Enabling improvements in health care with commercial and Medicare FFS data

Optum Labs connects healthcare thought leaders with highly curated, real-world data to unlock insights that advance the flow of science to improve health outcomes for all.  

A Qualified Entity is an organization permitted to combine Medicare data with other claims data for the purposes of reporting on quality measures that can be used to improve the performance of health care providers and suppliers.

The Qualified Entity program was created as part of the Affordable Care Act to facilitate health system improvement using insights from data.

The program allows Qualified Entities to apply to receive Centers for Medicare and Medicaid Services (CMS) claims data for the purpose of combining that data with a commercial claims data set and using it to report back publicly on health system quality measures.

Once certified in the Qualified Entity Certification Program (QECP), Qualified Entities are eligible to receive standardized extracts of Medicare Parts A and B claims data and Part D prescription drug event data.

Visit QEMedicareData.org

To become a Qualified Entity, an organization must complete a comprehensive application process that demonstrates expertise in performance measurement, the ability to combine Medicare data with existing claims data, and adherence to rigorous data privacy and security procedures.

As a certified national Qualified Entity, Optum Labs receives 100% of the Parts A, B and D CMS claims and enrollment data. Our scope for public reporting is national, including all states, Puerto Rico and the District of Columbia.

The Optum Labs Qualified Entity public reports present measures performance through two distinctive lenses:

• Comprehensive Care Process Measures are presented in the sub-domain of diabetes, an important disease area.
• Transition to Medicare Measures are presented in the sub-domains of diabetes and hospitalizations and harm, focusing on conditions requiring highly coordinated care.

Measures available to Qualified Entities for public reporting are maintained on a list of Standard and Alternative measures by the QECP.

To see the current list of Standard and Alternative measures, visit Report Resources on the QECP website. 

The measures included in the Optum Labs Qualified Entity public report were selected for clinical and thematic fit with each report.

The Comparing Process and Outcomes report measures were selected that are anticipated to have a relationship, e.g., a change in the process leads to a change in the outcome. The selected Transition to Medicare report measures are anticipated to provide insight into the quality of complex care.

Additional information on the measures and calculations can be found in the detailed report companion guide.

Some of the measures in the Optum Labs Qualified Entity reports are standard, and others are QECP-approved alternative measures. Standard measures are those that are developed and curated by other organizations, such as NCQA, PCPI, CMS and more.

Optum Labs calculates standard measures using our data sources for the Comparing Processes and Outcomes report. QECP alternative measures are those that Optum Labs modified to support a reporting theme.

Optum Labs created alternative measures to support the Transition to Medicare report, as we needed to develop a methodology to identify patients who are transitioning to Medicare coverage for the first time.

Additional information on the measures and calculations can be found in the detailed report companion guide.

While Optum Labs followed measure specifications to calculate the standard and alternative measures in the reports, some differences exist between data sources that can lead to differences in measure results.

For example, there may be billing variations and/or differences in enrollment duration of individuals that may impact measure results across different data sources. This can create systematic shifts in results, known as statistical bias.

In addition, outcome measure rates presented in the report are crude (raw) unadjusted rates, which may differ from similar measures from the same population, gathered by other means.

Two primary sources of data were combined and then used to calculate the measures in the Optum Labs Qualified Entity public reports.

The first includes a 100% sample of medical claims data received under the QECP for Medicare Parts A, B, D from 2015 through 2021. The second includes data contained in the Optum Labs Data Warehouse.

All data used in Optum Labs reporting comes from real-world data sources and is not collected expressly for reporting purposes.

More information about Medicare Parts A, B, D data Optum Labs received in the QECP can be found at the CMS Research Data and Assistance Center.

Visit ResDAC.org

The Optum Labs Data Warehouse includes de-identified, longitudinal health information on enrollees and patients, representing a diverse mixture of ages, ethnicities and geographical regions across the United States.

The claims data in the Optum Labs Data Warehouse includes medical and pharmacy claims, laboratory results and enrollment records for commercial and Medicare Advantage enrollees. The electronic health record (EHR)-derived data includes a subset of EHR data that has been normalized and standardized into a single database.

All data used to create the Optum Labs Qualified Entity public reports are de-identified in compliance with HIPAA.

There are inherent limitations in using these data sources and they may deviate from national quality reporting system benchmarks, such as HEDIS®, stars or other quality programs, which often make use of supplemental data collection from medical charts and subjective judgment from medical personnel.

To learn more about limitations overall or for specific measures in this report, please refer to the detailed report companion guide.

All measure rates reported at the national, census region and state levels include combined data from Optum Labs Data Warehouse and Qualified Entity Medicare Data. When coverage type is stratified, commercial and Medicare Advantage rates do not include Qualified Entity Medicare data.

Both Optum Labs and CMS enforce a cell suppression policy to protect data privacy. In addition, measure results may not be considered valid if the number of individuals available for measure calculation falls below a certain minimum.

When this happens, the results are suppressed and indicated as a single asterisk (*) that indicates “insufficient data” for the measure.

In each report, the percent change is calculated against the mean actual performance for each measure in the reference year. The basic calculation for a given mean rate in year i, with a reference mean rate (ref) is:

Percent change (i) = Mean rate (i) - Mean rate (ref)
                                         Mean rate (ref)

For the Comprehensive Care Process Measures report, percent change in mean performance for each of the years (i), 2015-2021, is calculated against mean performance in the reference year 2015. As such, the percent change values in this report indicate the degree to which actual performance in a given year for a measure is higher (positive %), the same (0%), or lower (negative %), as compared to the mean measure performance in 2015, the baseline year for trends is this report.

For the Transition to Medicare report, percent change in mean performance for years (i), two years before transition (Year -2) through two years after transition (Year +2), is calculated against mean performance in the reference year, which is the year a member first transitions from commercial to Medicare as primary insurance (Year 0). As such, the percent change values in this report indicate the degree to which actual performance in a given year before or after first transition to Medicare as primary insurance for a measure is higher (positive %), the same (0%), or lower (negative %), as compared to the mean measure performance during the year of first transition to Medicare as primary insurance, the baseline year for trends is this report.