and HEDIS Measures

Transcription

1 1 SC Medicaid Managed Care Initiative and HEDIS Measures Ana Lòpez De Fede, PhD Institute for Families in Society University of South Carolina Regina Young, RNC SC Department of Health and Human Services Bureau of Care Management This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

2 2 Approach to Measuring Quality Measures must address populations in: Managed Care Plans Medical Home Networks Fee-for-Service Data Challenges Coding restrictions Administrative versus Hybrid Data Accuracy of data This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

3 3 SC Quality Improvement Approach CAHPS Quality Profile HEDIS State Measures This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

4 4 HEDIS Measures NCQA defines HEDIS as a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

5 5 HEDIS Domains of Care Effectiveness of care Access/availability of care Satisfaction with the experience of care Health plan stability Use of services Cost of care Informed healthcare e choices ces Health plan descriptive information This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

6 6 Effectiveness of Care Prevention/Screening Respiratory Conditions Diabetes Behavioral Health Medication Management This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

7 7 # Group Category Measures Description Continuous enrollment 1 Effectiveness Prevention & of Care Screening 2 Effectiveness of Care Prevention & Screening Childhood Immunization Status (CIS) Lead Screening in Children (LSC) The percentage of children two years of age who had vaccinations by their second birthday. The measure calculates rates for one, two, three, or four + vaccinations. The percentage of children one to three years of age at the end of the Fiscal Year who had one or more capillary or venous lead blood tests for lead poisoning. 3 Effectiveness of Care Prevention & Screening Breast Cancer Screening (BCS) The percentage of women years of age who had a mammogram to screen for breast cancer. This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements. The measurement The measurement The measurement year and the year prior to the measurement Age Children who turn two years of age during the measurement Children who turn two years of age during the measurement Women years as of December 31 of the measurement Report two age stratifications and a total rate years years Total The total rate is the sum of the two numerators divided id d by the sum of the two denominators.

8 8 4 Effectiveness of Care Prevention & Screening Cervical Cancer Screening (CCS) The percentage of women years of age who received one or more Pap tests to screen for cervical cancer. Medicaid: The measurement Women years as of December 31 of the measurement 5 Effectiveness Prevention & Colorectal Cancer The percentage of The measurement years as of of Care Screening Screening () members years of age who had appropriate screening for colorectal cancer. year and the year prior to the measurement December 31 of the measurement 6 Effectiveness of Care Prevention & Screening Glaucoma Screening in Older Adults (GSO) The percentage of Medicare members 65 years and older, without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye-care professional for early identification of glaucomatous conditions. The measurement year and the year prior to the measurement 67 years and older as of December 31 of the measurement This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

9 9 7 Effectiveness Respiratory Appropriate The percentage of children 3 30 days prior to Children 3 months of Care Conditions Treatment for months 18 years of age who the Episode Date as of July 1 of the Children With were given a diagnosis of upper through 3 days year prior to the Upper Respiratory respiratory infection (URI) and after the Episode measurement year Infection (URI) were not dispensed an antibiotic Date (inclusive). to 18 years as of prescription. June 30 of the measurement 8 Effectiveness of Care Respiratory Conditions Use of Appropriate Medications for People With Asthma (ASM) The percentage of members 5 56 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement The measurement year and the year prior to the measurement 5 56 years by December 31 of the measurement Report three age stratifications tifi ti and a total rate. 5 9 years years years Total The total is the sum of the three numerators divided by the sum of the three denominators. This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

10 10 9 Effectiveness of Care Diabetes Comprehensive Diabetes Care (CDC) The percentage of members years of age with diabetes (type 1 and type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) (cannot be calculated due to lack of LOINC/CPTII codes) HbA1c good control (<7.0%) (cannot be calculated due to lack of LOINC/CPTII codes) Eye exam (retinal) performed LDL-C screening LDL-C control (<100 mg/dl) (cannot be calculated due to lack of LOINC/CPTII codes) Medical attention for nephropathy Blood pressure control (<130/80 mm Hg) (cannot be calculated due to lack of LOINC/CPTII codes) Blood pressure control (<140/90 mm Hg) (cannot be calculated due to lack of LOINC/CPTII codes) The measurement years as of December 31 of the measurement This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

11 11 10 Effectiveness of Care Behavioral Health Follow-Up Care for Children Prescribed ADHD Medication (ADD) This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements. The percentage of children newly prescribed attentiondeficit/hyperactivity disorder (ADHD) medication who have at least three follow-up care visits within a 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed. Two rates are reported. 1. Initiation Phase. The percentage of members 6 12 years of age as of the Index Prescription Episode Start Date with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. 2. Continuation and Maintenance (C&M) Phase. The percentage of members 6 12 years of age as of the Index Prescription Episode Start Date with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Members must be Six years as of March 1 continuously enrolled in of the year prior to the the organization for 120 measurement year to 12 days (4 months) prior to years as of February 28 the Index Prescription of the measurement Start Date through 30 days (1 month) after the Index Prescription Start Date.

