What is it

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Q Mark, Incorporated
HEDIS 101

• What is it?
• Why is it done?
• HEDIS is a registered trademark of the National
  Committee for Quality Assurance (NCQA).

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HEDIS Overview

• What is HEDIS?
• Why do HEDIS?
• How are HEDIS data collected?
• What is the physicians role?
• How does HEDIS benefit members?

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What is HEDIS?
Healthcare Effectiveness Data and Information Set
(HEDIS) 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. HEDIS performance measures
relate to many significant public health issues
such as cancer, heart disease, smoking, asthma,
and diabetes. HEDIS also includes a standardized
survey of consumers experiences that evaluates
plan performance in areas such as customer
service, access to care, and claims processing.
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Why do HEDIS ?
Historically, health plans participated in HEDIS
to remain competitive in the market and to
illustrate their commitment to quality
initiatives. State and federal regulators, such
as the Centers for Medicare Medicaid Services
(CMS), also use the results in their oversight of
these plans. Consumers use the results to make
choices about health plans, and HEDIS data are
either required or expected by employers. Health
plans use HEDIS measures to identify and maximize
opportunities to improve care.
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How is HEDIS Collected?

• Annually, health plans collect data and report
  HEDIS by first checking their internal claims
  systems. This is known as administrative claims
  data. This, however, does not always provide a
  complete set of data many health plans choose to
  conduct medical record review in a clinical
  location as well. This process is known as
  hybrid methodology.
• Continued . . .

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How is HEDIS Collected? (contd)
To review the medical records, a clinical
location is contacted to schedule an on-site
visit so the appropriate medical records can be
reviewed. If there is evidence that a service
was provided for a specific HEDIS measure
indicator, and it meets the requirement for the
HEDIS measure, the service is added to the
numerator. If the service was not provided or
does not meet the HEDIS measure requirement, it
is not counted toward the numerator. Continued .
. .
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How is HEDIS Collected? (contd)

• At the end of the process, the number of service
  events found in the medical records is added to
  the administrative data to calculate the final
  rate for each HEDIS measure.

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What is the Physicians Role?

• Physicians should keep accurate, legible, and
  complete medical records for their patients.
• Contractually, as part of the conditions for
  participation in a health plan provider network,
  physicians are obligated to allow access to
  review medical records. Generally, members sign
  a release of medical records when they enroll
  with the health plan.
• Physicians need to encourage patients to receive
  appropriate preventive services to ensure their
  health and well-being.
• HEDIS reporting has been mandated for National
  Committee for Quality Assurance (NCQA)
  accreditation since 2000, so physicians and their
  staff should become familiar with HEDIS to
  understand what health plans are required to
  report. Confidentiality is maintained at all
  times.

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How Does this Benefit Members?

• Measuring health care services enables health
  plans to develop targeted initiatives or
  educational programs aimed at improving their
  members health based upon their unique health
  care needs.
• HEDIS results enable employers to make an
  informed decision when choosing a health care
  insurer for their employees.
• Continued . . .

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How Does this Benefit Members? (Contd)

• Results are reported on an aggregate level and no
  individual member results are ever reported.
  This is to ensure compliance with HIPAA
  regulations and also ensures that the
  confidentiality of every members personal health
  information is maintained at the highest level.
  All staff involved in the production of HEDIS
  results sign confidentiality agreements.

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Why is HEDIS Important?

• HEDIS measures support and encourage preventive
  health programs.
• HEDIS measures ensure that results will be
  comparable across health plans.
• HEDIS holds health plans ultimately responsible
  for the quality of care they provide to their
  members and for ensuring that specific services
  have been provided.

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HEDIS Goals

• To accurately reflect health plans performance
  by utilizing HEDIS specifications, providing a
  means for public comparison
• To comply with accrediting bodies and state
  regulatory requirements such as NCQA, The Joint
  Commission, CMS, and state-specific reporting

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TIME is the Driving Force!

• HEDIS is based on services or care rendered
  primarily in the calendar year prior to the
  reporting year.
• The date of service timeframe ranges vary from
  measure to measure.
• A timeline, based on specific milestones in each
  project, is established for each HEDIS season.
• In order to publicly report HEDIS results, an
  organization must undergo a HEDIS Compliance
  Audit, conducted by a certified HEDIS audit firm.

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TIME is the Driving Force! (contd)

• Milestone items may be the Baseline Assessment
  Tool (BAT), delivery of hybrid samples, or
  submission of the Interactive Data Submission
  System (IDSS), among others.
• All deadlines tie into the next phase of the
  process and must be met, or reporting will be
  delayed or prohibited.
• Results are reported in June of the reporting
  year via the IDSS.

