Client Conference. Welcome to San Antonio! HEDIS 101 Carlo Teano & Jenna Morgan. Introductions

Transcription

1 Client Conference Welcome to San Antonio! HEDIS 101 Carlo Teano & Jenna Morgan Introductions 1

2 We Are Attest Largest NCQA Licensed Organization CHCAs since inception Top performing & improvement minded clients Collaborative and Transparent Support non-financial audits Why HEDIS? Accreditation Medicare Stars State Requirement Exchange Mandate Group/Employer Contracting Other Reasons Objectives High-level HEDIS overview Attest audit approach Tools and resources Audit expectations 2

3 What is HEDIS? H. E. D. I. S Gold standard in performance measurement 95 measures 7 domains of care 4 data collection methods Acronyms What is HEDIS? Stakeholders NCQA Plans Members Employer Groups Licensed Organizations Drives intiatives Required reporting Objectives High-level HEDIS overview Attest audit approach Tools and resources Audit expectations 3

4 Transparent Collaborative The Attest Way Educational Value Oriented Our Audit: Phases Pre- Onsite Onsite Post- Onsite Our Audit: Pre-Onsite November-December Kick Off Call January Roadmap CAHPS & QRS Enrollee Survey Review Benchmarking Before Sampling February-March SDS Review Source Code Review 4

5 Kick Off Call November-December Audit Logistics Discuss Any Major Changes ShareFile Queries Timeline HEDIS Team Participation is Key! Timeline NCQA-Driven Deadlines Tailored During Kick Off Call Some Target Date Flexibility Added to Final Audit Report Tracked Within Issue Log Issue Log Primary Communication Tool Living Document Timeline Core Set Approvals Source code review Supplemental data 5

6 Roadmap R.O.A.D.M.A.P. 1 st Major Audit Deliverable Information Management & Measure Reporting Organized by Sections Appendix 1 CAHPS & QRS Enrollee Survey January Plan Role Sample frame and CAHPS form Vendor deadline HOQ Attest Role Sample frame review Approval letter with final sample HOQ Benchmarking Review & Tool Benchmark early All rates reviewed Standardized Excel output Shared document Unveil the unknown 6

7 Outlier Toolbox Rate Research Tool Requires Plan Action Validates Rates & Populations Troubleshooting High/ Low Rates High/ Low Eligible Populations Outlier Toolbox EP Benchmarking EP Benchmarking Rate Benchmarking Rate Benchmarking Measure Measure High/ Low/ High/ Large Increase Low/ Identifier Name Large Increase Large Decrease Large Decrease ABA Adult BMI Confirm limited to Confirm that the age Confirm counting Confirm plan Assessment members with visits in criteria is correct members, not events considering 2 years 2015 or 2016 Confirm all Confirm not counting of data Confirm applied outpatient claims from height and weight Confirm not looking optional exclusion all sources loaded recordings instead of for only BMI on visit Confirm anchor date Confirm two years of BMI that qualified is applied visits used Confirm weight member for EP Confirm all Confirm all requirement for hybrid Confirm reviewers enrollment segments enrollment segments is being followed aren't looking for BMI linked correct, applies linked correct, applies Confirm plan pays for age-growth charts for to in-house and plans to in-house and plans applicable HCPCS >18 yr olds that 'normalize' that 'normalize' codes Confirm excluding enrollment data prior enrollment data prior Confirm not using for pregnancy in MY to loading in software to loading in software ranges and thresholds and PY Confirm that the age criteria is correct SDS & Source Code Reviews February-March Supplemental Data Roadmap Section 5 2 types PSV Source Code Core set SCR team 7

8 Our Audit: Onsite February-April Interviews & Demos Rate Review Collaborative: Focus on plan needs You help drive the agenda! Our Audit: Post-Onsite May-June MRRV Frozen Counts Sample Selection Issue Log Closure IDSS Rate Review Patient-Level Detail Review Final Audit Report Objectives High-level HEDIS overview Attest audit approach Tools and resources Audit expectations 8

9 Tools and Resources - NCQA HEDIS Volumes 2 & 5 Policy/Program Clarifications FAQs Other E-Publications HEDIS User Groups Conferences & Webinars IDSS Tools and Resources - Attest Communications Manual Issue Log Outlier Toolbox World Class Audit Tools PCS Q&A Specialized Teams Client-Only Conference Calls Objectives High-level HEDIS overview Attest audit approach Tools and resources Audit expectations 9

