SNP Training Topic 1: Introduction to NCQA and HEDIS

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SNP Training - Topic 1Introduction to NCQA and
HEDIS

• March 11, 12 14, 2008

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Overview

• Describe the SNP evaluation project NCQA is
  executing on behalf of CMS
• Give a general understanding of HEDIS
• Purpose and uses
• How are measures developed
• How are measures calculated
• How are measures audited
• How are results submitted to NCQA

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Introduction to NCQA SNP EvaluationBrett
KayDirector, SNP Assessment
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A Brief Introduction to NCQA

• Private, independent non-profit health care
  quality oversight organization founded in 1990
• Committed to measurement, transparency and
  accountability
• Unites diverse groups around common goal
  improving health care quality

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Achieving the Mission

• 3 out of 4 Americans enrolled in an HMO are in an
  HMO accredited by NCQA
• More than 90 percent of managed care
  organizations report HEDIS quality data
• 38 states and the federal government rely on NCQA
  Accreditation and HEDIS
• More than 8,600 physicians have earned NCQA
  Recognition programs form the basis of quality
  improvement programs and P4P nationwide

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Goal for SNP Evaluation Program

• Robust and comprehensive assessment strategy
• Applies to all SNPs
• Responsive to the special in SNP
• Can be implemented soon

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Three-Year Strategy
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Project Time Line Phase 1

• March 14 - Release final SP measures
• April 15 - Release ISS Data Collection Tool
• S P Measures
• April 25 - Release IDSS Data Collection Tool
• HEDIS Measures
• June 30 - HEDIS submissions and SP measures
  submissions due to NCQA
• Sept 30 - NCQA delivers SNP Assessment Report to
  CMS

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Training Education

• Five training topic areas, focus is on content
  and data submission
• Introduction to NCQA HEDIS
• SNP Subset of HEDIS Measures
• Interactive Data Submission System (IDSS)
• Structure Process Measures
• Interactive Survey System (ISS)

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Additional Resources

• NCQA SNP Webpage www.ncqa.org/snp.aspx
• FAQs (HEDIS)
• Training descriptions schedule
• Final HEDIS and SP measures (March 14)
• NCQA Policy Clarification Support (PCS)
• http//app04.ncqa.org/pcs/web/asp/TIL_Client
• Login.asp
• HEDIS Audit information
• http//www.ncqa.org/tabid/204/Default.aspx

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NCQA Policy Clarification Support (PCS)

• Web address
• http//app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.
  asp
• Link from SNP Web page www.ncqa.org/snp.aspx

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PCS (contd)

• Under Standard Categories/HEDIS Domain, select
  one of the following options
• SNP General Reporting Guidance
• SNP HEDIS
• SNP Structure Process Measures
• Menu options under Standard/Measures
• If SNP General Reporting Guidance was
  selected
• Not Applicable

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PCS (contd)

• Menu options under Standard/Measures
• If SNP HEDIS was selected
• (COL) Colorectal Cancer Screening
• (GSO) Glaucoma Screening in Older Adults
• (SPR) Use of Spirometry Testing in the Assessment
  and Diagnosis of COPD
• (PCE) Pharmacotherapy of COPD Exacerbation
• (CBP) Controlling High Blood Pressure
• (PBH) Persistence of Beta Blocker Treatment After
  a Heart Attack
• (OMW) Osteoporosis Management in Older Women
• (AMM) Antidepressant Medication Management
• (FUH) Follow-Up After Hospitalization for Mental
  Illness
• (MPM) Annual Monitoring for Patients on
  Persistent Medications
• (DDE) Potentially Harmful Drug-Disease
  Interactions
• (DAE) Use of High Risk Medication in the Elderly
• (BCR) Board Certification
• Other

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PCS (contd)

• Menu options under Standard/Measures
• If SNP Structure Process was selected
• SNP 1 Complex Case Management
• SNP 2 Improving Member Satisfaction
• SNP 3 Clinical Quality Improvements
• Other

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Contacts

• Brett KayDirector, SNP Assessment202-955-1722k
  ay_at_ncqa.orgCasandra MonroeAssistant Director,
  SNP Assessment202-955-5136monroe_at_ncqa.org

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HEDIS 101Cindy Ottone, MHADirector, HEDIS
Policy
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Overview

• Review the background for HEDIS
• Identify the components of the HEDIS collection
  and submission process
• Examine the measuredevelopment process

HEDIS
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What Is HEDIS?

