1. Therese Hoyle◊ and Gary Urquhart§
Immunization Information Systems as a Data Source for Health Plan Quality Measures
Christine M. Layton*; Alan C. O’Connor*; Bobby Rasulnia§; Todd Osbeck†;
Therese Hoyle◊ and Gary Urquhart§
*RTI International; §Centers for Disease Control and Prevention; †Priority Health, and ◊Public Health Consultant

2. Overview Background Objective for the Study Methods Results
What IIS are and why they’re natural partners for health plans (and public health agencies).
Objective for the Study
To describe the business case for one health plan’s use of a state-based IIS as a data source to measure quality.
Methods
Primary (key-informant interviews) and secondary data were used to estimate immunization rates with and without IIS data and to calculate the cost effect.
Results
The use of IIS data resulted in a benefit-to-cost ratio of $8.06 and improved immunization rates.
Intangible benefits.
Conclusions
IIS and health plans leverage of each other’s mandates is a win-win.
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3. Background: Immunization Information Systems
Are not just immunization registries.
Are “cradle-to-grave” sources of health information for indicators such as:
Immunization records as well as:
Blood lead levels
Newborn screening results
Preventive health measures, e.g., BMI.
Are supported by the CDC
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4. Why Would a Health Plan Leverage an IIS?
Health plans have been called “natural partners” for IIS because they use data similar to those in IIS for quality measurement and HEDIS reporting.
Is there a business case for health plans to make use (“leveraging”) of IIS’ surveillance mandate?
Priority Health began using MCIR as the primary means for recording members’ immunizations in 2004, following NCQA certification.
What was the “business case” for using IIS?
Health plans have been described as “natural partners” for IIS because they use data similar to those in IIS to measure product performance.3 The National Committee for Quality Assurance (NCQA) established the Health Plan Employer Data and Information Set (HEDIS) as a set of performance benchmarks against which health plans can be compared. HEDIS measures include up-to-date (UTD) immunization status for children at 2 years of age. HEDIS measures for adolescents are currently in transition, with prior measures dropped in 2006 and new measures to be implemented in HEDIS permits data collected from chart reviews, claims, and, where approved, IIS data. Thus, there may be a business case for a health plan to use IIS as a data source for immunization histories.
This study reviews the business case for Priority Health, Inc.—a Michigan-based managed care organization—to establish Michigan’s IIS, the Michigan Care Improvement Registry (MCIR), as the preferred reporting mechanism for members’ immunization data. In 2003, NCQA affirmed MCIR data’s acceptability for HEDIS, and Priority Health began populating its information systems with MCIR data in Claims had been the principal source of immunization data. The Michigan Department of Community Health (MDCH) and Priority Health saw the potential for a mutually advantageous relationship: MCIR would benefit from Priority Health encouraging providers to populate the IIS, potentially increasing observed immunization and population coverage rates; and Priority Health and its providers would benefit from a single point of entry for immunization data. This analysis examines Priority Health’s decisional processes, the use of IIS data for quality and physician performance programs, and the consequent incremental costs and benefits accruing to Priority Health.

5. Michigan Care Improvement Registry (MCIR)
Established in 1997
Funded through tobacco settlement
Contains 4.7 mil. person records (MI pop’n 10 mil.)
Links to:
Vital records
WIC
Medicaid
Department of Education
Childhood Lead Poisoning Prevention Program
MCOs/health plans
MCIR’s success was recognized this Monday and their work has been presented at past NIC. The registry was established in 1997 using funds from MI’s share of the tobacco settlement. MCIR contains records from about half of the state’s population.
MCIR includes linkages with a variety of public agencies and organizations—usual suspects--like vital records, WIC, and Medicaid as well as Pb poisoning prevention program and—relevant for this presentation—MCOs/health plans.
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6. Priority Health
Provider-owned, not-for-profit health plan based in Grand Rapids, MI.
480,000 members.
Health plan rated #1 by the National Business Coalition on Health.
HMO ranked 15th nationally by NCQA for the best commercial health plan product in 2008.
Focus on health care quality reflected by:
HEDIS -- benchmarks
Physician Incentive Program (PIP) – pay for performance
“Apples on the Web” – public reporting of quality measures
Priority Health has a really strong commitment to health care quality. In fact, quality—as mesured by HEDIS benchmarks--is integral to Priority Health’s corporate strategy.
HEDIS is the Healthcare Effectiveness Data and Information Set. HEDIS was created by the National Committee for Quality Assurance (NCQA) as a set of performance benchmarks to permit comparison of health plans. HEDIS measures include a childhood immunization measure which is up-to-date status for children 2 years of age. The measure used is what’s known as the Childhood Combination 2 which is the 4:3:1:3:3:1. HEDIS has also included a measure for adolescent immunization, but because this measure has been changing, I’m not going to get into details right now.
PIP is Priority Health’s Physician Incentive Program. The PIP is a pay-for-performance program which was introduced in 1997 when Priority Health moved from a risk-based reimbursement model to capitation. Within a capitated payment system, providers receive a set amount per member per month to provide clinical care for the Priority Health members within their practice. The PIP includes a variety of preventive health services such as Pap testing, mammography, diabetes and asthma management. Childhood immunization has been part of PIP since its inception in Adolescent immunization was incentivzed starting in 2004 and then was removed in 2007 when NCQA removed adolescent immunization from its HEDIS measures. To receive the payment—which is basically 20% of their full capitation—provider practices must meet the 90th percentile HEDIS benchmark for Priority Health Members in their HMO product.
In addition to the PIP, Priority Health also uses what they call “the Apples on the Web” to report provider performance. Providers’ performance toward HEDIS measures are reported using a range of 1 to 4 apple icons. This approach appeals to providers who use the system to track their progress. Likewise, it introduces some friendly competition between provider groups. With these programs, meeting HEDIS benchmarks awards providers twice: the financial incentive as well as a high quality rating.

