HEDIS ® HEDIS ® requirements for Anthem, MDwise and Managed Health Services A Combined Managed...

HEDIS®

HEDIS® requirements for Anthem, MDwise and Managed Health Services

A Combined Managed Care PresentationOctober 20-22, 2009

HEDIS® is a registered trademark of the National Committee for Quality Assurance

P0418 (10/09)

Agenda

Hoosier Healthwise

Introduction of Managed Care Representatives What is HEDIS HEDIS Measures Data Reporting Chart Reviews HEDIS Barriers Missed Opportunities Flyer Presumptive Eligibility and NOP Anthem Managed Health Services MDwise Questions & Answers Drawing

2

HEDIS Overview

What is HEDIS? HEDIS – Healthcare Effectiveness Data and

Information Set National Committee for Quality Assurance (NCQA)

uses these performance measures for commercial, Medicare, and Medicaid.

HEDIS is the most used set of performance measures in the Managed Care industry, developed and maintained by NCQA.

Hoosier Healthwise 3

HEDIS Overview

Majority of HEDIS is measures from administrative results-claims, but some of the measures are pulled from hybrid results-medical record review.

Administrative data is calculated by a claim or an encounter submitted to the health plan.

Hybrid reviews are a random sample of member medical records. Hybrid data can consist of administrative data and a sample of medical record data.

Annual State mandated quality improvement initiative required of all Managed Care Health plans.

Retrospective review of medical care and services from the prior year.


HEDIS Overview

Results from the HEDIS data collection serve as measurements for quality improvement processes and preventive health programs.

HEDIS rates are used to evaluate the effectiveness of a health plan’s ability to demonstrate an improvement in preventive health outreach to its members.


HEDIS Overview

Data is reported to NCQA in June of the reporting year.

Data reflects events that occurred during the measurement year (calendar year).

Example: HEDIS 2009 data is reported in June 2009. Data reflects events that occurred in January –

December 2008 (per specs) HEDIS 2009 = 2008 data


HEDIS Overview

Denominator – Eligible members of the population. Numerator – Members that meet the criteria of the

measure. Anchor Date – The specific date the member is

required to be enrolled to be eligible for the measure.

Continuous Enrollment – The minimum amount of time a member must be enrolled to be eligible for a measure.

Provider Specialty – Certain measures must be performed by a specified provider specialty.


HEDIS Score Barriers

Claims not submitted due to members that have third party liability. Members that are assigned to the wrong Primary Medical Provider. Claims are submitted without the appropriate diagnosis or CPT

codes that will count towards the measures. The provider specialty does not count towards the measure. The member is not continuously enrolled. The services are not all documented in the members medical chart. All components of the required measure were not provided. New member and previous medical records are not obtained or

transferred when a member changes PMPs. Appointment availability when a member tries to schedule

preventive services. Appointment availability for new members on the PMP panel.

8Hoosier Healthwise

HEDIS Measures – Hybrid Review

Cervical Cancer Screening – CCS* Women 24 – 64 years of age who had a pap

smear during the measurement year or the two years prior to the measurement year or have documentation of a hysterectomy. The claim must have the appropriate coding and with the appropriate provider specialty to count toward the measure.

* OMPP Incentive Measure



Comprehensive Diabetes Care – CDC Members 18 – 75 of the measurement year who

received an LDL – C screening, and care of diabetes during the measurement year. The claim must have the appropriate coding to count toward the measure.

Required testing and documentation: Hemoglobin A1c (Test and Result) LDL – C Lipid screening (Test and Result)* Retinal Exam (Dilated eye exam/Retinopathy) Urine screening (ACE or ARB medication therapy)

(attention to Nephropathy) Blood Pressure Documented (<130/80) (<140/90)




Well – Child Visits in the First 15 Months of Life – W15* Members 0 – 15 months of age must receive 6 or more well – child

visits with a PMP that document in the medical record the following: health and developmental history (physical and mental) i.e.

developmental questionnaires regarding sleep habits, feeding, motor skills, teething, interaction with others, walks alone, teething/chewing objects, and PCP observation.

a physical exam i.e. general appearance, height, weight, heart, lungs, abdomen, head circumference, deformities, reflexes present, fontanels, and alertness.

health education/anticipatory guidance i.e. injury prevention, circumcision care, thermometer use, choking prevention, bathing, car seat use, temper tantrums, and lead poisoning.

