What is HEDIS?? [PDF]

CARE GAPS do they have? -Understand your incentive program with your health plans if you have one. 15. Give Good Care bu

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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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