Better” than peers (by the indicated percentage) in that category.  Bars/numbers below the axis indicate the provider is “Worse” than their peers (by the indicated percentage) in that category.

  • Provider performance based on peers.
  • Performance Categories


Provider Ranking (Graph)

  • Provider Score – shows Provider’s score in relation to peers
  • Ranking


Provider Group vs. Same Specialty Performance Metrics

The individual metrics in the Provider vs. Same Specialty Performance Metrics, are grouped by category.  Each metric shows the Provider performance vs peers.

  • Cost: 
    • PMPM – a rollup of PMPM; based on direct and indirect costs
    • Paid/Claim – the amount paid per claim; based on direct and indirect costs.
    • Paid/Admit – Average paid amount per Admit; based on direct and indirect costs
    • % Level 4/5 – Percentage of Level 4 and 5 E&M claims against all office visits; based on direct costs
  • Utilization:
    • ALOS – the ALOS of the Provider’s panel members with admissions.
    • Admissions/1000 – Admissions/panel size * 1000.
    • ER Visits/1000 – ER Visits/panel size * 1000.
    • Lab Radiology/1000 – Lab and Radiology Procedures/panel size * 1000.
  • Quality:
    • Readmissions/1000 – Readmissions/panel size * 1000.
    • EKG (%) – Percentage of EKG procedures.
    • Avoidable ER (%) – Percentage of ER visits flagged as avoidable.
    • Complications (%) – Number of complications/panel size * 1000.
  • Rx:
    • PMPM – Pharmacy PMPM Costs; based on direct and indirect costs.
    • Scripts/Member – The average number of scripts per member.
    • Brand/Generic – The percentage of brand vs. generic of all.
    • Formulary/Non-Formulary – The percentage of formulary vs. non.  Dependent on receiving the formulary/non-formulary flag on the pharmacy claims.
  • Prevention:
    • Breast Cancer (%) – Breast Cancer Screening
    • HbA1c (%) – Hemoglobin A1c Testing
    • Eye Exam (%) – Eye Exam
    • Adult Infl Vac (%) – Adult Influenza Vaccination
    • CAP (%) - (Children’s Access to Care) Percentage completed (of eligible members < 20 years).
    • W15 (%) – (Well visit first 15 months of life) Percentage completed (of eligible members).
    • W34 (%) – (Well visit, 3rd, 4th, 5th, 6th years) Percentage completed (of eligible members).
    • AWC (%) – (Adolescent Well Child Care) Percentage completed (of eligible members 12 to 21 years.