The claim must have the appropriate coding and submitted with the appropriate provider specialty to count towards the measure.

* OMPP Incentive MeasureHoosier Healthwise 11


12Hoosier Healthwise


Well – Child Visits in the Third, Fourth, Fifth and Sixth Years of Life – W34* Members 3–6 years of age in the measurement year must receive

one well – child visit with a PMP each year that documents in the medical record the following: health and developmental history (physical and mental) i.e.

developmental milestones, disposition, communication with others, vocabulary, independence with dressing, and toileting.

a physical exam i.e. general appearance, height, weight, heart, lung, abdomen, BMI percentile, vision, hearing, abuse/neglect, eyes/strabismus, and alertness.

health education/anticipatory guidance i.e. balance meals with snacks, limit sweets, caution with strangers, second hand smoke, childcare planning, bed time, friends, and limit setting.





Adolescent Well – Care Visits – AWC* Members 12 – 21 years of age in the measurement year must

receive one well – child visits with a PMP that document in the medical record the following (school physical, preventive care visits with a Pap, or post partum visit): health and developmental history (physical and mental) i.e.

developmental questionnaires regarding social and emotional development, school progress, physical activity, depression, menarche, and peer relationships.

a physical exam i.e. general appearance, height, weight, heart. Lung, abdomen, tanner stage, BMI, head eyes, heart, lungs, acne, and pap smears.

health education/anticipatory guidance i.e. balanced meals, sex education, safety, smoking, drug and ETOH avoidance, regular exercise, breast self exams, seat belt use, suicidal ideation, and partner selection.


* OMPP Incentive MeasureHoosier Healthwise 15

HEDIS Measures – Missed Opportunities

A member comes in for a problem focused or sick visit and per the HEDIS measure is in need of preventive services; well child visit, immunizations, or a screening, and these services were not provided at the visit.

A member was in the office for a postpartum visit and per the HEDIS measure is in need of a pap and the service was not provided at the visit.


HEDIS Measures – Missed Opportunities



Childhood Immunization and Lead Screenings – CIS and LSC The health plan is looking for all childhood

immunizations and lead screenings to be completed on or before the child’s second birthday.



Immunizations for Adolescents – IMA The health plan is looking for a percentage of

adolescents 13 years of age who had the following by their 13th birthday: one dose of meningococcal vaccine given on

or between the 11th and 13th birthday AND one tetanus, diphtheria toxoids, and

acellular pertussis vaccine (Tdap) given on or between the 10th and 13th birthday OR

one tetanus, diphtheria toxoids vaccine (Td) given on or between the 10th and 13th birthday.



Controlling Blood Pressure – CBP Members 18 – 85 years old with a diagnosis of

Hypertension (High Blood Pressure) on or before June 30th of the measurement year. Latest documented blood pressure during

measurement year; control of ≤ 140/90. The following information is pulled: problem list and

progress notes. If the member is pregnant during the measurement

year, the member is excluded for the measure.



Cholesterol Management for Patients with Cardiovascular Conditions – CMC Members 18 – 75 who were diagnosed with

Myocardial Infarction, Coronary Bypass Graft, Coronary Angioplasty, Ischemic Vascular Disease Documentation of LDL drawn and LDL control < 100



Body Mass Index – BMI BMI is a screening tool for obesity that will assist

in determining BMI– for – Age Percentiles Documentation for BMI percentiles for children <16

years old and BMI value for children >16 years old. Documentation of Educational materials, Nutritional

Counseling, Activity plans and education.



Adult BMI Assessment – ABA The percentage of members 18-74 years of age

who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year.



Weight Assessment and Counseling – Children and Adolescents – WCC There are 3 required components of this

measure: Age 3 – 17 years old. BMI percentile or percentile graph must be

documented on all children less than 16 years old, BMI value for over 16 years old will be accepted.

Counseling and Nutrition in the form of discussion on diet, anticipatory guidance for nutrition, or counseling on nutrition.

Counseling for Activity in the form of discussion of current physical activities, counseling for increasing activity, or anticipatory guidance on activity.



