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HEDIS® 101
Kristen Swift, MHAManager, Policy Measures
August 28, 2018
These slides are current as of 08/28/2018. NCQA reserves the right to change the content of the information, as appropriate.
These slides are only meant to be key speaking points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation.
These materials are copyrighted and may not be further used, shared or distributed without permission of NCQA.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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Agenda
NCQA OVERVIEW
HEDIS BACKGROUND
MEASURE DEVELOPMENT PROCESS
HEDIS DATA COLLECTION AND SUBMISSION PROCESS
HOW HEDIS DATA IS USED
HEDIS RESOURCES
What is NCQA?
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HEDIS 101
Background of HEDIS
What is HEDIS?
Healthcare
Effectiveness
Data &
Information
Set
• Most widely used set of standardized performance measures in health care
• Approximately 92 process and outcome measures and standardized member satisfaction survey (CAHPS®)
• Used by commercial, Medicare, Medicaid and Marketplace plans
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HEDIS 2018 Publications
Volume 1 – Overview & Background
Volume 2 – Technical Specifications (non-survey measures)
Technical Specifications for Physician Measurement
Volume 3 – Survey Measures (CAHPS)
Volume 5 – HEDIS Compliance Audit
Volume 6 – Health Outcomes Survey (HOS)
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HEDIS 2019 Data Reporting
• Data reflect events that occurred during themeasurement year(calendar year)• MY = January 1 – December
31, 2018
• Data are reported to NCQA in June of the reporting year• For HEDIS 2019 results are
reported in June 2019
HEDIS 2019
BP Reading -December
2018
Eye Exam -June 2018
Mammogram - January
2018
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From Idea to a Measure
HEDIS 101
Desirable Attributes of a HEDIS Measure
Relevance
Scientific SoundnessFeasibility
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MAPs CPM BOD
Who Decides on HEDIS?
Measurement Advisory Panels (MAPs)
• Support measure development process
• Specific clinical and/or implementation expertise
Committee on Performance Measurement (CPM)
• Oversees entire measurement development process
Board of Directors
• NCQA’s Board has the final say on which measures are added to or retired from HEDIS
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HEDIS Measure Life Cycle
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HEDIS Domains and Measures
HEDIS 101
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HEDIS Domains
Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization and Risk Adjusted Utilization
Health Plan Descriptive Information
Measures Collected Using Electronic
Clinical Data Systems
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List of HEDIS Measures
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Collecting HEDIS Data
HEDIS 101
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Four HEDIS Data Sources
Administrative Medical records
Electronic Clinical Data (ECDS)
Claims Encounter Eligibility Provider
Surveys
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Data Flow ChainAdministrative vs. Medical Record Data
Service provided
Service documented
Data entered intohealth plan systems
HEDISClaim/
Encounter Form
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Data Sources
Medical Records
• Primary care• Behavioral health• Ancillary• Specialty care• Acute Facilities
Administrative• Membership data• Provider data• Claims/encounter
data• Hospital discharge
data• Pharmacy data• Carve-out data
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Administrative vs. Hybrid Data
Administrative• Data is less expensive• Easy to run on a more continuous basis• Easy to generate reminders
Hybrid • Data may be more accurate• It is better for data that isn’t in claims (i.e., lab results, BP
readings)• Resource-intensive, but can potentially reduce sample
size
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Anatomy of a HEDIS Measure
HEDIS 101
Summary of Changes, Description and Definitions
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Eligible Population Criteria
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Selecting an Eligible Population
• Age (DOB)
• Enrollment date and type
• Dates of service
• Diagnosis and procedure codes
• Provider specialty
• Required benefit
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Administrative Specification
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Administrative SpecificationValue Set Directory
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Hybrid Specification
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Calculating a HEDIS Rate
HEDIS 101
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The first step for both methods is the same
Identify the eligible population based on
patient demographicsN = Denominator
(1,000 members)
Step 1. Identify the eligible population
Calculating a Typical HEDIS Rate
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Step 2. Did the ‘care’ event occur?
Number of patients in the denominator that satisfy the measure (340 patients)
Entire eligible population(1,000 patients)
= 34.0%
Administrative Method
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Denominator Identification
For administrative method, STOP• The eligible population = Denominator
For hybrid method, CONTINUE• The denominator is a sample drawn from the eligible population
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A. Use administrative data to determine if the event occurred in sample population a = number of events found with administrative data = 140)
B. Audit charts only for members who do not satisfy criteria per administrative data (411 – 140 = 271)
C. Identify members who satisfy criteria in the chart audit (b = 205)
Step 2. Draw sample (n = 411)
Step 3. Did the event occur?
Hybrid Method
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a+bn = 140 + 205
411 = 345411
= 83.9%
Step 4. Calculate rate
Administrative Chart
Hybrid Method
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Interactive Data Submission System (IDSS)
HEDIS 101
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Feb March April May June
IDSS Timeline
HOQ launched; orgs provide necessary updates
NCQA processes updates
NCQA provides submission IDs to orgs
IDSS is opened
Orgs begin data submission for applicable measures
All data is due to NCQA by June 15
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IDSS: Data Elements TableOrganizations that submit HEDIS data to NCQA must provide the following data elements.
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HEDIS Compliance Audit
HEDIS 101
HEDIS Compliance Audit
• Data collection and calculation methods can vary across plans.
• A standardized audit methodology for verifying the reliability of HEDIS data collection and rate calculation processes.- It identifies, quantifies and converts errors and reduces bias.
• The audit outcome indicates whether or not a measure is reportable.
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Audit Outcomes
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Is an Audit Required?
Accreditation Yes
Medicare Yes
Quality Compass Yes
Some states Yes
Some purchasers (OPM) Yes
Most Medicaid programs Some
Special projects No
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How HEDIS Measures and Data are Used
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How HEDIS Measures and Data are Used
NCQA AccreditationNCQA Health Plan
RatingsNational Quality
Forum
Health plan operations and quality improvement
State or other regulatory requirements
NCQA Health Plan Ratings
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HEDIS Scoring for Accreditation
• HEDIS scores are worth 50 points– HEDIS measures = 37 points
– CAHPS Ratings/Composites = 13 points
• In general, the points are evenly distributed among the measures
• The following are exceptions and are worth double points– Comprehensive Diabetes Care
– CAHPS Rating of Health Plan
NCQA Health Plan Ratings
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HEDIS Reporting by State42 States Report HEDIS to NCQA and/or Use HEDIS for Other Purposes
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Additional HEDIS Resources
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NCQA Website
Policy Clarification Support
http://my.ncqa.org
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Frequently Asked Questionshttp://faq.ncqa.org/
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Thank you