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outlier measure

outlr_meas_ind
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A boolean indicator identifying a CMS Star Ratings measure on which a health plan performance is significantly below the national average, flagged by CMS as a potential signal of poor quality that may trigger additional regulatory scrutiny, potential sanctions, or low-enrollment warnings. CMS flags outlier measures when a plan performs at or below the first percentile of national performance for two or more consecutive years, indicating persistent quality failures that warrant regulatory intervention. Outlier measure status can trigger CMS intermediate sanctions that restrict plan marketing and enrollment activities while the plan implements corrective action.

Healthcare data teams monitor outlr_meas_ind for all rated measures, generate early warning alerts when performance approaches outlier thresholds, track corrective action plan implementation for measures at risk of outlier designation, and report outlier risk status to health plan leadership and board members as a regulatory compliance indicator requiring immediate management attention.

Standard Abbreviation

outlr_meas_ind

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
    qlty_key        INTEGER        NOT NULL  -- surrogate key,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    plan_key        INTEGER        NOT NULL  -- FK to DIM_PLAN,
    meas_yr         SMALLINT                 -- measurement year,
    hedis_meas_cd   VARCHAR(20)              -- HEDIS measure code,
    denom_ind       CHAR(1)                  -- denominator eligible,
    numer_ind       CHAR(1)                  -- numerator met,
    excl_ind        CHAR(1)                  -- exclusion indicator,
    gap_open_ind    CHAR(1)                  -- care gap open,
    star_rtg_nbr    DECIMAL(3,1)             -- star rating,
    qlty_scr        DECIMAL(5,2)             -- quality score,
    perf_thrsh_pct  DECIMAL(5,2)             -- performance threshold,
    raf_scr         DECIMAL(10,3)            -- risk adjustment factor,
    outreach_cnt    SMALLINT                 -- outreach attempts,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →

Why This Term Matters

Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.

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