Frequency of Ongoing Prenatal Care – FPC* Members who delivered a live birth on or between

November 6 of prior year to November 5 of measurement year and were continuously enrolled 42 days prior to delivery. Documentation of all prenatal visits. ≥81 percent of expected visits.

*OMPP Bonus Measure



Prenatal and Postpartum Care – PPC* Members who had a live birth in the measurement

year who had their first prenatal visit within 42 days of enrollment or during the first trimester.

Postpartum Care* Members who had their postpartum visit on or

within 21 – 56 days of delivery.

The claims must have the appropriate coding and submitted with the appropriate provider specialty to count towards these measures.

*OMPP Bonus Measure


Presumptive Eligibility and Prenatal Measures

For a limited time, a pregnant woman who has been determined by a Qualified Provider (QP) to be ‘presumptively eligible’ may receive ambulatory prenatal services while her Hoosier Healthwise application is being processed.

The Package is known as “Package P”. OMPP and the MCO’s worked jointly to develop a universal

assessment for pregnant women known as the Notification of Pregnancy (NOP) to do the following:

Identify health risk factors Monitor risk factors Increase the percentage of pregnant women

assessed during the first trimester Increase average birth weights Reduce smoking rates Reduce the number of pre – term deliveries


Presumptive Eligibility and Prenatal Measures

Providers are reimbursed $60 for submission of valid NOP.

Reimbursement is limited to one form per pregnancy.

A valid NOP must be submitted within 5 calendar days via the Web interChange.

The pregnant member gestation must be LESS than 30 weeks gestation for NOP reimbursement.


HEDIS Measures

Follow up Care for Children Prescribed ADHD Medication – ADD* Members 6 – 12 years of age who receive a new prescription

for an ADHD medication (had a negative ADHD medication history for 120 days prior) must receive a follow – up visit with a practitioner with prescribing authority during the 30 – day initiation Phase.



HEDIS Measures

Follow up After Hospitalization for Mental Illness – FUH* Members 6 years of age and older as of the date of

discharge from an acute inpatient stay must receive an outpatient visit with a mental health practitioner within 7 days after the discharge.



Quiz

What does HEDIS stand for?

What are 5 of the OMPP bonus measures?

What are 3 barriers that cause services not to count toward HEDIS measures?


MCO HEDIS Interventions


Anthem

HEDIS Summit conducted in January 2009. Successfully disseminated knowledge on all aspects of HEDIS, identified critical elements and best practices to improve HEDIS performance

Successfully developed three HEDIS workgroups- member, provider, and data, focusing on strategies and building on existing programs.


Anthem

Provider focused strategies: Aligned the Physician bonus program with the State’s P4P

Program including OB providers. Working on providing real time HEDIS data to physicians through

ManagedCare.com. Developed a plan to deliver “members with gaps in care” reports

to providers in person, by mail, or by fax, and assisting with tracking mechanisms for preventive/well care appointments to capture missed opportunities

Incorporating age appropriate forms into current practice guidelines


Anthem

Provider focused strategies Developed provider tool-Kits containing educational required

materials, forms, and preventive care codes, to assist network physicians in utilizing best practices from around the country in order to improve care to members; thus improving HEDIS performance.

CRC field staff are receiving training to assist physicians and their office staff to access and utilize the ManagedCare.com reports.

Developing provider trainings via webinar and face to face contact meetings

Providing medical records feedback from current year HEDIS abstractions


Anthem

Member focused strategies: Clinical Quality Health Services Team implemented

member interventions for all incentive measures and several NCQA accreditation measures:

Outreach efforts include automated calls, mailings and home visits to members.

For select measures such as ADHD and diabetes measures, the call center staff make appointments for members and ensures transportation to their appointment.


Anthem

Member focused strategies: Data driven member interventions will be implemented

using real time HEDIS reports. Implemented incentives for timely prenatal and

postpartum visits. Developing marketing strategies to promote preventive

visits/medical home Working with Indiana WIC to design the cover sleeve for

the WIC checks to include information about the importance of preventive visits and keeping member’s contact information current with the State (so we can find our members).


Anthem

Member focused strategies: CRC ER initiative capturing members seen in the ER with

follow up phone calls and education toward true ER Member focus toward promoting “Medical Home” and

importance of annual well care visits with unlimited transportation services to get members to those appointments


Anthem

Data focused strategies: Accurate and periodic monitoring of HEDIS performance of

Anthem, network physicians, and physician groups through ManagedCare.com.