10 Audit Expectations Turnaround Time Accountability Transparency Communicate Goals Mutually Your team Attest team Recap HEDIS Overview Attest Audit Approach Tools and Resources Season Expectations Navigating the Workshop Main Sessions (Wednesday-Friday) Concurrent Sessions (Thursday) Option 1 Option 2 Option 3 Option 4 HEDIS Data Aggregation & ETL Medical Records: 2017 Client Experience Medicaid Reporting Tactics Patient Level Detail Files 10

11 Enjoy the Workshop! 2018 Client Conference Welcome to San Antonio! Welcome to San Antonio Bob Oakleaf 11

12 Meet Our Team On The Horizon More Changes A Bright Future Ground Rules Respect Others No Sidebars Wait for Microphone 100% Focus Phones/ Off Be Yourself & Be Honest Keep an Open Mind Discomfort is Optional 12

13 Questions Key Logistics Restrooms Food & Drink Special Meals Name Badge What s in Store for Day 1? HEDIS 2018 Specification Updates 2018 Strategies For Success 13

14 Day 2 At a Glance Looking Beyond HEDIS 2018 Challenging Administrative Measures Strategies For Medical Record Abstraction & Validation Supplemental Data Concurrent Sessions Day 2 Concurrent Sessions New Format! Select 2 of 4 Options: HEDIS Data Aggregation & ETL Medical Records: 2017 Client Experience Medicaid Reporting Tactics Patient Level Detail Files Overview of Day 3 Benchmarking Process & Measure Trends PCS & FAQ Highlights What To Do Between Now & January 1st 14

15 Affinity Event Inovalon Dave & Buster s Games, Food, Wine & Beer Shops At Rivercenter 6-9 PM, Wed Oct 11th HEDIS 2018 Specifications Update Melissa Sheesley 15

16 Agenda General Guidelines Changes Measure Changes New Measures General Guideline Changes GG 9 Timeline Preliminary Rates submitted by April 13 May 9 MRR Abstraction completed and counts submitted May 15 Records sent to auditor June 1 Plan locked IDSS General Guideline Changes Clarified GG 10, Deleted GG 32 GG 33 Home visits (TU) Clarified GG 34 codes in medical record GG 45 same claim 16

17 Guidelines for Sampling Minimum Required Sample Size (MRSS) is required Final Sample Size (FSS) no longer allowed Effectiveness of Care Pregnancy exclusion only allowed if Female* *Added to all applicable measures Effectiveness of Care WCC appetite Nutrition counseling IMA added 2-dose HPV BCS & COL Required Exclusions BCS: Digital Breast Tomosynthesis 17

18 Effectiveness of Care COA Several minor clarifications CWP/URI Revised episode date Clarification about ED or Observation visit IP Stay Effectiveness of Care CDC minor changes Direct transfer Changed populations (MMA, AMR, CBP, OMW) Added telehealth (MH/CD) Access/Availability of Care ADV Removed value sets IET Rx benefit, other changes PPC Decision Rule 3 18

19 Utilization and RA Utilization IAD/ MPT breakdown HAI clarifications PCR Added MCD Acute Hospital Utilization (formerly IPU) Added Observation Stay Discharges Outlier vs. Non-Outlier PPD and PUCD New Data Elements Hospitalization for Potentially Preventable Complications Added observation stays Chronic/Acute ACSC outlier/non-outlier Exclusion members in longterm institutional settings 19

20 Retired Measures (TU) Frequency of Ongoing Prenatal Care MPM : Removed Digoxin (all LOB) Measures reported unchanged QRS Changes Slight tweaks to questions Access to care Added In last 6 months, Publicly Reported Follow-up after ED for MH (FUM) Follow-up after ED for AOD (FUA) Standardized Healthcare- Associated Infection Ratio (HAI) Depression Readmission (DRR) 20

21 New Measures Transitions of Care (TRC) Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions(FMC) Use of Opioids at High Dosage (UOD) Use of Opioids from Multiple Providers (UOP) New Measures Depression Screening and Follow-Up for Adolescents and Adults (DSF) Unhealthy Alcohol Use Screening and Follow-Up (ASF) Pneumococcal Vaccination Coverage for Older Adults (PVC) Eligible Pop 18+ years old CE = Date of Discharge + 30 days (Acute or Non-Acute) Transitions of Care Notification of Inpatient Admission 1 medical record Communication in PCP Chart Receipt of Discharge Information Patient Engagement After Inpatient Discharge Medication Reconciliation Post-Discharge Hybrid only Hybrid only Admin + hybrid Admin + hybrid Communication in PCP Chart Follow-up visit (office, home, tele or transitional) Same as MRP 21

