HEDIS 2019 Specifications and Reporting Update. Agenda. GG9: Timeline. Melissa Sheesley

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1 HEDIS 2019 Specifications and Reporting Update Melissa Sheesley Agenda Volume 2 General Guidelines (GG) Updates Appendix 3 update V2 Measure Changes NCQA Guidance Allowable Adjustment of HEDIS GG9: Timeline Select Non certified Measures for Review: Nov 1 Plan Submits All Non certified Code: Feb 1 Source Code Review Complete / Corrective Action Complete: Mar 1 CAHPS Approval: Jan 31 SDS Nonstandard Collection: Mar 1, Approval: Mar 29 Submit Prelim Rates Using Certified Code: April 17 MRR Frozen Counts: May 9 Plan Lock Final Data: June 3 Submit Auditor Locked Data & PLD: June 17 1

2 GG 15: Dual Enrollment Evaluate at Measure level End of CE period Date of Service or Date of Discharge Apply Consistently GG15: Quick Reference Product Where to Report Commercial / Medicaid Commercial Medicaid / Medicaid Primary Coverage Commercial / Commercial Single Submission (same / combined product): Include Member Once Different Submissions (products): Include in Both Commercial / Medicare Report Primary Medicaid / Medicare Dual Eligibles Include in Both if Enrolled with same Org May Exclude if PFFS with other Org or Unknown other Medicare Primary Exception: PCR Remove from Medicaid reporting and only include in Medicare MMP Include in both Medicare and Medicaid General Guideline 31 Via PCS Removed Practitioner Accountability Requirement 2

3 GG 38 Biometrics member collected vs. monitoring devices GG 43 Codes in conjunction GG Updates GG44: ED/OBS to IP Stay Clarifies Identification of Event Same Claim Separate Claim Inpatient Claim Submitted ED or OBS code included as a claim line Consider as an ED/OBS visit that resulted in IP stay ED/OBS Claim Submitted Inpatient Claim Submitted Compare ED/OBS Date of Service to Admit through Discharge Date If day before or at anytime during span, consider ED/OBS led to IP stay Other Updates Sample Size Reduction Effectiveness of Care Denied claims for Overuse Domain Socioeconomic Status for Medicare (4 measures) 3

4 SES Determination What is the CE period? Does member meet CE? Was member assigned LIS (low-income status) or DE (dual-eligibility) status? Does member have disability? Use last 3 months of CE to determine CE Practitioner Types Added FQHC as PCP Type Must meet criteria Cannot also be Rural Health Clinic Must be approved by auditor Risk of Continued Opioid Use (COU) Hospitalization Following Discharge from a SNF (HFS) Adult Immunization Status (AIS) Prenatal Immunization Status (PRS) New Measures 4

5 Retired Measures Pneumococcal Vaccination Coverage for Older Adults (PVC) Rolled into AIS measure Relative Resource Use (RRU) measures HAI suspended (TU) Practically New: CBP Members w/ HTN whose BP was <140/90 Admin Data Allowed No References to Diabetes No Sample Reduction No member-reported results Eligible Population: Two visits with Dx of HTN in MY or PY. Exclude ISNP/LTI, advanced illness and frailty Numerator: Most recent in MY On or after 2 nd Dx of HTN EOC: Which Services Count? Overuse/ Appropriateness subdomain categories 1. Denied claims not for numerator but for EP 2. Denied claims not for EP or numerator 3. Must include all claims for exclusions 5

6 EOC Measure Changes WCC Nutrition/ Physical Activity obesity/eating disorders CIS - MMR, VZV, Hep A b/t 1 st and 2 nd Bday IMA Meningococcal- Added CVX 114, 167 EOC Measure Changes BCS, COL, CDC (*Eye) Added SES (MCR) Exclusion Logic changes (all products) EOC Measure Changes COA Defined Standardized Tool; Med Review, FSA, PA - POS 21, 51 don t count PCE- Step 2 6

7 EOC Measure Changes Telehealth SPR, ART MMA, AMR SPC, SPD, ART CDC SSD, SMD, SMC, SAA, APP EOC Measure Changes PBH, SPC, SPD, ART, OMW Exclusion ISNP/LTI, Advanced Illness and Frailty EOC Measure Changes AMM Clarified EP and added POS Value Sets 7

