Agenda 1 Fundamentals of HEDIS Auto-assignment Medicare STAR
program HEDIS medical record abstraction Medical record review
validation Off-season supplemental data collection Quality
improvement interventions
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H Healthcare Effectiveness D Data and I Information Set What is
HEDIS? HEDIS Overview PresentationAugust 11, 2014 2
Slide 4
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 PresentationAugust 11, 2014 3
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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 PresentationAugust 11, 2014 4
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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
PresentationAugust 11, 2014 5
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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 LACs
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 PresentationAugust 11, 2014
6
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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
PresentationAugust 11, 2014 7
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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 PresentationAugust 11, 2014 8
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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
PresentationAugust 11, 2014 9
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Auto-Assignment Measures for HEDIS 2014 Childhood Immunization
Status (CIS) Children who received these vaccines by their 2 nd
birthday: 4 DTaP + 3 IPV + 1 MMR + 3 HiB + 3 HepB + 1 VZV + 4 PCV
Well Child Visits 3 rd, 4 th, 5 th, and 6 th 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 1 st
trimester Comprehensive Diabetes Care (CDC) HbA1c screening in MY;
LDL-C control in MY HEDIS Overview PresentationAugust 11, 2014
10
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Background STAR Ratings Strategy 1.Better Care 2.Healthier
People/Healthier Communities 3.Lower Cost Through Improvements
Medicare STAR Program HEDIS Overview PresentationAugust 11, 2014
11
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Star Ratings Structure Outcomes Intermediate Outcomes Patient
Experience Access Process HEDIS Overview PresentationAugust 11,
2014 12
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Star Ratings Excellent Above Average Average Below Average Poor
HEDIS Overview PresentationAugust 11, 2014 13
Slide 15
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
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