7. Pathways for Data Exchange

8. Research Objective
To assess the use of Immunization Information Systems (IIS) as a single point of data entry for use in managed care organization’s (MCO):
physician incentive program (PIP),
internal quality tracking program (“Apples on the Web”, and;
external quality reporting program (HEDIS).
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9. Methods
Business case.
Data were collected through key informant interviews and from the MCO’s data systems.
Immunization coverage rates and MCO quality measures from 2004 through 2007 were analyzed with and without the IIS as a data source.
A cost-benefit-analysis was performed.
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10. Result: Health Plan Leverages IIS Data
Priority Health providers were already responsible for reporting immunization records as part of existing data collection used for:
HEDIS
Apples on the Web
PIP
Priority Health’s use of MCIR data facilitated its quality measurement activities.

11. Why Does Priority Health Leverage MCIR?
MCIR is a single point of data entry and leverages Michigan providers’ legal obligation to record childhood immunizations
MCIR enables providers to demonstrate progress in meeting immunization measures at no additional cost or reporting burden, irrespective of whether a claim was filed.
MCIR offered Priority Health an opportunity to acquire immunization data on members who receive immunizations outside the provider network.
Priority Health’s immunization measures are sensitive to members’ ages, and providers need accurate and timely data to track their performance. Priority Health believes that MCIR data offer three key advantages. First, MCIR is a single point of data entry and leverages Michigan providers’ legal obligation to record childhood immunizations. Priority Health and MDCH estimate that 80% to 90% of providers were regularly updating MCIR when Priority Health announced that MCIR would be the primary means for recording immunizations and demonstrating progress toward incentive and quality goals.
Second, MCIR enables providers to demonstrate progress in meeting immunization measures at no additional cost or reporting burden, irrespective of whether a claim was filed. Claims had been the principal source of immunization data, but reliance on claims data under capitation may underreport immunization because providers may not submit all immunization claims, as the reimbursement amount may be deemed too low to justify the cost of claim preparation. In addition, claims might not be timely, as providers may only submit claims when the request for reimbursement includes multiple office visits and the claim’s value exceeds the cost of claim submission. Thus, claims data alone may not be an accurate representation of UTD immunization status.
Third, MCIR offered Priority Health an opportunity to acquire immunization data on members who receive immunizations outside the provider network, such as health departments and provider offices outside of Priority Health, or members who transfer to Priority Health from other health plans.

