HEDIS OVERVIEW PRESENTATION August 11, 2014 PRESENTED BY: CARINA YAPYUCO, RN RACHEL GRAY, RN HANIA ALHINNAWI , RN CLARICE MAYO, LVN HEDIS Overview Presentation

Agenda Fundamentals of HEDIS Auto-assignment Medicare STAR program HEDIS medical record abstraction Medical record review validation Off-season supplemental data collection Quality improvement interventions HEDIS Overview Presentation

Healthcare Effectiveness Data and Information Set What is HEDIS? HEDIS Overview Presentation

What is HEDIS? Most widely used set of standardized performance measures in the managed care industry Developed by the National Committee for Quality Assurance (NCQA) - HEDIS was introduced in 1993 Encourages accountability and quality improvement in health care HEDIS Overview Presentation

Why is HEDIS important? Measures quality performance and identifies areas in need of quality improvement Triple Aim Initiatives Cost Containment Ranking among health plans and states Auto-assignment Medicare Stars Program NCQA accreditation HEDIS Overview Presentation

Who decides on HEDIS? HEDIS measures are developed by: NCQA Board of Directors Committee on Performance Measurement (CPM) - oversees entire measure development process Measurement Advisory Panels (MAPs) - condition specific, clinical experts HEDIS Overview Presentation

HEDIS 2014: 80 measures across 5 domains of care Effectiveness of Care - Are we providing adequate, effective prevention, screening & care? Access/Availability of Care - Are we meeting members’ needs? How accessible is care? Experience of Care (CAHPS) - Survey captures members’ overall experience & satisfaction Utilization and Relative Resource Use - Use of Services; Cost of Care for chronic diseases Health Plan/MCO Descriptive Information - How do factors such as LAC’s organizational structure & management contribute to our ability to provide quality care to our members? HEDIS Overview Presentation

HEDIS Data Reporting Measurement Year (MY) - data reflect delivery of service during the calendar year, e.g., from 01/01/13 to 12/31/13 Reporting Year (RY) - data reported to NCQA in June of the year following MY HEDIS 2014 (RY) = 2013 data (MY) HEDIS Overview Presentation

HEDIS Data Collection Three data collection methods: Administrative - claims, encounter, Rx, Labs - BCS, PCR, OMW, ASM, AAB, MPM, ART, LBP Hybrid - administrative & medical record data - W34, PPC, CCS, CBP, CDC, COL, COA, MRP Surveys - CAHPS, HOS HEDIS Overview Presentation

Auto-Assignment Incentive employed by the states to promote quality improvement Based on high quality scores, administrative performance, access to care, financial health and stability Medicaid beneficiaries are assigned automatically to the best MCO when they fail to choose their own health plan HEDIS Overview Presentation

Auto-Assignment Measures for HEDIS 2014 Childhood Immunization Status (CIS) Children who received these vaccines by their 2nd birthday: 4 DTaP + 3 IPV + 1 MMR + 3 HiB + 3 HepB + 1 VZV + 4 PCV Well Child Visits 3rd, 4th, 5th, and 6th years (W34) Children who had well-child visits with a PCP in MY Cervical Cancer Screening (CCS) Pap smear during MY or 2 years prior to MY (age 21-64), OR Pap + HPV during MY or 4 years prior to MY (age 30-64) Prenatal & Postpartum Care (PPC) Prenatal care in the 1st trimester Comprehensive Diabetes Care (CDC) HbA1c screening in MY; LDL-C control in MY HEDIS Overview Presentation

Medicare STAR Program Background STAR Ratings Strategy Better Care Healthier People/Healthier Communities Lower Cost Through Improvements HEDIS Overview Presentation

Star Ratings Structure Outcomes Intermediate Outcomes Patient Experience Access Process HEDIS Overview Presentation

Star Ratings Above Average Below Average Excellent Average Poor HEDIS Overview Presentation