Develop reports of members with gaps in care to assist with member and provider interventions.

Evaluate the effectiveness of member and physician interventions to identify best practices.


Anthem

Healthy Habits Count for You and Your Baby – Prenatal Program – Anthem The Healthy Habits Count for You and Your Baby Program,

hereafter referred to as the “prenatal program”, provides members with a comprehensive program of prenatal and postpartum care. The program is designed to identify members who are pregnant, encourage early and on-going prenatal and postpartum care and provide case management for members with high-risk pregnancies while increasing members’ access to prenatal care.


Anthem

Healthy Habits Count for You and Your Baby – Prenatal Program – Anthem Key components:

Prenatal member education booklet Case management when appropriate Access to free prenatal care (first 30 weeks of gestation) and related

health education Gifts for timely prenatal and postpartum care Referrals for social services including crib program Breastfeeding support line


Anthem

Healthy Habits Count for You with Asthma – Asthma Education – Anthem Analysis of Anthem claims prevalence report reveals that asthma

ranks among the top diagnoses. Given the high rate of members with asthma, the Anthem Healthy Habits Count with Asthma (“HHCA”) program is designed as a multifaceted program encompassing health education, member outreach, case management and physician clinical support.

Anthem collaborates with plan physicians and pharmacies to promote the diagnosis, treatment and management of asthma according to the most current asthma clinical practice guidelines set forth by the National Heart, Lung, and Blood Institute (NHLBI). The HHCA member and provider interventions were developed in accordance with the NHLBI asthma recommendations for asthma treatment and management.


Anthem

Key components: Member stratification into 3 risk levels – low, medium & high

based on hospitalization and use of quick relief meds Condition monitoring Patient adherence Consideration of other health conditions Lifestyle issues Asthma member education booklet which includes asthma action

plan and peak flow meter monitoring


Anthem

Childhood Obesity Program – Office Toolkit for Providers In response to the increasing prevalence of childhood

obesity, Anthem is facilitating standard screening for obesity and encouraging children and their families to eat healthy and be physically active. The 2009 Childhood Obesity Office Toolkit is designed to support a physician’s office in providing care around healthy weight, nutrition, and physical activity.


Anthem

Childhood Obesity Program – Office Toolkit for Providers

Key components in the toolkit include: Get Up and Get Moving Family Activity Book Body Mass Index (BMI) brochure for parents AAFP Childhood Obesity CME Bulletin Online BMI training for clinical staff Anthem Blue Cross and Blue Shield BMI wheel CDC BMI growth chart for age and sex Provider’s Family Counseling Guide to address childhood obesity


Managed Health Services - HEDIS Initiatives

OMPP & NCQA Focused Performance Measures

Educational Material – MHS has developed and issued education material such as HEDIS Quick Reference Guide and Healthwatch (EPSDT) chart tool

Provider Education Session – HEDIS Education sessions offered throughout The State to assist our provider network in education regarding what is needed to achieve goals .

Scorecard Mailing - Quarterly scorecard information to PMP network. Provides a snapshot of current metrics and listing of members identified as not receiving service to date and aid in patient outreach

Billing/Claims assistance – MHS team providing one on one education sessions with office to provide instruction on appropriate EPSDT and HEDIS billing procedures.

Member Outreach – Outreach calls and mailings issued to members identified as in need of services. Connections team available to assist provider with member contact.



Preventative Health Action Committee – Multi departmental workgroup set up to identify and develop clinical quality improvement activities encompassing HEDIS and Benchmark measures for appropriate delivery and management of healthcare interventions. Current initiatives include:

Smoking Cessation Intervention Chlamydia Screen Quarterly Health Initiative Focus (Women,

Children, Respiratory and Diabetic Health) Educational Update/Material



Member Outreach Programs

Connections – Takes the plan to the member to promote preventative health

Birthday Postcards – Postcards sent to members in need of well services two months before their birthday

Preventative Reminder Calls – Outreach calls to members in need of select preventative service reminding importance



Coordinated Care Programs

Start Smart For Your Baby Asthma Diabetes Lead Emergency Department Diversion



Health Check Health Day – MHS coordinated outreach event. MHS will do for you:

Encourages specialty type screenings for age-, gender- and disease state-specific members.

