107 / 537
Employer Group ABC
Incurred:
Apr 2014 thru Dec 2015
Paid:
Apr 2014 thru Mar 2016
37
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Page
Table 4.3.2 identifies the top 25 QRMs that have the highest variance between ‘Actual’ value and ‘Norm’ value for ‘%
of Individual with Care Gap’. These QRMs indicate opportunities for better disease management to reduce gaps and
prevent high cost claims.
Table 4.3.2 Top 25 QRMs for Gaps in Care
44
Gaps in Care
% of Individual
with Gap/Risk
Clinical Condition
Members
with
Condition
Description
Actual
Norm
Geriatric
>= 65 years old
(E)
279
Patients without long office visit in the
last 12 months.
67.74%
20.70%
Misc
Patients with
Intervertebral
disc disorder or
back pain or
neck pain, with
seizure
medication,
muscle
relaxants,
benzodiazepines
or opiates
442
Patients with more than 5 prescribing
providers for the mentioned drugs
39.59%
0.00%
Pediatric
Pediatric patients
with depression
started on non-
SSRI therapy (E)
6
Patients who did not receive a
psychiatrist referral near the time of
starting non-SSRI therapy.
50.00%
16.11%
Pediatric
Pediatric patients
with depression
started on non-
SSRI therapy
6
Patients who did not receive a
psychiatrist referral near the time of
starting non-SSRI therapy.
50.00%
16.15%
Behavioral
Lithium in the
last 6 months (E)
16
Patients without serum creatinine test
in the last 6 months.
75.00%
44.23%
Behavioral
Behavioral
health-related
admission in last
6 months (E)
13
Patients without a behavioral health
office visit during the last 6 months.
30.77%
5.29%
Behavioral
Lithium in the
last 6 months (E)
16
Patients without lithium level in the last
6 months.
81.25%
55.83%
Behavioral
Behavioral
health-related
admission in last
6 months
13
Patients without a behavioral health
office visit during the last 6 months.
30.77%
5.39%
RF
Renal
Failure/ESRD-on
Dialysis (E)
22
Patients without serum albumin test in
the last 12 months.
50.00%
26.31%
Misc
GI bleed-related
admission (E)
8
Patients without CBC or hematocrit
within 6 weeks of discharge from GI
62.50%
40.56%
44
Note:
Excluding QRMs related to flu shots and pneumonia and the ones having members with condition less than 5.