8 EOC Measure Changes ADD Num 1 &2 Value Sets and Setting; Rate 2: CE member must be in same product/line for 300 days after IPSD EOC Measure Changes FUM, FUH Added Dx of intentional self-harm to EP; New Age stratification; FUH- MH Practitioner required SSD, SMD, SMC, SAA, APP Schizoaffective disorder Supplemental Data Use Changes NCS, PSA, LBP, DDE, UOD only allowed for exclusions URI, AAB, APC, DAE, UOP May not be used 8

9 Measure Changes UOD, UOP - EP: 2 or more disp. Events on different DOS UOD Numerator: Clarified daily dose calculation and IPSD Measure Changes AAP, AMB Added telehealth to numerator IET Initiation on same data as IESD must be with diff provider except if member qualified with certain meds. Methadone does not count to numerators for other cohort Measure Changes PPC Specialty Focus; Decision Rule 3 - removed internal codes for LMP/EDD and risk assessment from admin specs 9

10 Measure Changes IPU Removed MS-DRGs IAD, MPT Categorization 1 st Event in each Category Counts; Telehealth added Measure Changes PCR New SES; Updated reporting strata; Readmit exclusions, Expanded conditions Stay tuned for 2020 Measure Changes AHU Review outlier/ non-outlier criteria for COM & MCR; many code changes; No SDS EDU, HPC No SDS HPC Clarified outlier vs. non-outlier 10

11 QRS Changes Clarified GG 17 (benefits) Similar GG for HEDIS 2019 CDC Removed HbA1c Testing Allowable Adjustment for HEDIS Make NCQA s measures broader Allow plans to modify CE or product line criteria NCQA released expanded HEDIS VSD Maintain the clinical intent Provided as part of Volume 2 Questions 11

12 HEDIS 2018 Measure Trends Kevin Gregory Back to the HEDIS 2018 Interesting Trends New Measures Results ECDS Reporting STARS Measures Added 2 Dose HPV Series IMA HPV & Combo 2 IMA HPV HEDIS 2017 HEDIS 2018 Change 10 th 12% 20% +8 Mean 20% 31% th 27% 43% +16 IMA Combo 2 HEDIS 2017 HEDIS 2018 Change 10 th 11% 18% +7 Mean 18% 29% th 25% 39%

13 IMA-Meningococcal Removed CVX 114 Affected Selected Registries, Admin Drop No Impact on Benchmarks Overall HEDIS 2019 Change CVX 114 Added Back CVX 167 Added FUH 7 Day Removed Visits on Discharge Date Product Line 10 th Change Mean Change 90 th Change Commercial Medicaid Medicare Removed Value Sets Rate HEDIS 2017 HEDIS 2018 ADV Change 10 th 32% 38% +6 Mean 51% 54% +3 90th 67% 69% +2 13

14 MPT & IAD Any Services Inpatient Intensive OP / Partial Hosp Outpatient ED Telehealth Feb 1st March 1 April 1 May 1 HEDIS 2017 Logic June 1st HEDIS 2018 Logic TRC Reporting Stats Reporting Status Subs All Indicators Hybrid 141 Admin Only Reporting 13 All Indicators BR 10 Full EP Excluded 2 TRC: Notification Admin Rate Hybrid Rate Difference 10 th N/A <1% N/A Mean N/A 10% N/A 90th N/A 23% N/A 14

15 TRC: Receipt of Discharge Info Admin Rate Hybrid Rate Difference 10 th N/A 0% N/A Mean N/A 5% N/A 90th N/A 9% N/A TRC: Patient Engagement Admin Rate Hybrid Rate Difference 10 th 61% 68% +7 Mean 72% 78% +6 90th 84% 86% +2 TRC: Med Rec Admin Rate Hybrid Rate Difference 10 th 4% 13% +9 Mean 18% 39% th 38% 61%

