2025 PCMH Core Quality Metrics
| Core Metric | Description | Threshold |
|---|---|---|
| 1. Breast Cancer Screening – Electronic HEDIS BCS-E | The percentage of members 40–74 years of age who were recommended for routine breast cancer screening and had a mammogram to screen for breast cancer. | ≥ 40.00% |
| 2. Blood Pressure Control for Patients with Diabetes (HEDIS BPD) | The percentage of members 18- 75 years of age with diabetes (type 1 and type 2), whose blood pressure was adequately controlled (<140/90 mm Hg). | ≥ 62.00% |
| 3. Eye Exam for Patients with Diabetes (HEDIS EED) | The percentage of members 18- 75 years of age with diabetes (type 1 and type 2) who had a retinal eye exam. | ≥ 51.00% |
4. Glycemic Status Assessment for Patients with Diabetes (HEDIS GSD) • Glycemic Status <8.0% |
The percentage of members 18–75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year: Glycemic Status <8.0%. | ≥ 47.00% |
5a. Child and Adolescent Well-Care Visits 12-21 years (HEDIS WCV) • Ages 12-17 years |
The percentage of members 12-17 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. | ≥ 57.00% |
5b. Child and Adolescent Well-Care Visits 12-21 years (HEDIS WCV) • Ages 18-21 years |
The percentage of members 18-21 years of age who had at least one comprehensive well-care visit. with a PCP or OB/GYN practitioner during the measurement year. | ≥ 39.00% |
| Family Core Metrics | Description | Threshold |
|---|---|---|
| 1. Breast Cancer Screening – Electronic HEDIS BCS-E | The percentage of members 40–74 years of age who were recommended for routine breast cancer screening and had a mammogram to screen for breast cancer. |
≥ 40.00% |
| 2. Blood Pressure Control for Patients with Diabetes HEDIS BPD | The percentage of members 18- 75 years of age with diabetes (type 1 and type 2), whose blood pressure was adequately controlled (<140/90 mm Hg). |
≥ 62.00% |
| 3. Controlling High Blood Pressure HEDIS CBP | The percentage f members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose Blood Pressure (BP) was adequately controlled (<140/90 mm Hg) during the measurement year. |
≥ 60.00% |
| 4. Cervical Cancer Screening – Electronic HEDIS CCS-E | The percentage of members 21–64 years of age who were recommended for routine cervical cancer screening who were screened for cervical cancer |
≥ 52.00% |
| 5. Childhood Immunization Status – Electronic – Combination 10 HEDIS CIS-E | The percentage of children 2 years of age who had 4 DTaP, 3 polio, 1 MMR, 3 HiB, 3 HepB, 1 VZV, 4 PCV, 1 HepA, 2 or 3 RV, and 2 influenza vaccines by their second birthday. |
≥ 42.00% |
| 6. Eye Exam for Patients with Diabetes HEDIS EED | The percentage of members 18- 75 years of age with diabetes (type 1 and type 2) who had a retinal eye exam. |
≥ 51.00% |
| 7. Glycemic Status Assessment for Patients with Diabetes HEDIS GSD Glycemic Status <8.0% | The percentage of members 18–75 years of age with diabetes (types 1 and 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement year: Glycemic Status <8.0%. |
≥ 47.00% |
| 8. Immunizations for Adolescents – Total rate- Electronic -Combination 2 HEDIS IMA-E | The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one Tdap vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. |
≥ 26.00% |
| 9a. Child and Adolescent Well-Care Visits 12-21 years HEDIS WCV Ages 3-11 years | The percentage of members 3-11 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. |
≥ 65.00% |
| 9b. Child and Adolescent Well-Care Visits 12-21 years HEDIS WCV Ages 12-17 years | The percentage of members 12-17 years of age who had at least one comprehensive well-care visit. with a PCP or OB/GYN practitioner during the measurement year. |
≥ 57.00% |
| 9c. Child and Adolescent Well-Care Visits HEDIS WCV Ages 18 – 21 years | The percentage of members 18-21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. |
≥ 39.00% |
| 10a. Well-Child Visits in the First 30 Months of Life HEDIS W30 Well-Child Visits in the First 15 Months | The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. Children who turned 15 months old during the measurement year: Six or more well-child visits. |
≥ 61.00% |
| 10b. Well-Child Visits in the First 30 Months of Life Well-Child Visits for Age 15 Months – 30 Months | The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. Children who turned 30 months old during the measurement year: Two or more well-child visits. |
≥ 71.00% |
| Pediatric Core Metrics | Description | Threshold |
|---|---|---|
1. Childhood Immunization Status – Electronic – Combination 10 HEDIS CIS-E |
The percentage ofchildren 2 years of age who had 4 DTaP, 3 polio, 1 MMR, 3 HiB, 3 HepB, 1 VZV, 4 PCV, 1 HepA, 2 or 3 RV, and 2 influenza vaccines by their second birthday. | ≥ 42.00% |
| 2. Immunizations for Adolescents – Total rate- Electronic -Combination 2 HEDIS IMA-E | The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine, one Tdap vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday. |
≥ 26.00% |
| 3. Upper Respiratory Infection HEDIS URI 3 months–17 years | The percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event. |
≥ 93.00% |
| 4a. Child and Adolescent Well-Care Visits HEDIS WCV Ages 3 – 11 years | The percentage of members 3-11 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. |
≥ 65.00% |
| 4b. Child and Adolescent Well-Care Visits HEDIS WCV Ages 12 – 17 years | The percentage of members 12-17 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. |
≥ 57.00% |
| 4c. Child and Adolescent Well-Care Visits HEDIS WCV Ages 18 – 21 years | The percentage of members 18-21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year. |
≥ 39.00% |
| 5a. Well-Child Visits in the First 30 Months of Life HEDIS W30 Well-Child Visits in the First 15 Months | The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. Children who turned 15 months old during the measurement year: Six or more well-child visits. |
≥ 61.00% |
| 5b. Well-Child Visits in the First 30 Months of Life Well-Child Visits for Age 15 Months – 30 Months | The percentage of members who had the following number of well-child visits with a PCP during the last 15 months. Children who turned 30 months old during the measurement year: Two or more well-child visits. |
≥ 71.00% |