22 Follow-up after ED Visit for People w/ Chronic Conditions Denominator Age 18+ CE: 365 days prior to ED visit through 7 days after ED visit between 1/1 and 12/24 Include all visits but limit to only the first one within an 8 day period Dx: 2 or more chronic conditions in MY or PY (before ED visit) Numerator Follow-up within 7 days after the ED visit Include visits that occur on same day as ED visit OP, BH, Telephone, Transitional Care, Case Mgmt, Complex Care Mgmt Use of Opioids at High Dosage Lower rate = better COM, MCD, MCR Age 18+ Medical and Rx Benefit Numerator: Average MED >120mg MED Use of Opioids from Multiple Providers Lower rate = better COM, MCR, MCD 3 rates Prescribers Pharmacies Prescribers & Pharmacies 22

23 Depression Screening and Follow-up (DSF) Initial Population Depression Screening Follow-up on Positive Screen Age 12+ CE: MY, 1 gap Denom: Members in Initial Population Denom: All members from Numerator 1 who screened positive for Depression Exclusion: Bipolar disorder MY or PY; Depression in PY; Hospice MY Num: Members screened for clinical depression using an age-appropriate standardized tool Jan 1-Dec 1 MY Num: Follow-up care on or 30 days after positive screening Unhealthy Alcohol Use Screening and Follow-up (ASF) Initial Population Alcohol Screen (Rate 1) Counseling & Follow-up (Rate 2) Age 18+ as of 11/1/PY CE: MY, 1 gap Denom: Members in initial population Denom: Members who were screened and had positive result meaning unhealthy alcohol use Exclusion: Alcohol use disorder, dementia, hospice Num: Members who were screened using systematic tool and had a result 1/1/MY -11/1/MY Members who had follow-up care on date of initial positive screen of 61days following Pneumococcal Vaccine Coverage for Older Adults (PVC) Denominator Numerator Age 65+ CE: MY, 1 gap Exclude: Active chemo, bone marrow transplant, anaphylactic reaction, hospice Immunocompentent: PCV13 and PPS23 at least 12 months apart *First occurrence after age 60 Immunocompromising: PCV13 and PPS23 at least 8 weeks apart Members who qualify for either = Hit 23

24 Questions 2018 Strategies for Success Laura Hart Objectives Challenges of HEDIS 2017 Focus HEDIS 2018 Tools for Success 24

25 Challenge Category Measures Data Medical Record Review Audit Specification Complexity 2017 New Measures Impact HAI FUA, FUM Measure Change Reality Check Interpretation Matters Process Knowledge Key In This Corner Data Source Identification Data Clean-up / Consolidation Mapping 25

26 Record Obstacles Time Crunch Provider-Member Mismatch Over-read Errors Validation Documentation Audit Awareness Supplemental Data Increased # of sources Focus on QA Rate Reviews & Certification Queries Focus on 2018 Know What s New Anticipate Similar Challenges Prepare the Game Plan Be Ready to Adjust 26

27 What s Going On? Organization Changes Structure Focus: community, goals Process Updates Vendor Management Deep Dive into Data Are you being efficient? Redundancy Consolidation Are organizational goals aligned? Prepare for Data Demands Step 1: Technical Specification Step 2: Implementation Guide / Layout Changes Step 3: Warehouse Review Step 4: ETL Updates 27

28 Closer Look: Opioids Rx Data Elements NPI Day Supply Quantity Dispensed Reversals Closer Look: ECDS Voluntary Report: Highly Encouraged How do you flag? ECDS Layout Hierarchy Mapping Requirements Compressed Timeline Medical Record Cut-off May 9: MRR Counts May 31: Corrective Action Plan Lock: June 1 28

29 Mitigate Risk Be Prepared Do a Test Run Clean up Provider File Notify Providers Set Expectations Identify In-House Records Rely On Supplemental Data Load Early Identify New Sources Auditor Communication Query Success 6 Categories Driven by Preliminary Rates Refer to Outlier Toolbox Ask Questions 29

30 Onsite Query Auditor Selects Measure(s) Plan Provides Detail Auditor Selects Members / Events Prior to onsite Prepare staff Review Systems Onsite Tools for Success Communications Manual Issue Log Outlier Toolbox Vendor Reports Audit Team Things to Remember Team Effort Pace Yourself Utilize All Resources 30

31 Questions Looking Beyond HEDIS 2018 Bob Oakleaf Looking Beyond HEDIS 2018 We tend to be mono focused on the next HEDIS season We will look more broadly at health care quality Future of HEDIS 31

32 My POV on Health Care My biases Everyone should have health coverage We should be measuring and improving health care for everyone Quality results available to all What a Difference a Year Makes Last Year ACA Increasing Quality Reporting for QHPs Medicaid expansion in Managed Products MACRA/MIPS What a Difference a Year Makes QHP Enrollment QHP STARS MACRA/MIPS 32

