What is HEDIS (Healthcare Effectiveness Data and Information Set)?
HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of many State contracts. Through HEDIS, NCQA holds Managed Health Services (MHS) accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership. HEDIS consists of over 36 Effectiveness of Care type measures as well as Access to Care and Use of Services measures. These rates are calculated based on claims/encounter data and/or medical record review data. The rates are reported to NCQA and to the state if required by contract.
Why are HEDIS scores used ?
As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s ability to demonstrate an improvement in preventive health outreach to its members. Physician specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician incentive programs such as pay for performance and quality bonus funds. These programs pay providers an increased premium based on their individual scoring of quality indicators such as those used in HEDIS.
How are HEDIS rates calculated?
HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual PAP test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services, and utilization of acute and mental health services. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care, and well-child care.
Who will be conducting the Medical Record Reviews?
MHS has contracted with MedAssurant, a national medical record review vendor, to conduct the medical record reviews on our behalf. Medical record review audits are usually conducted March through May each year. At that time, you may receive a call from an MedAssurant representative if any of your patients are selected into HEDIS samples for MHS. Your prompt cooperation with the MedAssurant representative is greatly needed and appreciated.
What about HIPAA?
As a reminder, Protected Health Information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. MedAssurant has signed a HIPAA compliant Business Associate Agreement with MHS which allows them to collect PHI on our behalf.
How can I make HEDIS season less stressful?
We realize early spring can be a time of increased stress in the provider office with multiple organizations requesting copies of medical records in addition to the increased incidence of sick visits. We are pleased to be able to contract with MedAssurant, who is able to offer several medical record correspondence options including confidential fax, traditional mail, or onsite review by qualified staff. These various options allow you as the provider to choose the most convenient method for your practice.
What can be done to improve my HEDIS scores?
- Understand the specifications established for each HEDIS measure.
- Submit claim/encounter data for each and every service rendered. Chart documentation must reflect services billed. All providers must bill (or report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation.
Who should I contact at MHS for Assistance?
If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact MHS Quality Improvement (877) 647-4848.
CAHPS 2010
The Consumer Assessment of Healthplan Providers and Systems (CAHPS) is a nationally administered survey overseen by the Agency for Healthcare Research and Quality (AHRQ). Per State requirement, each MCO conducts a yearly CAHPS survey. The survey allows members the opportunity to rate their satisfaction with Managed Health Services (MHS) as well as with our service providers. The survey is sent to a random sample of MHS members that meet certain requirements for continuous eligibility with MHS. Our 2010 survey will be mailed to members in March.
Members who receive the survey will rate us in eight main categories including
Rating of Health Plan, Customer Service, Getting Needed Care, Rating of PCP, Rating of Specialists, Getting Care Quickly, Communication with Physicians, and Rating of Healthcare. CAHPS scores are considered by the National Committee on Quality Assurance (NCQA) when a health plan seeks NCQA accreditation. As you know, MHS is seeking NCQA accreditation, so it will be eligible to re-bid on our State contract for 2011. CAHPS is worth 13 of the 100 possible points MHS can receive towards NCQA accreditation.
Results from the 2009 Adult Survey revealed opportunities to improve our scores for several areas, including Rating of Personal Doctor, Rating of Specialists, Getting Needed Care, Rating of the Health Plan, and Communication between members and providers. MHS internal CAHPS workgroups have developed multiple initiatives to improve MHS’ 2010 CAHPS scores.
Providers are encouraged to: ensure members are getting appropriate care and getting care quickly, ensure that members’ questions about their health are fully addressed and understood; even soliciting questions during each office visit, and ensure that members feel like they are treated with courtesy and respect by the doctors and their office staff. If a member mentions to you that they have received a CAHPS survey, please encourage them to complete it and put it in the mail. Thanks for your support.
You can also find information about HEDIS on our Quality Improvement pages.
This entry is filed under Blog, Providers.
