hedis overview presentation
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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 - PowerPoint PPT PresentationTRANSCRIPT
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?
HEDIS Overview Presentation—August 11, 20144
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
HEDIS Overview Presentation—August 11, 20145
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 Overview Presentation—August 11, 20146
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
HEDIS Overview Presentation—August 11, 20147
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 Overview Presentation—August 11, 20148
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
HEDIS Overview Presentation—August 11, 20149
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
HEDIS Overview Presentation—August 11, 201410
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
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BackgroundSTAR Ratings Strategy
1. Better Care2. Healthier People/Healthier
Communities3. Lower Cost Through Improvements
Medicare STAR Program
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Star Ratings Structure
OutcomesIntermediate OutcomesPatient ExperienceAccessProcess
HEDIS Overview Presentation—August 11, 201413
Star Ratings
Excellent
Above Average
Average
Below Average
Poor
HEDIS Overview Presentation—August 11, 201414
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
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HEDIS Star Rates
0
1
2
3
4
5
6
HEDIS 2013
HEDIS 2012
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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
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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
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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
HEDIS Overview Presentation—August 11, 201419
Medical Record Retrieval: L.A. Care
HEDIS Overview Presentation—August 11, 201420
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
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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.
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Final Medical Record Review Validation
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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
HEDIS Overview Presentation—August 11, 201427
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
HEDIS Overview Presentation—August 11, 201429
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)
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HO&A 2014 Interventions
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Questions?
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