33 QHP Enrollment Effectuated QHP enrollments: 3/2016: 10.8 million 3/2017: 10.3 million QHP STARS ACA mandated reporting of quality 2017 OE was to be go live Only 2 states reported QHP STARS Manitowoc, WI 29 plan options, all had a STARS score displayed 26 had 4 STARS 3 had 3 STARS 33

34 CMS Program to move physicians to Value Based Payments. Alternative Payment Methods (APMs) Merit Based Incentive Program (MIPS) MACRA/MIPS MACRA/MIPS APMs = Incentive Payments/Risk Specific Conditions MIPS = Quality Reporting Incentive Payments MIPS Excluded: <$30K Medicare, < 100 Medicare patients, new to Medicare = 940,000 Included: 419,000 MACRA/MIPS 34

35 MIPS Measures Quality reporting Example; Internal Medicine 37 potential measures, pick 6 including one outcome Cover at least half of Medicare members 15 of 37 are HEDIS 5 of other measures with cross over affect Possible reporting set: CBP, COL, BCS, CDC Eye, CDC HbA1C Level, OWM MIPS Financial Incentives Penalties for not participating Bonus for submitting 2017 results, March 2018 submission, impacts 2019 payments Increase from +/- 4% to 9% Coverage/Quality Scorecard Progress on Coverage: D Progress on Quality Reporting: C- 35

36 Future State of HEDIS HEDIS Beyond 2018 Hybrid will go away Faster turn over of measures More risk adjusted measures Socio-economic status reporting Questions? Challenging Administrative Measures Glen Braden 36

37 Understanding and Impacting Challenging Measures HAI Risk Adjusted Measures PCR IHU (AHU), EDU, HPC The horror HAI Overview All acute discharges Sum discharges by Hospital Need ID to match NHSN SIR National Healthcare Safety Network (NHSH) calculates SIR Pull Scores from Table HSIR Weight Scores 4 infection ratios HAI Overview (MRSA) Proportion of Total Discharges Acute Proportion Proportion Proportion Classification Discharges High Mod Low Hospital 1 High Hospital 2 Moderate Hospital 3 Low Total 10 37

38 HAI Example Unknown Proportion (added Hospital 4) Plan Weighted SIR Acute Proportion Proportion Proportion Proportion Plan Discharges High Mod Low Unknown SIR Weighted Hospital Hospital Hospital Hospital Total Final HAI Table Proportion of Number of Number of Proportion of Proportion of Proportion of Total Total Hospitals Hosptials Total Total Total Discharges Plan- Classification Inpatient with with Discharges Discharges Discharges from Hospitals Weighted Discharges Inpatient Reportable from High SIR from Moderate from Low SIR with SIR Discharges SIR Hospitals SIR Hospitals Hospital Unavailable SIR HAI-5 (MRSA) HAI changes and what they mean to you Added # of Hospitals with Inpatient Discharges Mapping and that HSIR table Removed contracted ALL Hospitals (really?) 38

39 HAI Changes Clarified Unavailable Hospitals Required to report but do not have a reported SIR Are not required to report to NHSN Critical Access, Long term Care Cancer Hospitals, Children s Have discharges but are not listed in table HSIR HAI Changes Clarified Unavailable Hospitals Required to report but do not have a reported SIR Are not required to report to NHSN Critical Access, Long term Care Cancer Hospitals, Children s Have discharges but are not listed in table HSIR Audit Considerations HAI is required for Medicare Bias is a +/- 10% change in Rate Use of Service GG s How big is the proportion of Unavailable? Not Required/ No SIR Or Not Mapped 39

40 HAI Red Flag Example Proportion of Number of Number of Proportion of Proportion of Proportion of Total Total Hospitals Hosptials Total Total Total Discharges Plan- Classification Inpatient with with Discharges Discharges Discharges from Hospitals Weighted Discharges Inpatient Reportable from High SIR from Moderate from Low SIR with SIR Discharges SIR Hospitals SIR Hospitals Hospital Unavailable SIR HAI-5 (MRSA) HAI Take Away 1. May not need to map all Hospitals, but most of the Hospital discharge volume must be mapped 2. If UOS is ok, HAI will be too if you do #1 right Risk Adjusted Measures PCR - Acute IP Re-admissions vs expected AHU Acute & observation discharges vs expected For Non- Outliers EDU ED visits vs expected HPC Acute & observation discharges vs expected for certain conditions 40