16 MRP vs TRC Med Rec Rate MRP TRC MR Difference 10 th 31% 13% +18 Mean 50% 39% th 72% 61% +11 UOP & UOD Rate Conversion HEDIS 2018: Rate Adjusted per 1,000 HEDIS 2019: Switched to Percentage Still based on Numerator and Denominator Example: Absolute Num= 80 Den = 800 Adjusted per 1, per 1,000 Percentage (per 100) 10% UOD Product Line 10 th Mean 90 th Commercial 3% 5% 8% Medicaid 2% 6% 10% Medicare 4% 7% 11% 16

17 UOP: 4+ Pharmacies Product Line 10 th Mean 90 th Commercial 2% 5% 7% Medicaid 3% 8% 16% Medicare 1% 4% 6% UOP: 4+ Prescribers Product Line 10 th Mean 90 th Commercial 11% 16% 21% Medicaid 17% 25% 31% Medicare 9% 14% 20% UOP: 4+ Combo Product Line 10 th Mean 90 th Commercial 1% 3% 4% Medicaid 2% 5% 10% Pharmacies Prescribers Medicare 0% 2% 4% 17

18 FMC No Significant Different in vs 65+ Percentile Rate 10 th 42% Mean 52% 90th 61% PCR Readmission Rate New Medicaid Measure Medicaid Com Medicare 10 th 11% 6% 12% Mean 17% 8% 16% 90th 23% 10% 21% ECDS Measure Reporting 5 Organizations 13 Submissions With ECDS Reporting 4 Commercial 7 Medicare 2 Medicaid CMS Voluntary ECDS Reporting Medicaid Slowing Starting to Require 18

19 ECDS: DMS 2nd Year Measure 10 Subs with Rates of 0% 1 Sub Did Not Report 2 Subs Reported Using EHR Data Source. Rates % ECDS: DRR 2nd Year Measure 10 Subs with Zero Rates 1 Subs Did Not Report 2 Subs Reported Using EHR Data Source F/U PHQ-9: 10-27% Remission: 4-5% Response: 5-10% New for HEDIS 2018 Reported in all 13 Submissions Screening: 1 Sub Reported 0% Other Subs: % Follow-up Positive Screen Extremely Small EPs Unreliable Rates ECDS: DSF 19

20 ECDS: ASF New for HEDIS COM Subs Did Not Report this ECDS measure 11 Subs Reported Rates were 0% for both indicators in all Reported Submissions ECDS: PVC New for HEDIS 2018 Reported in 11 COM & MCR Submissions All Had Claims Hits Only 3 Had Additional Hits From EHR and HIE/CM Rates Ranged from 2% to 27% STARS Means Mean Rate: Absolute Change HEDIS 2018 vs HEDIS CDC Poor* CDC Neph PCR ART BCS CDC Eye COA Pain ABA CBP COA MR COA FSA COL MRP OMW 20

21 Questions? Execution of Changes, New Measures and Audit Updates Laura Hart Agenda Steps to Prepare for Change Overview of New Measures Successful Completion of ROADMAP Audit Changes 21

22 What Changed? Review Summary of Changes & Technical Update (TU) Final V2 with TU Released by 10/31 How Does it Impact Your Plan? Volume 2 Changes Do You Have the Data Required by Changes? Develop a Plan Are Updates to Extract- Transformation-Load (ETL) / Mapping Processes Needed? Communicate with Auditor Do Not Work in a Vacuum Keep Your Auditor in the Loop Ask Questions 22

23 New Measures COU Risk of Continued Opioid Use HFS - Hospitalization Following Discharge from a Skilled Nursing Facility AIS Adult Immunization Status PRS Prenatal Immunization Status COU Members 18+ with NEW Episode of Opioid Use 2 Rates 15+ Calendar Days Covered by Opioid from IPSD to 29 days after 31+ Calendar Days Covered by Opioid from IPSD to 61 days after EP Based on SNF Discharges Members 18+ discharged from SNF (Jan 1 Dec 1) and had unplanned acute hospitalization 2 Categories: Admission within 30 days Admission within 60 days HFS 23