Create and mail letter of invitation to targeted members.

Call members to schedule appointment, arrange transportation and provide follow-up reminder calls.

Provide specific billing details to ensure screening credit is received.

Complete a scheduling form (dictated by you) and send (via fax) updates as new/changed/ canceled appointments arise

Have a team on site to promote health messages, provide health-related giveaways and answer questions about MHS



Health Incentive Program

CentAccount™ Healthy Rewards program gives members a monetary incentive through a flexible spending account for completing annual well visits and health screenings.

CentAccount MasterCard accepted at participating groceries and pharmacies, and is restricted to the purchase of health-related items, such as over-the-counter medicine. Can also be used at www.diapers.com to purchase items such as diapers and bottles,


MDwise – HEDIS

MDwise developed a Network Improvement Program (NIP) Team to focus on the following: OMPP Key Performance Measures. Analyze provider data and work on opportunities

for improvement in the provider community. Work with the Quality Improvement Team to

review medical records. Work with Provider Relations to conduct

seminars and training opportunities.


MDwise - HEDIS

MDwise will provide the following to provider offices: Group Comparison reports for providers

produced from data out of ManagedCare.com Opportunity Reports Educational Tools Updates on the Web site 2009 Key HEDIS Measures Poster Well – Child First Campaign/Mini Poster Utilization Reports


MDwise - HEDIS

The Network Improvement Program (NIP) Team will be conducting provider onsite visits to discuss HEDIS and Key Performance measures in short training sessions.

Training Session can consist of the following: Reports Educational Tools Forms and Documentation Guidelines Best Practices Provider Resources


MDwise Educational Opportunities

To ensure quality of care is provided to MDwise Hoosier Healthwise members.

Assist Providers in gaining knowledge in the following: HEDIS measures and requirements Components of each measure Forms and tools Opportunities for improvement Meet performance measure standards for the

State and NCQA


MDwise Member Outreach

Newborn letters with well – child visit schedule. Newborn list to each Delivery System. NURSE on – call post card that focuses on well –

child care and women’s screenings including mammograms .

Member eligible lists to PMP’s at each Delivery System.

Education and weekly report of members with new ADHD scripts to PMP’s.

Outreach calls to parents of members with new ADHD scripts to schedule a follow up appointment within 30 days.


MDwise Member Outreach

Case Management follow up and education on the need for follow up after Hospitalization for Mental Illness.

Education on the LDL measure to members and providers.

Member and Provider Newsletters. ProviderLink (provider newsletter) Steps to Wellness (member newsletter)

BLUEBELLEbeginnings program for Pregnant members. Member Services provides outreach calls to schedule

post partum visits with members.58Hoosier Healthwise

MDwise Programs

NURSEon-call: Speak with a nurse 24 hours a day.

RIDEwise: MDwise members get free rides to and from doctor visits.

WEIGHTwise: Offers support to members who want to lose, gain, or stay at a healthy weight.

TEENconnect: Helps pre – teens and teenagers get more involved in their health care.

WELLNESSchats: These are educational events. They take place in your community and are hosted by MDwise.


MDwise Programs

HELPlink: Work with a member advocate who knows about health, school, and community services.

SMOKE-free: Get help kicking the tobacco habit.

MS.BLUEBELLE’S club for kids: Our kids club offers special activities and mailings that teach kids to make healthy choices.


MDwise Programs

BLUEBELLEbeginnings: MDwise wants to improve birth outcomes. MDwise pregnant Members can call to join the program. MDwise representatives conduct a prenatal assessment and help the mom pick a doctor for her baby. It is very important for Hoosier Healthwise members to pick a doctor for their baby BEFORE the baby is born. MDwise will send out important information to the member about the pregnancy, being a parent, and a free gift for the baby.

INcontrol: This program provides information and education about chronic illness. Members learn to manage asthma, diabetes, or other chronic illness.


Well – Child First


2009 Key HEDIS Measures


HEDIS Questions and Answers


Drawing


HEDIS ® HEDIS ® requirements for Anthem, MDwise and Managed Health Services A Combined Managed...

Documents

Transcript of HEDIS ® HEDIS ® requirements for Anthem, MDwise and Managed Health Services A Combined Managed...