41 SDS Nightmares Huge increase in EHR feeds Can impact Observed Events Discharges Denominator and Numerator Cannot impact Risk Adjustment SDS Take Aways Always flag SDS records as denied Does not impact UOS/ Risk Adjusted Does impact EOC SDS cannot impact Risk Correct Coding Encounter data is not SDS Understanding PCR Events Historical (wrong) Thinking Look for first IP stay to identify index stay Readmission in 30 days? Next Index stay A single can t be an index stay and a readmission 41

42 Understanding PCR Events Correct Understanding All acute inpatient stays are Index Stays unless specifically excluded Member died Diagnosis exclusions Planned stays (Chemo, Rehab, Transplant, other planned) Understanding PCR Events Readmissions (Numerator) An index stay within 30 days the previous index stay s discharge date Admit Discharge Index Stay? Readmission? Stay 1 3/4/17 3/7/17 Yes No Stay 2 6/15/17 6/27/17 Yes No Stay 3 7/2/17 7/8/17 Yes Yes Stay 4 9/12/17 9/13/17 Yes No 4 Index stays & 1 readmit Investigation Take it to the member level Pull all claims for 1 member Compare to counts from software Paid/ Denied Exclusion criteria Other sources? 42

43 AHU (IHU) Benchmarking Observed should be lower than PY Added Observation but Excluded Outliers if 3 or more stays Non-Outliers and Outliers Members Rates now Observed/ Expected per 1000 Non-Outlier members Surg + Med = Total? Not always HPC Benchmarking (Same impact?) Lower observed than PY Required Exclusions Institutional SNP members Living in long-term care institution LTI Flag in Monthly Membership File Outliers (3 or more) Concerns? Observation coding concerns Rev Code 0760, 0762, 0769 ED vs Obs or Admit vs Obs? Medicare PLD Changes are coming Outlier / Non-Outlier for AHU/ HPC Clarified rounding rules for AHU/ EDU/ HPC 43

44 Take Aways Member Date of Death Use as Enrollment termination date if possible Review how your vendor identifies member death (possible area for mapping) Load SDS data as denied not capitated encounters Correct coding on hospital claims? Monthly Membership File (LTI indicator) Strategies for Medical Record Abstraction and Validation Kelli Graziano, MD Objectives 2018 Changes Problem Measures Exclusions Best Practices 44

45 Changes for 2018 New hybrid measure Measure retired Changes to existing measures MRRV Timeline Transitions of Care New Measure 4 components All need to come from same chart Frequency of Prenatal Care Good news! Measure has been retired 45

46 Medication Reconciliation Post Discharge New current medication list requirement Method used to identify current meds outside scope Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Nutrition component Reference to appetite alone is no longer compliant What is the child eating? Immunizations for Adolescents Added the option for a 2 dose HPV vaccination series Must be 146 days apart 46

47 Care for Older Adults Continence added to ADL options Cranial nerve assessment does not meet sensory component Speech assessment clarified MRRV Timeline New deadline May 9 Abstraction must be completed No exceptions Problem Measures Medication Reconciliation Post Discharge (MRP) Controlling High Blood Pressure (CBP) Comprehensive Diabetes Care Eye/A1c (CDC) Colorectal Cancer Screening (COL) Prenatal and Postpartum Care (PPC) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) 47

48 Need to see evidence of a reconciliation, not just a med review Comparison between inpatient and outpatient medications Need appropriate provider type MRP Compliant Reconciliation Compliant Reconciliation 48

49 Documentation must come from the chart of the provider managing HTN Need to clarify when submitting specialist notes Reading and diagnosis cannot come from same date of service Eligible blood pressures CBP CBP Common Error CDC Eye and HbA1c Any evidence of retinopathy is considered positive Needs to be a clear date of testing 49

50 Hypertensive Retinopathy Hypertensive Retinopathy HbA1C Date Error 50

51 COL Counting FIT testing as FIT DNA testing Testing method not specified COL Screening Errors FIT vs FIT DNA Type not specified PPC EDD Delivery Date Need to use consistent methods to identify EDD Can use either at a member level 51

52 WCC Developmental assessments do not count Acute/chronic conditions do not count Nutrition Counseling Errors Physical Activity Counseling Errors 52

53 Exclusions General guidance Comprehensive Diabetes Care Controlling High Blood Pressure Prenatal and Postpartum Care General Guidance Take the hit! Increase rates Required vs Optional New mandatory exclusion for select measures Know the specs Comprehensive Diabetes Care 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 53

54 Controlling High Blood Pressure Cannot confirm diagnosis Optional: ESRD, Kidney transplant, dialysis Pregnancy Non acute stay in MY Prenatal and Postpartum Care EDD or DOD not on or between Nov 6 of PY and Nov 5 of MY Non-live births Best Practices Submitting MRR questions Convenience Sample Record abstraction Record submission 54