24 AIS (ECDS) Commercial, Medicaid, Medicare Initial Population: Members 19+ Participation Period: 1/1/ /31/2018 Exclusions AIS Rates Influenza 7/1/17 7/30/18 Td/Tdap 1/1/09 12/31/18 Composite Rate Zoster 1 Dose (Live) On/After 50 th birthday 2 Doses Recombinant On/After 50 th birthday Pneumococcal 13 valent & 23 valent After age months apart PRS (ECDS) Commercial & Medicaid Initial Population: Delivery during MY Participation Period: 28 days prior to delivery through delivery date Exclusions: Hospice or Delivery < 37 weeks 24

25 PRS Rates Influenza: Adult flu shot 7/1/PY through delivery date or anaphylactic reaction to flu shot during or before MY Tdap: Vaccine during pregnancy (including delivery date) or prior anaphylactic reaction or encephalopapthy due to Tdap or Td Combo: Qualified for Both Numerators ROADMAP Changes Updated Content Focused Questions Identify Potential Risk HEDIS Roadmap New Section 25

26 Section 6: Enquiring Minds How do you determine what goes to vendor? How is data prepped? What QA is completed and when? Audit Updates Complete Survey Sample Frame (Appendix 1) Bye-Bye MRSS Reports Onsite Data / Query Focus MRRV Transitions of Care ECDS Reported = Audited Convenience Sample Exempt: Passed MRRV for all measures validated in PY No significant process changes Not reporting any new measures May still request one 26

27 Issue Log: Structure Standard Issues Convenience Sample Completion Report Impact Report Management Rep Letter (MRL) Core Set Timeline Reorganization Timeline: Important Dates Task NCQA Deadline Auditor selects a core set of noncertified measures for code review. By November 1 Organization submits source code for hybrid measures, systematic sampling, CAHPS By December 3 and QHP enrollee survey sample frames to auditor for review (for noncertified measures). Auditor completes source code review for noncertified hybrid measures, systematic sampling, CAHPS and QHP enrollee survey sample frames, and organization addresses all corrective actions. Organization submits all remaining core set measures source code for auditor review (for noncertified measures). Auditor completes source code review for all remaining core set measures and organization addresses all corrective actions. By December 31 By February 1 By March 1 Barriers to Auditor Lock Issue Closure Benchmark & Tier 4 Corrective Actions MRL Receipt Between June 3 June 14 27

28 Understand Changes Technical Specifications Roadmap Audit Process Next Steps Develop a Game Plan Prepare Staff Execute Summary Questions? Data Savvy Medical Record Projects Christy Patterson 28

29 Goals Administrative Data Knowledge Medical Record Data Knowledge Better Outcomes for MR Results Off Season Data Mining Potential New Data Source Identified? Same vendor showing over and over Provider group with EMR Potential Data Issues Trends in valid data errors found in MRR Provider with more chase this year Hybrid - Smart Choice? Count of Measures & Submissions Resource Availability Volume and Type of Medical Records ROI on Higher Reported Rate 29

30 Data Completeness What are you working with? Vendor Data Encounter/Capitated Data Expected External Files Registries State Files Know Data Flow What moves when? Issues with Warehouse Refresh Claims Lag- Especially Hospital Data Lag Administrative Refresh Pro Reducing Open Chases Add Missing Data Con New Recent Data Risk Falling Below MRSS 30

31 Supplemental Data Data Being Collected What is the end goal? Timing of Loading What is the end goal? ROI of Source Is this worth it? Provider Mapping Strategies Know Each Others Goals Hybrid = Good Chases Data = High Administrative Rates Understand the Impact of Mapping Decisions Where do the specialties come from? Chase Clean-up Leverage MR Vendor Knowledge MR Management Vendors Abstraction Vendors Provider Affiliation Listings Build Provider Chart Database 31

32 Backing Out Data Know How To Do It! File Identification Pushing to MR Project Updating MR Chases Time it Correctly May Is Not Good Inform Those Impacted ASAP Chase Completion Reports NCQA Standard Items By Measure and Member 100% Closed What does that mean? System Closed How does that figure in? Completion Reasonable? Samples MR Denom Completion Measure Received Chased Rate ABA % AWC % CBP % CDC % CIS % IMA % LSC % PPC % W % W % WCC % Samples MR Denom Completion Measure Received Chased Rate ABA % AWC % CBP % CDC % CIS % IMA % LSC % PPC % W % W % WCC % 32