12. Result: Higher Observed Immunization Rates
As you can see, adding MCIR data resulted in higher observed immunization rates before chart reviews. The increase isn’t the same for all vaccines, but look at the overall increase for Childhood Combination 2: It went from about 35% coverage to nearly 90%. And the increase for Hep B was pretty striking. Given what I’ve heard in previous sessions here, I’m going to guess that this increase reflects birth doses which were added to the immunization record via vital records.
Notes: Immunization rate data are for current Priority Health members participating in the HMO and POS products in 2007 and are before chart reviews. IIS data were downloaded from the Michigan Care Improvement Registry (MCIR). Childhood combination 2 refers to children 2 years old who have received the following vaccinations: 4 doses of DTaP/DT, 3 IPV, 1 MMR, 3 Hib, 3 Hep B, and 1 Varicella by their second birthday. Adolescent combination 2 refers to adolescents 13 years old who had a second dose of MMR, 3 Hep B, and 1 Varicella by their thirteenth birthday.
IIS = immunization information systems.
2007 Data
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13. Priority Health’s HEDIS Administrative & Reported Rates
HEDIS reporting requires health plans to review a random sample of 411 patient charts annually for UTD immunization status for each population group in each commercial product. The number of charts to be reviewed may be reduced if each member in the sample the health plan has a complete internal UTD immunization record. The immunization coverage rate from internal records is the final sample size (FSS) administrative rate. The higher this rate is the fewer charts that must be reviewed manually at providers’ offices. The combined claims, IIS, and manual chart review rate is referred to as the hybrid reported rate, which is the final HEDIS measure reported to NCQA. MedMeasures software (ViPS, Inc., Baltimore, MD), which Priority Health uses for HEDIS compliance, was loaded with historical claims files alone to regenerate administrative rates for 2004 through 2007.

14. Change in HEDIS Administrative Rate for Childhood Immunizations with MCIR Data
The benefit is the area between the curves – can be translated into a cost impact

15. Priority Health and MCIR: Avoided Chart Reviews for HEDIS
Priority Health’s HEDIS rates for childhood and adolescent immunizations for 2001 through The administrative rate nearly doubled with the inclusion of MCIR data to calculate the administrative rate for 2004, which increased to 80.89% for childhood immunizations, up from 43.38% in As Priority Health continued to download MCIR data, the number of charts reviewed for HEDIS declined from 582 in 2003 to 51 in Similar trends were observed for adolescent immunizations.

16. Priority Health: Avoided Chart Reviews for PIP
Each spring, Priority Health conducts a PIP settlement to calculate and distribute incentive payments. When Priority Health has no MCIR data or claims record for a dose, providers are permitted to submit a supplemental submission to document that the dose was administered and should be counted toward the payment calculation. Currently, that submission is required to be a printed record from the MCIR. Before 2004, providers were alerted to missing doses via an automated message from Priority Health’s patient registries. Providers then faxed patient charts, which subcontractors reviewed to update patient registries. The provider response rate was approximately 90%.

17. MCIR as “Data Solutions Provider”
MCIR performs an electronic data exchange role, including data capture, management, and maintenance functions.
Data from MCIR and claims are merged weekly and matched using a proprietary algorithm.
In a recent merge, only 100 out of 7,400 records were “manually” reviewed.
Cost to Priority Health: ~$10,700 and about ~$1,000 per year to maintain.
Each avoided chart review saves Priority Health $6.00.

18. Summary of Costs, Benefits, and Net Benefits
Year
Costs
HEDIS Chart Review Savings
PIP Chart Review Savings
Net Benefit
2003
($10,662)
2004
(914)
$2,058
$30,336
31,480
2005
2,790
38,880
40,756
2006
2,946
34,548
36,580
2007
1,092
9,522
9,700
Total
($14,318)
$8,886
$113,286
$107,854
Note: A benefit-to-cost ratio of $8.06 was calculated as the net present value of benefits to the net present value of costs assuming a 10% discount rate. HEDIS = Health Plan Employer Data and Information Set; PIP = Physician Incentive Program. 18
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19. Conclusions
Priority Health’s programs are predicated on the ability to obtain comprehensive and accurate data as well as providers’ perceptions that the data informing the measures are true.
Priority Health to enhanced the transparency of its practices and acquired immunization data that were more timely and comprehensive.
Priority Health believes the principal source of value is enhanced relations with providers.
MCIR data also increased Priority Health’s assurance that its members were UTD on immunizations, and permitted providers to quickly determine the immunization status of their patients.
A good investment: BCR = 8.06, IRR = 310%

20. Result: What We Can’t Tell You
Much of the positive result of Priority Health’s use of MCIR data for its quality measures is too difficult to quantify.
Building relationships between health plan and providers
Increased transparency of data exchange
Provider participation and “buy in” for MCIR and Priority Health
Building relationships between MCIR and Priority Health
Increased trust of data from “outsiders”
Public private partnership

21. Acknowledgements
Many, many people at Priority Health and the MCIR generously shared their time, expertise, and data.
RTI
Priority Health
MCIR
Dallas Wood
Laura Stuursma
Bob Van Eck
Brian Myers
Eric Richter
Satish Challa
and many more
Laura Korten
Laura Rappleye
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22. Errata
Some data in the abstract from the conference agenda should be corrected:
The annual return on investment (ROI) calculated as 310%--not 36% as reported in the abstract.
This ROI reflects a benefit-to-cost ratio of $8.06.