• Healthcare
• Effectiveness
• Data
• Information
• Set

HEDIS is an evolving set of standard
specifications for measuring health plan
performance
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Where Did HEDIS Come From?

• Originally developed by employers and the HMO
  group in 1991 NCQA took charge of HEDIS in 1992
• Expanded in 1996 to cover all three product
  lines commercial, Medicare and Medicaid
• Addresses the leading causesof death
• Includes information on quality, utilization and
  cost

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How Are HEDIS Data Used?

• Federal, state and other regulatory requirements
• State of Health Care Quality report
• Performance-based accreditation
• MCOs use for RFP/RFI preparation
• Quality improvement activities and health plan
  operations
• Quality Compass, Quality Dividend Calculator
• US News and World Report - Ranking of Health Plans

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From Idea to Measure
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From an Idea to a Measure...

• Idea or concept is proposed by the Measure
  Advisory Panel (MAP)
• Develop the basics of the measure with the
  Technical Advisory Group (TAG)
• Draft technical specifications and measure
  work-up
• Conduct field-test

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From an Idea to a Measure...

• Evaluate field-test results and revise measure,
  if necessary
• Send to Committee on Performance Measurement
  (CPM)
• Public Comment process
• Final decision by CPM

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Desirable Attributes
Feasibility
Relevance
Scientific soundness
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Desirable Attributes

• Relevance Meaningfulness, health importance,
  financial importance, cost effectiveness,
  strategic importance, controllability, variance
  among systems, potential for improvement
• Scientific soundness Clinical evidence,
  reproducible, valid, accurate, case mix
  adjustment/risk adjustment

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Desirable Attributes

• Feasibility Precise specification, reasonable
  cost (emphasis on administrative measures),
  confidentiality, logistical feasibility,
  auditability
• Standardization All plans conducting the same
  specification allows for comparability across
  plans

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HEDIS Measure Life Cycle
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HEDIS Data, Domains, Measures and Submission
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Data Reporting

• Data are reported to NCQA in June of the
  reporting year
• Data reflect events that occurred during
  themeasurement year(calendar year)

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Data Reporting

• Example
• HEDIS 2008 data are reported in June 2008
• Data reflects events that occurred
  JanuaryDecember 2007 (per specs)
• HEDIS 2008 2007 data

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SNP HEDIS Measures

• Colorectal Cancer Screening
• Glaucoma Screening in Older Adults
• Use of Spirometry Testing in the Assessment and
  Diagnosis of COPD
• Pharmacotherapy Management of COPD Exacerbation
• Controlling High Blood Pressure
• Persistence of Beta-Blocker Treatment After a
  Heart Attack
• Osteoporosis Management in Women Who Had a
  Fracture

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SNP HEDIS Measures

• Antidepressant Medication Management
• Follow-up After Hospitalizationfor Mental
  Illness
• Annual Monitoring for Patients on Persistent
  Medications
• Potentially Harmful Drug-Disease Interactions in
  the Elderly
• Use of High-Risk Medications in the Elderly
• Board Certification

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Effectiveness of Care Measures

• Clinical quality of care
• Focus
• Preventive care
• Up-to-date treatments for acute episodes of
  illness
• Chronic disease care
• Appropriate medication treatment

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EOC Measures- Prevention and Screening

• Colorectal Cancer Screening
• Glaucoma Screening in Older Adults

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EOC Measures- Respiratory and Cardiovascular

• Respiratory Conditions-
• Use of Spirometry Testing in the Assessment and
  Diagnosis of COPD
• Pharmacotherapy Management of COPD Exacerbation
• Cardiovascular Conditions
• Controlling High Blood Pressure
• Persistence of Beta-Blocker Treatment

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EOC Measures- Musculoskeletal

• Musculoskeletal
• Osteoporosis Management in Women Who Had a
  Fracture

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EOC Measures- Behavioral Health

• Antidepressant Medication Management
• Follow-up After Hospitalizationfor Mental
  Illness

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EOC Measures- Medication Management