33 Internal Debrief Gather Facts Successes and Opportunities Send Neutral, but Informed Parties Include Right People Process Owners People Who Do the Work People Who Can Drive Decisions Questions? Data Mapping Glen Braden 33

34 Measures are ever changing RRU Retired HAI Suspended Opioid measures added General Changes MS-DRGs Claim number/ Same Service Medicare files Help us Help you Data Mapping & the Audit Not been a focus NCQA shift Risk based audit Roadmap changes Section 6 (IT) Section 7 (Business) Queries Certified Measures Data Preproduction (Sec 6) How produced Excluded populations List of Sources Ancillary SDS Warehouse Schedule 34

35 Mapping Null values Defaults Mapping applied Your warehouse data Detail/ header data Paid/ Denied Provider specialty Document workarounds Section 6, Con t Section 6 Attachments 6.1 Data Flowchart 6.2 Data layouts/ dictionary 6.3 HEDIS data repository 6.4 Organization to vendor mapping (not source code) 6.5 Non-standard code mapping 6.6 ASO contracts Data Integration and Rptg (7) Section 7 think high level Completeness Sources Data Preparation Data Integration Source code Data Reporting Attachment 7.1: Vendor s implementation guide 35

36 Why? Avoid Surprises and BR s Null/default values for facility/ provider claims FSP overstated Paid/ Denied not set correctly IPU, PCR, AMB, EDU, AHU, HPC Null NPI s - UOP Product & Benefits Identify Reporting Population MCR contracts MCD Duals Benefit Flags At member level RX benefit with limited benefits CD vs MH What claims should you load? EOC All Services Count Paid or not (final version) Run out In your Warehouse? Suspended Pending Reversed 36

37 Paid Allowable > 0 Capitated Denied Entire claim denied, Allowable = 0 Not service line level Bundling Payment Status Provider Elements Vendor Specific Mapping from your specialties to vendor s list Required to review Provider Specialty PCP identification FQHC s Chase Logic Mental Health Prescribing? Provider Elements (Pharmacy) Use Opioids from Multiple Providers Overuse measure Provider/ Pharmacy NPI Null or Unknown Default value Not available = BR 37

38 Medicare Socioeconomic status (SES) stratification Source MMR None, LIS/DE, Disability, or LIS/DE and Disability Use last 3 months 2 out of 3 Last one Not optional More Medicare Specific Auditor Questions: Vendors use monthly membership files? Flag set by Plan Hospice Indicator? Race Information? Language Information? HICN/ MBI numbers Either counts for 2018 Added to PLD? Data Source Matters No Supplemental Data for Risk measures (PCR) Observed events or Risk adjustment Socio-economic status (SES) LTI flag exclusion Frailty and Advanced Illness exclusion Denominator events Billing Errors 38

39 Diagnosis Codes Primary vs secondary Code Formatting (xx.xx) MRR Vendor data into HEDIS software system Event based? True/ False? Gotcha s More Gotcha s Product/ Submission Identification What s required How Id in software Dual SNP Consolidated H contracts Admin, SDS, and ECDS Medical Record Challenges & Measure Strategies Kelli Graziano, MD 39

40 Objectives 2019 Changes (A LOT!) 2018 Measure Challenges Exclusions Review MRR Best Practice Note: All things TRC will be addressed in the breakout session Hybrid Measure Changes Childhood Immunization Status (CIS) Immunizations for Adolescents (IMA) Care for Older Adults (COA) Controlling High Blood Pressure (CBP) Prenatal and Postpartum Care (PPC) Well Child Measures (W15, W34, AWC) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) Comprehensive Diabetes Care Eye/A1c (CDC) WCC Good news! Obesity or eating disorder services now numerator compliant 40

41 CIS MMR, VZV, Hep A Administered on or between 1 st and 2 nd birthday IMA Updated optional exclusions for Tdap Encephalopathy on or before 13th birthday 41