55 New format for submitting MRR questions Standardized excel format MRR Questions Cutoff date April 13 th Convenience Sample Exempt: Passed MRRV for all measures validated in prior year No significant process changes May still request one 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 55

56 Records on Hand Review Records Prior to Submission Hit highlighted? Abstraction Errors? Correct name? File Submission 1 zip file per measure Best Practices Questions? Thank you! Lunch Concurrent Sessions Begin at 1 pm 56

57 Supplemental Data Carlo Teano BUT FIRST CHARLIE S 1! OBJECTIVES What SDS are plans using most? What s Non-Standard? How do I pass PSV? What s the word on ECDS? 57

58 Top 5 SDS Top 5 SDS - #5 #5 Ancillary Data ROI = 9 Lab Nat l & regional vendors Clinics, hospitals Leakage Vision Provider specialty Mostly Standard 58

59 Top 5 SDS - #4 #4 Coordinated Care ROI = 7 Clinical care focus COA Case management RNs, NPs, pharmacist, care coordinators Communication is key Coordinated Care Expansion Clinical Document Architecture HL7 markup standard Allows IT processing Continuity of Care Document Not complete history Exchange information 59

60 Top 5 SDS - #3 #3 Year-Round Abstraction ROI = 7 More than HEDIS Provider office abstraction Target population Trained abstractors Frequent IRR Med records saved Top 5 SDS - #2 60

61 #2 Immunization Registries ROI = 8 State / county level Criteria-based pull Annual request Standard SDS CIS, IMA rates up Top 5 SDS - #1 #1 EMRs Best Practice! ROI = 8 Major push to access First BMIs and biometrics Meet w/clinics w/emrs If pulling from comments Turn into code, then not standard Consider SDS split 61

62 Biometrics Vitals Immunizations Medication review Screenings EMR Uses Example Standard EMR 1. Plan program pulls member from EPIC EMR 2. Direct to certified vendor 3. Send to EMR_IN file 4. Review file & data audit 5. Send SDS file to vendor 6. QA process Example Non-Standard EMR 1. Access database to groups monthly 2. Group opportunity to provide service evidence 3. Plan receives file Formatting & edit checks 4. Proof-of-Service checks 62

63 EMR Challenges Access Data structure Systems variability Provider abrasion Member targeting Mapping Enterprise support OBJECTIVES What SDS are plans using most? What s Non-Standard? How do I pass PSV? What s the word on ECDS? Non-Standard SDS Capture missing service data Not received via admin sources, manual Irregular submission, unstable format Follow clear P&Ps 63

64 Non-Standard SDS Examples EHR (uncertified emeasure modules) Provider portals Health info registry Home visit data collection Must show accountability Member-reported services NEW TU MY2017! Primary Source Verification Annual requirement Legal health record only Shows services rendered Pharmacy data Name, strength, route, fill date Hybrid follows hybrid rules TIP: PSV must not occur before Mar 1 unless all SDS processes are complete. Proof of Service That Counts Chart from provider or PCP Clinical visit report/ summary Lab, radiology Online EHR screen shot State / county immunization registry Minimum necessary Best Practice! 64

65 Proof of Service Not Allowed Member survey Completed by member Except LDM / RDM data Phone calls Recorded calls about services rendered OBJECTIVES What SDS are plans using most? What s Non-Standard? How do I pass PSV? What s the word on ECDS? What s an ECDS? Member database network PHI, healthcare experiences Care-related activities Evidence-based Quality management Outcome reporting Automated quality metrics 65

66 ECDS Domain of Care 6th domain of care: Effectiveness of Care Access/Availability of Care Experience of Care Utilization and Risk Adjusted Health Plan Descriptive Info Measures Collected Using Electronic Clinical Data Systems Data Collection Methods HEDIS data collection: Administrative Hybrid Survey Electronic Clinical Data Systems (ECDS) ECDS vs. SDS SDS no denominator events ECDS Uses same data classified as SDS Different reporting rules All reporting elements 66

67 ECDS Data Collection Source System of Record (SSoR) Authoritative source for measure Quality Data Element (QDE) Standard & Non-Standard SDS Subject to GG#33 review rules P&Ps, standard layout Automated load process Structured data elements Source Priority SSoR priority categorization 1. EHR 2. HIE/clinical registry 3. Case management registry 4. Administrative claims Assigned 1 SSoR * TIP: Must freeze ECDS-SSoR import by March 1 ECDS Data Systems EHR Real-time, patient-centered Medical & treatment history HIE/Clinical registry State, regional HIEs Immunization systems Public health agency systems 67

