0. HEDIS OVERVIEW PRESENTATION
August 11, 2014
PRESENTED BY: CARINA YAPYUCO, RN RACHEL GRAY, RN
HANIA ALHINNAWI , RN CLARICE MAYO, LVN
HEDIS Overview Presentation

1. Agenda Fundamentals of HEDIS Auto-assignment Medicare STAR program
HEDIS medical record abstraction
Medical record review validation
Off-season supplemental data collection
Quality improvement interventions
HEDIS Overview Presentation

2. Healthcare Effectiveness Data and Information Set What is HEDIS?
HEDIS Overview Presentation

3. What is HEDIS?
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
HEDIS Overview Presentation

4. 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

5. 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

6. HEDIS 2014: 80 measures across 5 domains of care
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 Overview Presentation

7. HEDIS Data Reporting
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 Overview Presentation

8. 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

9. 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

10. Auto-Assignment Measures for HEDIS 2014
Childhood 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
HEDIS Overview Presentation

11. Medicare STAR Program Background STAR Ratings Strategy Better Care
Healthier People/Healthier Communities
Lower Cost Through Improvements
HEDIS Overview Presentation

12. Star Ratings Structure
Outcomes
Intermediate Outcomes
Patient Experience
Access
Process
HEDIS Overview Presentation

13. Star Ratings Above Average Below Average Excellent Average Poor
HEDIS Overview Presentation

14. Star Measures Colorectal Cancer Screening (COL)
Comprehensive Diabetes Care (CDC)
Controlling High Blood Pressure (CBP)
Eye Exam
Nephropathy (Kidney Disease Monitoring)
Care of Older Adults (COA)
Medication Review
Blood Sugar Controlled
Functional Status Assessment
LDL <100 (Cholesterol Controlled)
Pain Assessment
Adult BMI Assessment (ABA)
Cholesterol Management for Patients with Cardiovascular Conditions (CMC)
HEDIS Overview Presentation

15. HEDIS Star Rates
HEDIS Overview Presentation

16. HEDIS 2014 Medicare Highlights for L.A. Care
5 STAR MEASURES (4)
3 STAR MEASURES (4)
CMC – Cholesterol Screening
CDC – Poor Control >9%
COL – Colorectal Cancer Screening
CDC – LDL <100
COA – Functional Status
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
HEDIS Overview Presentation

17. 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 Overview Presentation

18. 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 locked
July 1—Off-season medical record collection begins
HEDIS Overview Presentation

19. Medical Record Retrieval: L.A. Care
HEDIS Overview Presentation

20. Medical Record Retrieval: Plan Partner
HEDIS Overview Presentation

21. 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.
HEDIS Overview Presentation

22. Final Medical Record Review Validation
HEDIS Overview Presentation

23. 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.

24. Off-Season Medical Record Retrieval via Fax equest
HEDIS Overview Presentation

25. Off-Season Off-Site Medical Record Retrieval
HEDIS Overview Presentation

26. 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 Report
Provide education in Gaps in Care
Discuss “HEDIS at A Glance” Tool
HEDIS Overview Presentation

27. Supplemental Files Processing
Request supplemental data files from:
- PPG
- IPA
- MSO
- Plan Partners
HO&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)

28. HEDIS Overview Presentation

29. 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)
HEDIS Overview Presentation

30. HO&A 2014 Interventions
HEDIS Overview Presentation

31. Questions?
HEDIS Overview Presentation