42 Acute IP setting not eligible COA Clarified new examples of ACP Removed continence from ADLs CBP Almost an entirely new measure Now includes admin component No longer have to confirm HTN dx Event: 2 HTN dx in MY or PY CBP BP reading must occur on or after 2 HTN dx Removed DM flag 42

43 CBP No age thresholds Remote patient monitoring devices Cannot reduce sample size Procedure clarification CBP Chart pursuit unchanged If not the PCP/treating provider we need context CDC Remote BP monitoring devices Procedure clarification 43

44 PPC Documentation of gestational age with prenatal risk assessment / counseling or complete OB Well Child Measures Clarification for medical history, physical and mental development medical record requirements 2018 Measure Challenges Medication Reconciliation Post- Discharge (MRP) CDC (Eye and A1c) WCC N and PA Colorectal Cancer Screening (COL) 44

45 Added challenge of current medication list Must be evidence of provider type Must be in correct record MRP 45

46 CDC Eye All retinopathy is created equal Review exam and assessment Ensure both eyes were examined and images were adequate Non-Compliant Example Non-Compliant Example 46

47 Retinal Imaging Confirm that result is associated with clear date CDC HbA1c Cannot assume date of service Non-Compliant Example 47

48 COL FIT DNA vs FIT Unclear type of testing FIT vs FIT DNA FIT vs FIT DNA 48

49 FIT vs FIT DNA Ensure guidance is not in the context of an acute/chronic condition WCC N and PA Developmental assessments do not count Non-Compliant Example 49

50 Non-Compliant Example Non-Compliant Example Exclusion Strategies Opt for the hit Increase rates Required vs Optional Know the specs Multiple failures Palliative Care vs Hospice 50

51 TRC/MRP Supporting documentation must show continuous admission from time of dc thru 12/1 of MY CCS Must be clear evidence of cervical absence Non-Compliant Example 51

52 Non-Compliant Example CDC Require 2 years of supporting documentation 2 years of medical records 2 years of claims data Absence of diagnosis is not sufficient for valid data error EDD or DOD not on or between Nov 6 of PY and Nov 5 of MY PPC Non-live births 52

53 Best Practices Submitting MRR Questions Record Abstraction Record Submission MRR Questions Same standardized excel format Please provide context Cutoff date April 12 th Chart Submission Copy of Abstract Copy of Chart Highlight or Mark Not Entire Chart No Snippets Full Page(s), but Minimum Necessary Single PDF per person/measure preferred 53

54 Best Practices Records on Hand Review Records Prior to Submission Hit highlighted? Abstraction Errors? Correct name? File Submission 1 zip file per measure Thank you! Questions Supplemental Data & ECDS Carlo Teano 54

55 OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting ANNUAL SDS MAINTENANCE Mapping All Nonstandard coding schemes Use NCQA updated allowable codes Rx SDS must map to Medication Set Section 5 Changing value from source Attachment

56 ANNUAL SDS MAINTENANCE PSV Requirements Internal plan sampling Plan for collection and storage Have a process for retrieval Member s chart, clinical report/summary, EHR/registry screen shot counts Load after complete and source approved IMPACT REPORT Alignment with Section 5 Responses Analyze for ROI Data Meeting Expectations Mapping issues? ETL working properly? TIMING IS EVERYTHING When to Load SDS Prior to hybrid sampling At administrative refresh After approval Let Historical Results Guide You Utilize Impact Report 56

57 TRENDS EMR leading the Way More Low Impact SDS Consolidation of Like Sources EMR Lab Continuity of Care Document OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting SDS AUDIT TIMELINE Task HEDIS 2018 HEDIS 2019 Validating SDS may begin Dec 1 Dec 3 Stop all Nonstandard data collection & entry Mar 1 Mar 1 Attest approves all SDS Mar 30 Mar 29 57

58 GG 30. SUPPLEMENTAL DATA SDS may not be used for: Measures where the specification specifically indicates supplemental data cannot be used. NEW Example 1: SPC, SPD, OMW GG 30. SUPPLEMENTAL DATA SDS may not be used for: Measures where the specification specifically indicates supplemental data cannot be used. NEW Example 2: URI, AAB, APC, DAE, UOP, PCR, HFS, AHU, EDU, HPC, GG 30. SUPPLEMENTAL DATA Note: The lists of examples for standard and nonstandard supplemental data are not exhaustive. The final classification of all supplemental data sources is determined by the auditor. NEW 58

