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HEDIS OVERVIEW PRESENTATION. PRESENTED BY: CARINA YAPYUCO, RN RACHEL GRAY, RN HANIA ALHINNAWI , RN CLARICE MAYO, LVN. August 11, 2014. Agenda. Fundamentals of HEDIS Auto-assignment
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HEDIS OVERVIEW PRESENTATION PRESENTED BY: CARINA YAPYUCO, RN RACHEL GRAY, RN HANIA ALHINNAWI , RN CLARICE MAYO, LVN August 11, 2014
Agenda • Fundamentals of HEDIS • Auto-assignment • Medicare STAR program • HEDIS medical record abstraction • Medical record review validation • Off-season supplemental data collection • Quality improvement interventions
What is HEDIS? Healthcare Effectiveness Data and Information Set
What is HEDIS? • Most widely used set of standardized performance measures in the managed care industry • Developed by the National Committee for Quality Assurance (NCQA) - HEDIS was introduced in 1993 • Encourages accountability and quality improvement in health care
Why is HEDIS important? • Measures quality performance and identifies areas in need of quality improvement • Triple Aim Initiatives • Cost Containment • Ranking among health plans and states • Auto-assignment • Medicare Stars Program • NCQA accreditation
Who decides on HEDIS? HEDIS measures are developed by: • NCQA Board of Directors • Committee on Performance Measurement (CPM) - oversees entire measure development process • Measurement Advisory Panels (MAPs) - condition specific, clinical experts
HEDIS 2014: 80 measures across 5 domains of care • Effectiveness of Care - Are we providing adequate, effective prevention, screening & care? • Access/Availability of Care - Are we meeting members’ needs? How accessible is care? • Experience of Care (CAHPS) - Survey captures members’ overall experience & satisfaction • Utilization and Relative Resource Use - Use of Services; Cost of Care for chronic diseases • Health Plan/MCO Descriptive Information - How do factors such as LAC’s organizational structure & management contribute to our ability to provide quality care to our members?
HEDIS Data Reporting • Measurement Year (MY) - data reflect delivery of service during the calendar year, e.g., from 01/01/13 to 12/31/13 • Reporting Year (RY) - data reported to NCQA in June of the year following MY • HEDIS 2014 (RY) = 2013 data (MY)
HEDIS Data Collection • Three data collection methods: • Administrative • - claims, encounter, Rx, Labs • - BCS, PCR, OMW, ASM, AAB, MPM, ART, LBP • Hybrid • - administrative & medical record data • - W34, PPC, CCS, CBP, CDC, COL, COA, MRP • Surveys • - CAHPS, HOS
Auto-Assignment • Incentive employed by the states to promote quality improvement • Based on high quality scores, administrative performance, access to care, financial health and stability • Medicaid beneficiaries are assigned automatically to the best MCO when they fail to choose their own health plan
Auto-Assignment Measures for HEDIS 2014 Childhood Immunization Status (CIS) Children who received these vaccines by their 2nd birthday: 4 DTaP + 3 IPV + 1 MMR + 3 HiB + 3 HepB + 1 VZV + 4 PCV Well Child Visits 3rd, 4th, 5th, and 6th years (W34) Children who had well-child visits with a PCP in MY Cervical Cancer Screening (CCS) Pap smear during MY or 2 years prior to MY (age 21-64), OR Pap + HPV during MY or 4 years prior to MY (age 30-64) Prenatal & Postpartum Care (PPC) Prenatal care in the 1st trimester Comprehensive Diabetes Care (CDC) HbA1c screening in MY; LDL-C control in MY
Medicare STAR Program • Background • STAR Ratings Strategy • Better Care • Healthier People/Healthier Communities • Lower Cost Through Improvements
Star Ratings Structure • Outcomes • Intermediate Outcomes • Patient Experience • Access • Process
Star Ratings Excellent Above Average Average Below Average Poor
Star Measures Colorectal Cancer Screening (COL) Controlling High Blood Pressure (CBP) Care of Older Adults (COA) • Medication Review • Functional Status Assessment • Pain Assessment Comprehensive Diabetes Care (CDC) • Eye Exam • Nephropathy (Kidney Disease Monitoring) • Blood Sugar Controlled • LDL <100 (Cholesterol Controlled) Adult BMI Assessment (ABA) Cholesterol Management for Patients with Cardiovascular Conditions (CMC)
HEDIS 2014 Medicare Highlights for L.A. Care 5 STAR MEASURES (4) • CMC – Cholesterol Screening • COL – Colorectal Cancer Screening • ABA – Adult BMI • CDC – Nephropathy 4 STAR MEASURES (5) • CBP – Controlling Blood Pressure • CDC – Eye Exam • CDC – LDL Screening • COA – Medication Review • COA – Pain Assessment 3 STAR MEASURES (4) • CDC – Poor Control >9% • CDC – LDL <100 • COA – Functional Status
HEDIS Timeline • January 15—Off-season chart review ends • January 26—HEDIS abstraction training for internal and external Abstractor Nurses • February 21—Abstraction begins • March 3 & 4 — Audit Day • April 4— Refresh of all data • May 15—All abstraction ends • May 17— Auditor selects 16 records from each of 5 Groups in addition to all MRR exclusions
HEDIS Timeline • May 24—All selected records are submitted for validation by auditors • May 29—Auditor completes Medical Record Review Validation (MRRV) • June 8—IDSS completed and locked • July 1—Off-season medical record collection begins
Over-read process during HEDIS • L.A. Care over-reads 100% of all positive records, and 30% of all charts deemed as negative during the HEDIS season • L.A. Care works with Verisk to develop study items within the database to track major and minor errors for each abstractor • All abstractors are required to maintain an average of 95% or greater accuracy on all measures • Inter-rater reliability is measured during the first two weeks of the project then on an ongoing basis to ensure accuracy and consistency amongst abstractors, with re-education as necessary in areas of deficiency.
Supplemental Medical Record Retrieval and Abstraction (HEDIS - Off Season) • Supplemental medical record retrieval and abstraction activities start in July after the HEDIS results are submitted to NCQA • Conduct office visits by HOA/FSR staff • Provider education • Scanning/abstracting medical records from doctors’ offices and entered into internal databases.
Exit Interview with Provider and Staff • Discuss overall findings of the medical record audit • Discuss percentage of compliant vs non-compliant members in each measure - (# of records pulled vs # of compliant records) • Discuss Provider Feedback Report • Provide education in Gaps in Care • Discuss “HEDIS at A Glance” Tool
Supplemental Files Processing • Request supplemental data files from: - PPG - IPA - MSO - Plan Partners • HO&A formats the supplemental files and submit to vendor (Verisk). Three formats: VISIT, RX, LAB • Technical assistance and guidance are provided to the groups if necessary. • LA Care receives files in August, December and March (for lag data)
Benefits of Off Season Activities • Increases the administrative rates for L.A. Care resulting in a decrease in the number records for pursuit and abstraction during HEDIS season • Off season activities include office visits to high volume and low performing provider offices. This gives an opportunity to provide feedback to doctors/office staff regarding documentation, coding, reinforcement of preventive health guidelines, education on gaps in care, etc • More completeness in administrative data collection to avoid the data loss in the normal data transmission process (PCP IPA DDD (MSO) Plan Partners L.A. Care Health Plan Verisk)