12 12 11 Effectiveness Behavioral Health Follow-Up After The percentage of Date of discharge 6 years and older of Care Hospitalization for discharges for members 6 through 30 days as of the date of Mental Illness years of age and older who after discharge. discharge. (FUH) were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported. 1. The percentage of members who received follow-up within 30 days of discharge 2. The percentage of members who received follow-up within 7 days of discharge This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

13 13 13 Effectiveness of Care Medication Management Use of High-Risk Medications in the Elderly (DAE) The percentage of Medicare members 65 years of age and older who received at least one high risk medication The percentage of Medicare members 65 years of age and older who received at least two different high risk medications For both rates, a lower rate represents better performance. Note: NCQA will provide a comprehensive list of medications and NDC codes on its Web site ( by November 15, The measurement 65 years and older as of December 31 of the measurement This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

14 14 Access/Availability of Care Annual Dental Visits Prenatal and Postpartum Care This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

15 15 14 Access/ Availability Annual Dental Visit (ADV) The percentage of members years of of Care age who had at least one dental visit during the measurement This measure applies only if dental care is a covered benefit in the organization s Medicaid contract. 15 Access/ Prenatal and The percentage of Availability Postpartum Care deliveries of live births of Care (PPC) between November 6 of the year prior to the measurement year and November 5 of the measurement For these women, the measure assesses the following facets of prenatal and postpartum care. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 This presentation provides the 2009 HEDIS days of enrollment in the measures developed by NCQA and organization. monitored through the Institute for Families in Society evaluation activities. The managed Postpartum Care. The care entities under contract with the SC percentage of deliveries Department of Health and Human Services that had a postpartum should contact SCDHHS directly regarding visit on or between 21 HEDIS reporting requirements. and 56 days after delivery. The measurement 43 days prior to delivery through 56 days after delivery years as of December 31 of the measurement Report six age stratifications tifi ti and a total t rate. 2 3-years 4 6- years 7 10-years years years years Total None specified.

16 16 Use of Services Ambulatory Care Well Child and Adolescent Well Adults This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

17 17 16 Use of Services Ambulatory Care (AMB) This measure summarizes utilization of ambulatory care in the following service categories. Outpatient Visits ED Visits Ambulatory Surgery/Procedures Observation Room Stays 17 Use of Services This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements. Well-Child Visits in the First 15 Months of Life (W15) The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life. No well-child visits One well-child visit Two well-child visits i Three well-child visits Four well-child visits Five well-child visits Six or more well-child visits Note: This measure has the same structure as measures in the Effectiveness of Care domain. The organization should follow Guidelines for Effectiveness of Care Measures when calculating this measure. 31 days 15 months of age. Calculate 31 days of age by adding 31 days to the child s date of birth. Calculate the 15- month birthday as the child s first birthday plus 90 days. For example, a child born on January 9, 2006, and included in the rate of six or more well-child visits must have had six well-child visits by April 9, All 15 months old during the measurement

18 18 18 Use of Services Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) The percentage of members 3 6 years of age who received one or more well-child visits with a PCP during the measurement Note: This measure has the same structure as measures in the Effectiveness of Care domain. The organization should follow Specific Guidelines for Effectiveness of Care Measures when calculating this measure. The measurement Ages 3 6 years as of December 31 of the measurement 19 Use of Services Adolescent Well-Care Visits (AWC) This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements. The percentage of enrolled members years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement Note: This measure has the same structure as measures in the Effectiveness of Care domain. The organization should follow Specific Guidelines for Effectiveness of Care Measures when calculating this measure. The measurement Ages years as of December 31 of the measurement

19 19 20 (State Definition - Non-HEDIS Use of Services Well-Adult Visits The percentage of enrolled members years of age who had at least one comprehensive Se ces well-care e visit with a PCP or an OB/GYN practitioner during the measurement The measurement Ages years as of December 31 of the measurement Thi t ti id th 2009 HEDIS d l d b NCQA d it d th h th I tit t f F ili i S i t l ti This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

20 20 Satisfaction i with Care - CAHPS Definition The Consumer Assessment of Health Plans Survey (CAHPS) is the primary tool for assessing consumer satisfaction and experiences with care in the commercial, Medicaid, and Medicare markets. Different survey instruments are used for adult and child Medicaid enrollees. Measures Getting Needed Care Getting Care Quickly How Well Doctors Communicate Customer Service Shared Decision Making Health Promotion and Education Coordination of Care This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

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22 22 What you can do to improve reporting? ICD-9 Codes Multiple and Decimal Better CPT Codes Check Accuracy Complete all required fields Improve standardization across providers Audit encounter submission Consider NCQA certification Thi t ti id th 2009 HEDIS d l d b NCQA d it d th h th I tit t f F ili i S i t l ti ti iti Th This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

23 23 Upcoming Changes to Reporting Effective 2008 reporting of HEDIS measures by calendar CAHPS survey consistent with NCQA time frame. Field-testing other measures e.g., AHRQ Thi t ti id th 2009 HEDIS d l d b NCQA d it d th h th I tit t f F ili i S i t l ti This presentation provides the 2009 HEDIS measures developed by NCQA and monitored through the Institute for Families in Society evaluation activities. The managed care entities under contract with the SC Department of Health and Human Services should contact SCDHHS directly regarding HEDIS reporting requirements.

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