59 GG 30. SUPPLEMENTAL DATA Required Data Elements Standard Files must have standard file layouts, standard data fields and industry standard codes, and must include all elements required by measure specifications, including payment status when applicable. NEW Applies to W15, W34, AWC GG 30. SUPPLEMENTAL DATA Required Data Elements Nonstandard Home Visits Data collected or reported by practitioners who render the clinical service during home visits must have evidence of accountability by the practitioner and at a minimum include date, name and signature on each in-home form. NPI or TIN along with date would also be acceptable. NEW OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting 59

60 CONSOLIDATING LIKE SOURCES Groups Submit Collection & Oversight SDS Impact Target Population EMR DATA SDS COLLECTION Data Integration Data Receipt Validation & Quality Assurance Data Conversion & Mapping Mapping & Integration Groups Submit GROUPS SUBMIT Each Provider Group Responsibility Unique Submitter ID Extract via EMR Data Fields Deliver to Plan Monthly Multiple Purpose Clinical Business Operations TARGET POPULATION Groups Target Population Submit Groups Identify Plan Members Utilize Member Roster or Report Identify Payer in EMR System Verify Members in Plan Eligibility System 60

61 DATA RECEIPT Data Groups Receipt Submit Plan Outreach to Groups to Facilitate Encounter Rules Complete procedures only No referrals or orders Timing Adheres to HEDIS Raw Data Validation DATA CONVERSION & MAPPING Data Data Conversion Groups Receipt & Submit Mapping Format to HEDIS Engine Claims Output File Validation Report Unique records Duplicates Service dates Relevant codes DATA CONVERSION & MAPPING Data Groups Data Conversion Receipt & Submit Mapping HEDIS Clinical Codes 1+ CPTPx,CVX,ICD9Dx, ICD10Dx, ICD9Px, etc. CVX and CPTPx priority Invalid codes DOS required 12/31/MY limitation Requires Auditor Approval 61

62 DATA INTEGRATION Data Data Groups Data Conversion Receipt Integration & Submit Mapping Prior to Hybrid Sampling Administrative Refresh Quality Assurance Data collection Transformation Translation Specific to Certified Vendor / In-House Configuration SDS IMPACT Data Data Groups Data SDS Conversion Receipt Integration & Submit Impact Mapping Certified Vendor Protocol Supplemental Data Flags S = Standard NS = Nonstandard Different File IDs Result As Expected? OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting 62

63 CONTINUITY OF CARE DOCUMENT Electronic Document Exchange Standard ASTM & HL7 Sharing Patient Summary Info Shared by Applications EMR EHR Web browsers CCDA Document Type 9 CCDA TYPES Continuity of Care Document History and Physical Note Discharge Summary Consultation Note Diagnostic Imaging Report Procedure Note Operative Note Progress Note Unstructured Document (non-xml) CCD AS SUPPLEMENTAL DATA Provider Group Submission Member Identification Delivered Secure as CCD Files Data Translation & Formatting Code Mapping & Crosswalks Data Integration & QA 63

64 CCD AUDIT CONSIDERATIONS Standard Given no Human Intervention No PSV Mapping & Crosswalks Must be Approved Fully Documented Policies & Procedures Review Plan s Data Validation OVERVIEW HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting FUTURE OF HEDIS ECDS NCQA Digital Measures Vision Transition WILL Occur Staged approach NCQA to convert measures per year MY2019- MY2021 Recommendation: Prepare! 64

65 ECDS GUIDELINE 2 What s New in Guidelines? Guideline 2: Data Collection Methods SSoR may contain standard and non-standard supplemental data Clarified the Administrative Data may be refreshed ECDS GUIDELINE 3 Guideline 3: Expanded ECDS Definitions QDM Quality Data Model CQL Clinical Quality Language (HL7) Participation Defines Member s Eligibility Period Audit ECDS GUIDELINE 5 Guideline 5: Member Allocation Defines Continuous Enrollment Criteria for Participation Period Delineated by Line of Business NEW 65