Star Measures Colorectal Cancer Screening (COL) Comprehensive Diabetes Care (CDC) Controlling High Blood Pressure (CBP) Eye Exam Nephropathy (Kidney Disease Monitoring) Care of Older Adults (COA) Medication Review Blood Sugar Controlled Functional Status Assessment LDL <100 (Cholesterol Controlled) Pain Assessment Adult BMI Assessment (ABA) Cholesterol Management for Patients with Cardiovascular Conditions (CMC) HEDIS Overview Presentation

HEDIS Star Rates HEDIS Overview Presentation

HEDIS 2014 Medicare Highlights for L.A. Care 5 STAR MEASURES (4) 3 STAR MEASURES (4) CMC – Cholesterol Screening CDC – Poor Control >9% COL – Colorectal Cancer Screening CDC – LDL <100 COA – Functional Status ABA – Adult BMI CDC – Nephropathy 4 STAR MEASURES (5) CBP – Controlling Blood Pressure CDC – Eye Exam CDC – LDL Screening COA – Medication Review COA – Pain Assessment HEDIS Overview Presentation

HEDIS Timeline January 15—Off-season chart review ends January 26—HEDIS abstraction training for internal and external Abstractor Nurses February 21—Abstraction begins March 3 & 4 — Audit Day April 4— Refresh of all data May 15—All abstraction ends May 17— Auditor selects 16 records from each of 5 Groups in addition to all MRR exclusions HEDIS Overview Presentation

HEDIS Timeline May 24—All selected records are submitted for validation by auditors May 29—Auditor completes Medical Record Review Validation (MRRV) June 8—IDSS completed and locked July 1—Off-season medical record collection begins HEDIS Overview Presentation

Medical Record Retrieval: L.A. Care HEDIS Overview Presentation

Medical Record Retrieval: Plan Partner HEDIS Overview Presentation

Over-read process during HEDIS L.A. Care over-reads 100% of all positive records, and 30% of all charts deemed as negative during the HEDIS season L.A. Care works with Verisk to develop study items within the database to track major and minor errors for each abstractor All abstractors are required to maintain an average of 95% or greater accuracy on all measures Inter-rater reliability is measured during the first two weeks of the project then on an ongoing basis to ensure accuracy and consistency amongst abstractors, with re-education as necessary in areas of deficiency. HEDIS Overview Presentation

Final Medical Record Review Validation HEDIS Overview Presentation

Supplemental Medical Record Retrieval and Abstraction (HEDIS - Off Season) Supplemental medical record retrieval and abstraction activities start in July after the HEDIS results are submitted to NCQA Conduct office visits by HOA/FSR staff Provider education Scanning/abstracting medical records from doctors’ offices and entered into internal databases.

Off-Season Medical Record Retrieval via Fax equest HEDIS Overview Presentation

Off-Season Off-Site Medical Record Retrieval HEDIS Overview Presentation

Exit Interview with Provider and Staff Discuss overall findings of the medical record audit Discuss percentage of compliant vs non-compliant members in each measure - (# of records pulled vs # of compliant records) Discuss Provider Feedback Report Provide education in Gaps in Care Discuss “HEDIS at A Glance” Tool HEDIS Overview Presentation

Supplemental Files Processing Request supplemental data files from: - PPG - IPA - MSO - Plan Partners HO&A formats the supplemental files and submit to vendor (Verisk). Three formats: VISIT, RX, LAB Technical assistance and guidance are provided to the groups if necessary. LA Care receives files in August, December and March (for lag data)

HEDIS Overview Presentation

Benefits of Off Season Activities Increases the administrative rates for L.A. Care resulting in a decrease in the number records for pursuit and abstraction during HEDIS season Off season activities include office visits to high volume and low performing provider offices. This gives an opportunity to provide feedback to doctors/office staff regarding documentation, coding, reinforcement of preventive health guidelines, education on gaps in care, etc More completeness in administrative data collection to avoid the data loss in the normal data transmission process (PCP  IPA DDD (MSO)  Plan Partners  L.A. Care Health Plan  Verisk) HEDIS Overview Presentation

HO&A 2014 Interventions HEDIS Overview Presentation

Questions? HEDIS Overview Presentation