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HEDIS Domains

• Effectiveness of Care
• Access to and Availability of Care
• Satisfaction with the Care Experience
• Health Plan Stability
• Use of Services
• Cost of Care
• Health Plan Descriptive Information
• Health Plan Stability

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Definitions

• Request for Information (RFI)the process of
  validating health plan identification,
  information, membership, product line, and
  contacts it also documents any unique reporting
  requirements of an organization, and is one of
  the initial milestones for an organization.
• Baseline Assessment Tool (BAT)an NCQA-produced
  tool by which the health plan describes its
  organization, vendors, and project details the
  BAT is required for a health plan to be audited
  and is presented to the auditor in advance of the
  audit.
• Measurement Yeartypically a calendar year, but
  will vary by measure.
• Measurean individual HEDIS specification with
  detailed requirements.

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Definitions (contd)

• Product LineCommercial, Medicaid, Medicare
  Advantage, or Medicare Special Needs Plan
• Eligible Populationmembers within a product line
  who fit the measurement criteria, e.g., age,
  gender, continuous enrollment, benefits, or event
  and/or diagnosis
• Denominatorthe eligible population minus any
  exclusions
• Exclusionsconditions that prevent a member in
  the eligible population from being included in
  the denominator
• Numeratora count of all the members within the
  denominator who received the treatment or service
• Administrative Datainternal claims data are
  referred to as administrative data, e.g., claims
  data, pharmacy data, or lab data

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Definitions (contd)

• Hybrid Dataresults are obtained from both
  administrative sources and from conducting
  medical record review in clinical locations.
• Abstractionis the process of collecting data
  from medical records this is known as hybrid
  review.
• Samplerandomized sample of members from the
  eligible population who meet the specified
  criteria for a measure each measure has its own
  sample, the size of which depends upon a specific
  set of criteria.
• Oversample Rateused in the hybrid review
  methodology to substitute members found to be
  ineligible for the measure circumstances for
  substitution include data errors,
  contraindication to treatment, or an employee or
  dependent of the health plan has been selected in
  the sample.

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Definitions (contd)

• Measure Rotationallows use of audited and
  reportable rates from the previous year's data
  collection in lieu of collecting the measure for
  the current year.
• Why rotate?
• Rotation reduces the burden of data collection.
• NCQA specifies measures that can be rotated.
• Only commercial and Medicaid product lines are
  allowed to rotate.
• Measures are eligible for rotation every other
  year.

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Definitions (contd)

• Things to consider about rotation.
• The measure must be on the NCQA rotation list.
• The prior years measure was audited and
  reportable.
• The health plan remained constant since the prior
  year.
• If the measure was reported as NA last year, the
  NA status applies for the current year.
• Accreditation scoreswere they satisfactory?
• Is the measure used to demonstrate meaningful
  improvement for accreditation?
• The plan must indicate the measures it rotated in
  the IDSS.

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DataCollectionMethodologies
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Administrative Method

• This includes the eligible population based on
  established criteria defined within each HEDIS
  measure.
• This contains claims and encounter data only.
• The rate that is reported is based on all members
  who meet the denominator criteria, found through
  administrative data, who received the service
  required for the HEDIS measure.

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Administrative Data

• Administrative rates are required for HEDIS
  reporting and are calculated using claims and
  encounter data.
• Data Requirements
• Member DataDemographic member information
• Provider DataDemographic provider information
  can be used for provider profiling
• Enrollment DataUsed to determine eligibility for
  the measures
• Visit DataUsed to determine eligibility for
  certain measures, compliance, and utilization
  rates
• Pharmacy DataUsed to determine eligibility for
  certain measures, compliance, and utilization
  rates
• Lab DataUsed to determine eligibility for
  certain measures, compliance, and utilization
  rates
• Delivery DataNot required however, will be used
  for all pregnancy-related measures

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Administrative Data (contd)

• It is much simpler to use NCQA-Certified HEDIS
  software, which goes through a rigorous
  certification process developed by NCQA, than to
  use internally developed programming and source
  code.
• NCQA-Certified software eliminates many hours of
  programming and producing source code needed to
  pass the compliance audit. This frees up an
  organizations resources to concentrate on other
  areas of its business plan.

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Hybrid Method

• Includes members in a systematic sample taken
  from the eligible population.
• The rates are based on members selected in the
  sample who have received the service identified
  for the HEDIS measure where the data are found in
  clinical medical records.
• A health plan may not report a hybrid rate when
  the HEDIS measure is required to be reported
  strictly from administrative data only.