66 ECDS GUIDELINE 6 Guideline 6: Digital Measure Format Formerly Guideline 5 Digital Format Direct to Reporting System Measure Package 3 Types of Files ECDS GUIDELINE 7 Guideline 7: Presentation of Codes Value Sets Multiple Codes Direct Reference Codes Single Code Measures May Use Combination ECDS SECTION 5 UPDATES NEW Roadmap Section 5, 5.4F If this data source is being used for ECDS reporting, how is it made accessible to the care team upon request? 66

67 ECDS SECTION 5 UPDATES NEW Roadmap Section 5, 5.5K If this data source is being used for ECDS reporting, how is the source flagged to be used accordingly? ECDS SECTION 5 UPDATES Roadmap Section 5, Table 5.6 Measures and indicators affected by the supplemental data. List all measures that the supplemental data source will be used for, and whether it is being used for numerator events, exclusions (optional and required) or ECDS. NEW TAKE-AWAYS HEDIS 2018 Lessons Learned SDS General Guideline 2019 Highlights Consolidating Like Data Sources Continuity of Care Document ECDS Reporting 67

68 GLOSSARY OF TERMS ASTM American Society for Testing & Materials CCD Continuity of Care Document CCDA Consolidated Clinical Document Architecture CMS Centers for Medicare & Medicaid Services CQL Clinical Quality Language ECDS Electronic Clinical Data Systems EHR Electronic Health Record EMR Electronic Medical Record HL7 Health Level Seven NPI National Provider Identifier QDM Quality Data Model SSoR Source System of Record TIN TaxPayer Identification Number QUESTIONS HEDIS Project Management Manny Martin 68

69 What s The Point? Warm Up Submissions Vendors Team Members Warm Up, cont d CAHPS Roadmap Timeline 69

70 Setting the Play Submission Assignments Roadmap Assignments Vendor Coordination Anticipate Cutting your samples Claims Lag Year End Enrollment Anticipate, cont d Vendor Files Loading SDS s 70

71 Pick and Roll Internal Vendors Audit Team All Star Team External Team Members Formal Tracking Dependencies The Triangle Offense Roadmap Redesign Section 6 71

72 Shot Clock Violation SDS Load Before Approval Timing Matters Closing HEDIS Steamroll Mitigate, Anticipate, Celebrate Roger Lattimore Questions 72

73 Beyond HEDIS 2019 Laura Hart Look Beyond 2019 Reporting Health Care Quality at Large Future of HEDIS More Than HEDIS Healthcare Landscape Million Covered 8.8% of Population Not Covered in

74 QHP Decline in Number of Individual Market Issuers Effectuated QHP enrollments: 3/2016: 10.8 million 3/2017: 10.3 million 3/2018: 10.6 million Future of Marketplace Signs of Stabilization Unpredictable Impact Funding Cuts Individual Mandate Penalty State Actions ACA mandated reporting of quality 2019 will be 3 rd Pilot Year Expanding to 5 States QHP Stars 74

75 MIPS Year 1 Results 91% Participation Rate in Year 1 Errors in Scoring Logic Focus on Reducing Burden Patient over Paperwork Initiative Leverage Meaningful Use Value Based Care System MACRA/MIPS Expanding Participation Delayed Facility Based Measurement to 2019 performance year CY 2018 Requires Data Validation and Auditing Using Data from Non- Medicare Payers MIPS/HEDIS Impact COL AAB ABA COA CBP DAE WCC CIS IMA IET CCS CHL DDE FUH CDC AMM OMW MRP URI CWP BCS NCS PBH MMA 75

76 LTSS Program Patient Driven Outcomes Availability of Data Quality Focus Continued Focus on Rx Measures Expansion of Antibiotic Measures Opioid Measures Measure Retirement Measure Refinement Future of HEDIS Electronic Data Sources More ECDS Measures Brand New Seem Familiar? Hybrid Phase-out Phased Implementation Promote Alignment & Interoperability CMS Support 76

77 Measure Production Move from Source Code Review Certification for All CQL Adaptation Questions? 77