68 ECDS Data Systems (cont d) Case management system Member assessment Care planning & coordination Any system to support disease management Administrative claim Services incurred Paid / expects to pay NCQA Learning Collaborative Collaboration NCQA &13 plans reported ECDS measures Collection Clinical data to report on depression measures DMS, DRR, DSF Plan A Non-profit Low-income members MCD, ACA, MA, Duals 1.5M members KY, OH, IN, WV, GA 68

69 Plan A - ECDS Data Sources Care management system PHQ-9 data Registry data Nurse case managers Population health management Community-based Plan A - Lessons Learned Subject matter expertise required Closer partnering with regional / state HIEs Enterprise data use knowledge needed Much work remains Plan A - Best Advice to Plans Create a plan from your own conditions Structure, structure, structure Better communication Be realistic 69

70 Plan B San Juan, Puerto Rico MA HMO and PPO Government health plan 110k members Plan B - ECDS Data Sources APS MBHO Claims HIE & HRA platforms Plan B - Lessons Learned Provider network communication Need for structured data Operations changes required Adaptation is key 70

71 Plan B - Best Advice to Plans HIEs challenging and promising Cross-functional communication Strive for structure Verify information NCQA Updates as a Result Measure element level by data source Denominator Numerator Exclusions Clarifying definitions Point of care access ECDS Mission & Future ECDS innovation driver Sharing Interoperability NCQA actively engaging Plans EHR vendors Auditors 71

72 RE-CAP What SDS are plans using most? What s Non-Standard? How do I pass PSV? What s the word on ECDS? QUESTIONS? Benchmarking Process & Measures Trends Kevin Gregory 72

73 Objectives Timeline Benchmarking Logistics HEDIS 2018 Trends New Measure Results Benchmarking Milestones Audit Step Hybrid Rate Review Preliminary Benchmarking Complete Full IDSS Rate Review & PLD IDSS Plan Lock Deadline Rates Marked Final in IDSS Date Jan 30th May 4th May 18th June 1st June 15th Attest Benchmarking Tool 3 Year Rate Trending NCQA & Attest Admin & Hybrid EP per 1,000 Logic Tests MRSS Calculations 73

74 Preliminary Benchmarking Data Submission Options XML Upload File Full Excel Submission Supplemental Excel File New Measures Modified Measures ENP, MRSS Typically Subset of Measures IDSS Benchmarking XML Upload Validations & Calculations IDSS Downloads XML Processed Rates Workbooks Tier Warnings IDSS Lock Considerations All Rate Review Concerns Addressed IDSS Warning Messages PLD Must Tie Hybrid Frozen Counts Unchanged IDSS and Appendix 1 Consistency 74

75 Attest Feedback Excel Format One File Per Submission All IDSS Information Consolidated Multiple Tabs Not All Applicable During Preliminary Benchmarking Plan Responses Flagged Concerns Plan Explanation Outliers Acceptable Confirmation Needed Historical Log Brevity! Research Tools Outlier Toolbox Case Reviews Internal Resources SME Internal Reporting Vendor Tools 75

76 Example Rate Findings Outstanding Data Enrollment & Benefit Changes Supplemental Data Vendor Files ETL Issue HEDIS 2017 Trends COL Did Not Drastically Increase with HPV Only Dropped 2% With Males Added MRP Increased 25 Points Biometrics - Admin Rates Up ABA, WCC-BMI, CDC-BP, CDC- Control SPC dropped 13 Points in Medicaid STARS Means Mean Rate: Absolute Change HEDIS 2017 vs CDC-Poor* OMW PCR* ABA BCS ART CBP CDC-Eye COL 76

77 FUA Results 7 Day Follow-Up 10th Mean 90 th Medicare 6% 11% 20% Commercial 6% 14% 22% Medicaid 5% 13% 28% 30 Day Follow-Up 10th Mean 90 th Medicare 7% 15% 30% Commercial 8% 18% 28% Medicaid 6% 18% 37% FUM Results 7 Day Follow-Up 10th Mean 90 th Medicare 20% 38% 56% Commercial 25% 46% 64% Medicaid 24% 40% 65% 30 Day Follow-Up 10th Mean 90 th Medicare 33% 49% 69% Commercial 42% 61% 78% Medicaid 41% 55% 77% HAI Aggregate Results 10th 50th 90th CLABSI 0.26% 0.73% 1.00% CAUTI 0.33% 0.77% 1.06% MRSA 0.22% 0.64% 1.04% CDIFF 0.40% 0.84% 1.04% 77

