Idea Transcript
How to Maximize Incentives While Improving Outcome Measures ~What is HEDIS? ~A New World – Incentives for All ~How Do We Work Together
HEDIS
Confidential and Proprietary
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•HEDIS was designed to allow consumers to compare health plan performance across plans and against benchmarks
What is HEDIS?? Healthcare Effectiveness Data and Information Set
•Health Plans first reported HEDIS in 1991 •HEDIS is one component of the NCQA accreditation process for health plans
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Typical Measures: Childhood – Immunizations, Lead Screening, Well Child Visits •Adult Preventive – Breast & Cervical Cancer Screening •Respiratory Management – Pharyngitis Testing, Asthma Management •Comprehensive Diabetes Care – HbA1c, Retinopathy Screening, LDL Screening, Nephropathy Screening •Behavioral Health Measures – Follow Up After Hospitalization •Prenatal Care – Frequency, Pre/Post Visit •Access to Care – Ambulatory Services
• Measures focus largely on processes of care •Measures reflect care that patients actually receive and coded, not ordered for them • Measures are directly actionable for quality improvement activities
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Savings How are the measures calculated:
Calculating Administrative Compliance
Administrative – Claims based data (CPTs, ICD-9s, etc.) Hybrid – Claims data supplemented with Medical Records Data
ATC Membership Identify Measure for Calculation
100,000
CDC-Hb A1c Test
Apply Continuous Enrollment Criteria
50,000
Apply Demographics Criteria
1,000
Apply Claims Data Criteria
600 (CPT 83036 & 83037)
Calculate Rate (Compliance Level)
60% !
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So why is HEDIS important to Absolute Total Care? Accreditation: Standards CAHPS (Member Satisfaction Survey) HEDIS (Clinical measures)
54.14 points 13.00 points 32.86 points
Measure Specific Details
100.00 Additionally, the Medicaid plans are graded by the State on their performance. NCQA will also publish annual rankings based upon HEDIS and accreditation scores.
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NCQA defines date criteria for each measure, for example:
Other measures require the service to occur ON OR BEFORE the member’s birthday
Some measures require the event to occur by December 31st of the measurement year (MY)
Anchor Date = Member Birthday in MY
Childhood Immunizations – 24 months, 0 days
Anchor Date = December 31st of MY
Lead Screening in Children – 24 months, 0 days
Breast Cancer Screening
Well Child Visits in the First 15 Months of Life – 15 months, 0 days
Cervical Cancer Screening Hemoglobin A1c Test for Diabetics 11
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Some Measures Use Other Dates:
So what does a practice do to improve? -Understand the MEASURE
Pharyngitis Age Group: Children, 2 to 18 years old Time Period: July 1st of the year prior to June 30th of the measurement year. Continuous Enrollment (CE): 30 days prior to the Episode Date through 3 days after the Episode Date (inclusive). Episode Date (EPD): Date of Service for any outpatient or ED visit during the Intake Period with only a diagnosis of pharyngitis Criteria / Requirements: Child not on antibiotic for 30 days prior to visit Diagnosis of pharyngitis only Child receives strep test Antibiotic dispensed in 3 days
REQUIREMENTS -Understand the TIMELINE applicable -CODE! CODE! CODE CORRECTLY! -Know before the patient arrives, what CARE GAPS do they have? -Understand your incentive program with your health plans if you have one
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Give Good Care but MAKE IT COUNT! A New World – Incentives! 15
New World – Overview
Confidential and Proprietary
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New Incentive Program from SCDHHS- (Not Final)
Preliminary list of 10 performance measures grouped into domains with requirements for improvement
Goal • Improve HEDIS Scores. This will be done through Partners, such as SCPHCA. (It used to be only for NCQA accreditation) Why
Prevention and Screening (choose 3) – Lead screening in children, Breast Cancer Screening, Well Child Visits in first 15 months of life, Well Child Visits in year 3, 4, 5 and 6, and Adolescent Well Care Visit (required)
• Low scores in SC compared to national rates. SCDHHS wants to improve rates through the MCOs and MHNs. IOM Definition of Quality • The extent to which health services increase the likelihood of desired outcomes and are consistent with current professional knowledge (evidence based) Value Purchasing – A Key Element • Quality Management: to drive continuous improvement in the process of health care purchasing and in the delivery of health care services 17
Chronic Disease and Behavioral Health (choose 2) – Use of Appropriate Medications for People with Asthma, Appropriate Testing for Children with Upper Respiratory Infection, Appropriate Testing for Children with Pharyngitis, Follow up Care for Children Prescribed ADHD Medication (Initiation and Continuation), Followup Care after Hospitalization for Mental Illness 18
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Incentives, continued
Proposed Metrics – What are they again?
Access and Availability (choose 3) – Adult access to preventive/ambulatory health services age 20-44, 44-64; Children and adolescent access to primary care practitioners age 7-11, 12-19]; Prenatal Care, Postpartum Care
Consumer Satisfaction Survey (chose 1 from Adult and Child or 2 from either) – Rating of Health Care Plan, Rating of Personal Doctor, Rating of Specialist, Getting Needed Care (access issue)
HEDIS Measurements: “Measurement Year” is as defined as above or the designated time period as required by current Technical HEDIS Specifications.
Description
W-15 Well-Child Visits in the First 15 Months of Life
Percentage of Covered Persons turning 15 months within the Measurement Year who had six (6) or more visits with Provider before turning 15 months old
W-34 Well-Child Visits in the Third to Sixth Years of Life
Percentage of Covered Persons turning 3 years to 6 years within the Measurement Year who had one or more visits with Provider during the Measurement Year
AWC Well-Child Adolescent Visits in the Twelfth to Twenty-First Years of Life
Percentage of Covered Persons turning 12 years to 21 years within the Measurement Year who had one or more visits with Provider during the Measurement Year
ASM Use of Appropriate Medications for Asthma
Percentage of Covered Persons age 5- 56 who were dispensed at least one prescription for a preferred asthma therapy during the Measurement Year.
URI Appropriate Treatment for Children with Upper Respiratory Infections
Covered Persons 3 months – 18 yrs who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.
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P4P Proposed Metrics
P4P Proposed Metrics
HEDIS Measurements: “Measurement Year” is as defined as above or the designated time period as required by current Technical HEDIS Specifications.
ADD Follow up for ADHD Medication age 6-12 years
BCS Breast Cancer Screening
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HEDIS Measurements:
Description Covered Persons age 6-12 years with an IPSD within the look-back period with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit within 30 days of the prescription being dispensed in the Initiation Phase, had at least two followup visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Percentage of female Covered Persons age 42-69 years who had one (1) mammogram in the Measurement Year or the previous twelve months
“Measurement Year” is as defined as above or the designated time period as required by current Technical HEDIS Specifications.
Description
AAP - Adult Access to Preventive / Ambulatory Health Services age 20 and up
Adults age 20 and over with annual ambulatory or preventive care visit.
PPC - Timeliness of Prenatal/Postpartum Care
Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment in the plan. Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
CCS - Cervical Cancer Screening age 21-64
Percentage of female Covered Persons age 24-64 years who received one (1) or more Pap test(s) to screen for cervical cancer in the Measurement Year or the previous 24 months.
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Tools to Improve Results – CentAccount
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Operational Success Factors
Incorporate new patient intake questionnaire – Paper or EMR Ensure link between member and PCP, NOT CLINIC Align process and procedures with the target HEDIS health care quality improvement measures to maximize opportunity Integrate and reinforce the CentAccount member education and reward program What else?
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QUESTIONS? How Will You Approach This in Your Office?? Who will Help You? 25
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