Identifying Barriers to Achieving HEDIS Goals Peggy Ketterer, RN, BSN, CHCA Health Services Advisory Group

Background Plans are required to report a set of HEDIS ® measures on an annual basis AHCA has identified performance measure targets based on national Medicaid means and percentiles Measurement year 2007 was used as a baseline HEDIS ® is a registered trademark of the National Committee for Quality Assurance (NCQA)

Today’s Session Discuss data sources for each measure Discuss common data collection issues Discuss barriers to improving performance Discuss best practices/improvement efforts

Ground Rules Everyone must say something!! I expect each plan to talk about either one challenge or possible intervention. If you don’t speak, I’ll call on you!!!

Lower Performing Measures Prenatal Care Postpartum Care Cervical Cancer Screening Dental Visits Other measures – based on individual health plan performance

Prenatal Care Data sources: Eligibility Claims/encounters Medical records If available, other internal databases such as a prenatal care program

Prenatal Care Common data collection issues: Global billing Resource intensive medical record review Others?

Prenatal Care Barriers to Improving Performance: Plan doesn’t know about pregnancy early enough to get the visit performed Global billing does not typically allow for capture of individual visit dates Visits are not in appropriate timeframes Members are non-compliant Visit documentation does not contain necessary components Other barriers

Prenatal Care Best Practices/Improvement Efforts Open discussion of potential interventions Best practice resources Center for Health Care Strategies (CHCS) Toolkit – Toward Improving Birth Outcomes

Postpartum Care Data sources: Eligibility Claims/encounters Medical records If available, other internal databases such as a prenatal care program

Postpartum Care Common data collection issues: Global billing – no incentive for physicians to submit separate bill Resource intensive medical record review Others?

Postpartum Care Barriers to Improving Performance: Global billing does not typically require date of service for postpartum care visit Visits are not in appropriate timeframes Members are non-compliant Visit documentation does not contain necessary components Other barriers

Postpartum Care Best Practices/Improvement Efforts Open discussion of potential interventions Best practice resources

Cervical Cancer Screening Data sources: Eligibility Claims/encounters Medical records Lab vendors

Cervical Cancer Screening Common data collection issues: Capitated reimbursement for lab Inaccurate coding by providers Resource intensive medical record review Others?

Cervical Cancer Screening Barriers to Improving Performance: Members are non-compliant Other barriers

Cervical Cancer Screening Best Practices/Improvement Efforts Open discussion of potential interventions Best practice resources

Annual Dental Visits Data sources: Eligibility Claims/encounters Dental vendors

Annual Dental Visits Common data collection issues: Difficulty obtaining dental visit data from dental care vendors Difficulty identifying dental providers/provider type Others?

Annual Dental Visits Barriers to Improving Performance: Members are non-compliant Vendors do not submit complete encounter data Direct providers do not submit complete data Challenges in securing sufficient dental provider network Other barriers

Annual Dental Visits Best Practices/Improvement Efforts Open discussion of potential interventions Best practice resources

Other Measures Challenges Interventions/Improvement Efforts

Handouts Best Practices Resource List CHCS Toolkit – Toward Improving Birth Outcomes California Health Care Foundation - Improving Access to Dental Care in Medicaid CDC – Guide to Community Preventive Services

THANK YOU FOR YOUR PARTICIPATION!