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Hybrid Data Collection

• Purpose of hybrid review is to augment
  administrative results through medical record
  review of selected HEDIS measures.
• A systematic sample of 411 members from each
  measure is drawn to perform the hybrid review.
• Can be reduced based on prior years audit
  results.
• Provider locations are selected for pursuit of
  the medical record.
• Records are obtained through on-site, fax, and
  mail request methods.
• Final medical record results are combined with
  administrative data.
• Each measure is reported administratively or by
  hybrid methodology.

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Survey Method

• Data must be collected by a survey conducted by
  an NCQA-Certified survey vendor.
• Requirements are found in Volume 3 of the HEDIS
  Specifications.
• CAHPS (Consumer Assessment of Healthcare
  Providers and Systems) queries the members
  opinion of their encounter with the health plan
  or health care provider.
• CAHPS and the Medicare Health Outcomes Survey
  (HOS) are examples of surveys performed during
  the HEDIS process.

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Satisfaction with the Care Experience

• HEDIS/CAHPS 4.0H Adult Survey
• Commercial and Medicaid
• HEDIS/CAHPS 3.0H Child Survey
• Commercial and Medicaid
• Sub-Survey using the Child 3.0H population
• Children with Chronic Conditions
• Medicare Health Outcomes Survey (HOS)
• Administered by CMS for managed care
  organizations Medicare populations.

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Satisfaction with the Care Experience (contd)

• CAHPSConsumer Assessment of Healthcare Providers
  and Systems
• Provides a general indication of whether a health
  plan is meeting its members expectations
• States either can require the use of a specific
  survey vendor, or allow plans to perform their
  own survey

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Survey Methodology

• NCQA certifies licensed vendors to administer the
  survey.
• Currently 15 vendors are certified to collect
  HEDIS 2009 survey results.
• Vendors receive a pre-formatted eligibility file
  (known as the sample frame) to conduct the
  survey.
• Vendors create a sample population from the
  sample frame submitted by the health plan, and
  conduct the survey.
• Vendors present final reports to the health plans
  upon the surveys completion.

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HEDIS Compliance Audit
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HEDIS Audit Principles

• Verifies that the health plans HEDIS production
  processes conform to the HEDIS Technical
  Specifications (Volume 2)
• Measures the health plans information system
  capabilities and evaluates its ability to
  process medical, member, and practitioner
  information so it can accurately report HEDIS
  data
• Extrapolates to all HEDIS measures the results of
  a detailed source code review of a carefully
  selected and expandable subset of measures
  (referred to as the Core Set)

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HEDIS Audit Principles (contd)

• Goal is accurate, reliable, and publicly
  reportable data that purchasers and consumers can
  use to compare health plans
• HEDIS compliance audits must be conducted by an
  NCQA licensed organization and a certified HEDIS
  compliance auditor using NCQAs standard audit
  methodology to ensure consistency across audits

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HEDIS Audit Milestones

• Baseline Assessment Tool Submission
• Core Set Selection
• Onsite Audit ReviewSource Code Review
• Member, Provider, Claims, Repository
• Convenience Sample
• Medical Record Review Validation
• Benchmarking
• Audit Designation
• RReport NRNot Report NBNot a Benefit
• Lock IDSS for Submission

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Timeline
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HEDIS Reporting Cycle

• October to January
• Prepare data for administrative rates
• Create CAHPS file (if applicable)
• February to March
• Create administrative results
• Pull hybrid samples
• March to April
• Review medical records
• Refresh data
• May to June
• Merge medical record review results with
  administrative data.
• Submit final IDSS to NCQA, CMS, and state
  agencies
• February to June
• Audit oversight by certified HEDIS compliance
  auditor

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Sample Timeline

• Select HEDIS vendor, including budgeting for
  audit process and hybrid record review
• RFI kick-off call
• Submit BAT
• Determine measures to be rotated and/or sample
  size reductions
• Set goals
• Clean provider data
• Determine provider selection criteria logic
• Create hybrid sample
• Collect hybrid data
• Surveysregular vendor completion reports
• Complete IDSS
• Report results to committees

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HEDIS Reporting Solution

• Whether an organization is brand new to HEDIS
  reporting or has many years of experience, it is
  an overwhelming task to manage the entire HEDIS
  report production internally within an
  organization.
• Q Mark, Inc. has the capability to manage every
  aspect of HEDIS reporting that has been explained
  in the preceding information.
• Please contact Q Mark at info_at_qmarkinc.com or
  1-888-55Q-Mark (1-888-557-6275) and give us the
  burden of HEDIS reporting!