• Annual Monitoring for Patients on Persistent
  Medications
• Potentially Harmful Drug-Disease Interactions in
  the Elderly
• Use of High-Risk Medications in the Elderly

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Health Plan Descriptive Information

• Board Certification

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Collecting HEDIS Data
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Three HEDIS Data Sources
Claims Encounter Eligibility Provider
Medical records
Surveys
Administrative
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Data Flow Chain Breaks ? Inaccurate HEDIS Data
H E D I S
Service documented
Service provided
Data entered into health plan systems
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Data Sources

• Administrative
• Membership data
• Provider data
• Claims/encounter data
• Hospital discharge data
• Pharmacy data
• Carve-out data

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Selecting an Eligible Population

• Member ID
• Age (DOB)
• Enrollment date and type
• Dates of service
• Diagnosis and procedure codes
• Provider specialty
• Pharmacy

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Clinical MeasuresData Collection

• Defining the denominator is critical
• Administrative Claims and encounter data
• Denominator Based on all eligible members of the
  population

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Calculating a Typical HEDIS Rate
The first step for both methods is the same
Step 1. Identify the eligible population
Identify the eligible population based on patient
demographics
N Denominator (1,000 members)
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Administrative Method
Step 2. Did the care event occur?
Number of patients in the denominator that
satisfy the measure (340 patients)
34.0
Entire eligible population (1,000 patients)
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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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Hybrid Method
Step 2. Draw sample (n 411)
Step 3. Did the event occur?

• Use administrative data to determine if the event
  occurred in sample population a number of
  events found with administrative data 140)
• Audit charts only for members who do not satisfy
  criteria per administrative data (411 140
  271)
• Identify members who satisfy criteria in the
  chart audit (b 205)

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Hybrid Method
Step 4. Calculate rate
ab n
140 205 411
345 411
83.9



Administrative
Chart
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Example of A Measure- Glaucoma Screening
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HEDIS Compliance Audit
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NCQA HEDIS Compliance Audit

• A standardized audit methodology for verifying
  the reliability of HEDIS data collection and rate
  calculation processes
• Outcome is whether or not a measure is reportable

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Why a Standardized HEDIS Audit?

• Data collection and calculation methods can vary
  across plans
• A standardized audit identifies, quantifies and
  converts errors
• The audit reduces bias

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Interactive Data Submission System (IDSS)
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IDSS

• Web-based tool for HEDIS 2008 Corresponds to
  Volume 2 Technical Specifications
• Special project codes help identify specific uses
  for the IDSS

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IDSS Timeline

• IDSS available to the plans in April
• Include validations error and warning
• Completed IDSS (submissions) due from plans
• June 15 commercial and Medicaid
• June 30 Medicare (including SNPs)

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HEDIS Account Management Function

• Provide technical assistance to plans throughout
  the data submission process
• Ensure that plans are collecting data according
  to Volume 2 Technical Specifications

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And now

• Questions?

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Additional Information

• HEDIS 2008 Volume 2 Publication Purchase
• http//www.ncqa.org/tabid/78/Default.aspx
• October Specifications Update
• http//www.ncqa.org/Portals/0/PolicyUpdates/HEDIS
  20Technical20Updates/2008_Vol2_Technical_Update.p
  df

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Additional SNP Seminars

• SNP Subset of HEDIS Measures
• March 18th (2 sessions) 1100 - 1230 and 200 -
  330,
• March 19th 100 - 230,
• March 20th 1230 - 200,
• March 25th100 - 230,
• March 26th 100 - 230
• Interactive Data Submission System (IDSS)
• April 8th 100 - 230,
• April 9th (2 sessions) 1100 - 1230 and 200 -
  330,
• April 14th (2 sessions) 1100 - 1230 and 200 -
  330,
• April 16th 100 - 230

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Additional SNP Seminars

• Structure and Process Measures (SP)
• March 27th (2 sessions) 1100 - 1230 and 200 -
  330,
• April 1st 100 - 230,
• April 2nd (2 sessions) 1100 - 1230 and 200 -
  330,
• April 3rd 100 - 230
• Interactive Survey System (ISS)
• April 15th (2 sessions) 1100 - 1230 and 200 -
  330,
• April 17th 100 - 230,
• April 22nd (2 sessions) 1100 - 1230 and 200 -
  330,
• April 24th 100 - 230