78 HAI Product Line Comparison Product Line CLABSI Mean CAUTI Mean MRSA Mean CDIFF Mean Commercial 0.70% 0.75% 0.64% 0.80% Medicare 0.70% 0.78% 0.68% 0.81% Medicaid 0.76% 0.82% 0.75% 0.87% Not Widely Reported 3 Attest Submissions Low Volume of Members with ECDS Data Available CMS Encouraging ECDS Reporting ECDS Measures Questions 78

79 PCS & FAQ Highlights Christy Patterson Agenda What s the difference? Rules Around PCS & FAQs Review of Old Ones Still Applicable No Longer Applicable FAQ Frequently Asked Questions Commonly Asked Questions Big Spec Clarifications and Updates Same Information Shared Publicly 79

80 PCS Policy Clarification Support Plan/Auditor Specific Questions Clarifying Gaps & Gray Areas NOT Shared Publically Submitting to PCS Do s & Don ts Provide Context Specific Details Ask Question Directly Consider Answers to Similar Question 80

81 How Do I Know? Unofficially Official Attest Considers Official Carry Forward When Applicable GG or Spec Change=Likely NA now Those That Endure <30 Reduction Q: Rates are populated in IDSS for measures where the EP <30. Can I reduce using the rate? A: No, you can not reduce in the MY using a rate on an PY EP <30. 81

82 Membership Changes Q: Can plans reduce using the PY rates regardless if there is a significant change to submission being reported in the current year? A: If the submission ID has changed, a plan cannot reduce. If NCQA has determined the submission ID remains constant, yes the plan may reduce using the PY audited rates. Board Certification Auditing Q: Please confirm that BCR is on a 3 yr audit cycle and the rules around auditing. A:Yes it is on a 3 yr cycle UNLESS a plan is required to have it audited annually, there were significant changes in the reporting process, or is new to the audit firm. Cervical Cancer Exclusion Q: Can we exclude a woman from CCS who was born male? A: Yes if the person does not have a cervix they can be excluded. The documentation must be conclusive. 82

83 Tanner Stage Q: Does documentation of Tanner stage meet for the physical exam or physical developmental history? A: Yes for AWC only and it can not be used for both (aka pick one). It is not appropriate for W34 or W15. EDD Causing Exclusion Q: For PPC, if we enter the EDD and it is not in the measurement window (11/6/PY-11/5/MY) the member is being exclude even though the delivery date is in the window. Is this correct? A: Yes this was the intention. BP and Medication Change Q: Please clarify don t use BP readings taken on the same day as a diagnostic test or procedure that requires a change in diet or medication. A: The intent is to identify diagnostic or therapeutic procedures that require a medication regimen, a change in diet or a change in medication. 83

84 No Longer Applicable WCC Nutrition Q: Can notation of good appetite be used to confirm nutritional counseling occurred. A: Yes that documentation would count. Spec Revision: Documentation related to a member s appetite does not meet criteria. Different Claims Same DOS Q: GG states use all claims (including ancillary claims) on DOS to identify the qualifying event. Is this correct? A: Yes all claims for DOS should be used. Spec Revision: Unless otherwise, the codes must be on the same claim. 84

85 Now it s time for you to What To Do Between Now & January 1st Manny Martin WHAT S PAST IS PROLOGUE 85

86 Anatomy of a Mix FIX IT LATER SCHEDULED DEPARTURE Getting on the HEDIS Buss DATA SCRUBBING Implementation Guide New Measures SME s 86

87 DATA SCRUBBING Review Changes Digest New Elements Update Documentation DATA SCRUBBING Source System Changes Is Source Reliable? Don t Wait, Run Rates PROVIDER INFO Mapping Review Myth Busting Welcome Back BCR 87

88 CONTRACTS Expedite Negotiations Finalize, Update (Now) Review Oversight CAHPS Data Timeline CAHPS Form Secure Environment SUPPLEMENTAL DATA Start Gathering Data Send Questions Notify Auditor 88

89 SUPPLEMENTAL DATA Validate, Fix, Recollect Work Timeline Avoid Corrective Action TRAINING MRR Guides Hybrid Tools Abstraction Forms ROADMAP Review Changes Mostly Static Identify SME s 89

90 ROADMAP New Systems New SDS s New RM Sections KICK OFF CALL Expectations Gather Info Follow-up BY SEEKING, WE LEARN PY Issue Log PY MRR Project PY FAR 90

91 FINAL THOUGHTS Don t Wait Don t Defer Don t Cram FINAL THOUGHTS Do Ask Do Revisit Do Plan PREGUNTAS 91