HEDIS OVERVIEW PRESENTATION

HEDIS OVERVIEW PRESENTATION

PRESENTED BY: CARINA YAPYUCO, RN RACHEL GRAY, RN HANIA ALHINNAWI , RN CLARICE MAYO, LVN

August 11, 2014

Agenda

2

Fundamentals of HEDIS Auto-assignment Medicare STAR program HEDIS medical record abstraction

Medical record review validation Off-season supplemental data collection

Quality improvement interventions

Healthcare Effectiveness Data and Information Set

What is HEDIS?

HEDIS Overview Presentation—August 11, 20143

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

What is HEDIS?


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


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 2014: 80 measures across 5 domains of care


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 Reporting


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 2014Childhood 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


BackgroundSTAR Ratings Strategy

1. Better Care2. Healthier People/Healthier

Communities3. Lower Cost Through Improvements

Medicare STAR Program


Star Ratings Structure

OutcomesIntermediate OutcomesPatient ExperienceAccessProcess


Star Ratings

Excellent

Above Average

Average

Below Average

Poor


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)

Star Measures


HEDIS Star Rates

0

1

2

3

4

5

6

HEDIS 2013

HEDIS 2012


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 2014 Medicare Highlights for L.A. Care


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 lockedJuly 1—Off-season medical record

collection begins


Medical Record Retrieval: L.A. Care


Once this process is complete the Data Entry Associate will walk the charts over to the assigned Nurse Abstractor.

If “No” medical records have been received 3 days from the initial fax out date Scheduler

will call provider’s office to follow-up and refax request if

necessary.

Assigned Nurse will review chart for medical record

completeness.

Nurse Abstractor will comment directly into Verisk in ‘Comment

Field’ as needed. Then forward the chart back to assigned Scheduler for

further pursuit.

No

Nurse Abstractor will abstract the chart via

Verisk.Yes

Once the abstraction has been completed the chart will then be given to the

Over-reader.

Scheduler will do the following:

1. Retrieve MR placed into their assigned bins.

2. Log receipt of MR in Verisk and Access

Database3. Write CIN # on MR

document.4. Pull member folder from

file room.5. Forward folder to Data

Entry Associate for Scanning.

Scheduler will print all MR’s received via their Right-Fax

system and place the records in the alphabetically marked

bins.

Provider offices that fail to comply will be

forwarded to compliance.

NO

NO

Scheduler faxes out medical records request via Verisk.

Charts will then be filed into medical records room by the Data Entry

Associate .

The Data Entry Associate will then do the following:

1. Scan MR2. Forward to Supervisor for QC and Productivity check

Health Information Data Associate ensures that all the charts listed on the log sheet supplied by the Plan Partner is received.

Additional records are obtained from Plan Partner. Health Information Data Associate gives these records to Over-reader for the

over-read process.

Over-reader designates that additional documents are needed.Pending charts will be stored in the Lead Abstractors file cabinet marked “O/R charts for Follow-Up”.

Over-reader will follow up with the Plan Partner at the weekly

meetings.

Health Information Data Associate does the following:1. Log receipt of charts in the “Contact” field in Verisk & Access Database.2. Scan documents into the following location:\\pixley\HOA.

Health Information Data Associate will inform over-reader of missing charts

Yes

No

BCSC and CFST submit abstracted charts with shipment checklist to over-reader at LAC

Complete Record

No

Complete charts are over-read by the Over-reader

Yes

The Scheduler will follow up with Plan Partner on incomplete records.

Over-read charts that are deemed complete will be filed back into the medical records room by the Health Information Data

Associate

Medical Record Retrieval: Plan Partner


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.


Final Medical Record Review Validation


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.HEDIS Overview Presentation—August 11, 201424

Off-Season Medical Record Retrieval via Fax equest

HEDIS Overview Presentation—September 3, 201325

Off-Season Off-Site Medical Record Retrieval

HEDIS Overview Presentation—September 3, 201326

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 ReportProvide education in Gaps in CareDiscuss “HEDIS at A Glance” Tool


Supplemental Files ProcessingRequest supplemental data files from:

- PPG

- IPA

- MSO

- Plan PartnersHO&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) HEDIS Overview Presentation—August 11, 2014

28

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)


HO&A 2014 Interventions


Questions?


HEDIS OVERVIEW PRESENTATION

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