Identifying Barriers to Achieving HEDIS Goals

1
Identifying Barriers to Achieving HEDIS Goals
Peggy Ketterer, RN, BSN, CHCA Health Services
Advisory Group
2
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)

3
Todays Session

• Discuss data sources for each measure
• Discuss common data collection issues
• Discuss barriers to improving performance
• Discuss best practices/improvement efforts

4
(No Transcript)
5
Ground Rules

• Everyone must say something!! I expect
  each plan to talk about either one challenge or
  possible intervention.
• If you dont speak, Ill call on you!!!

6
Lower Performing Measures

• Prenatal Care
• Postpartum Care
• Cervical Cancer Screening
• Dental Visits
• Other measures based on individual health plan
  performance

7
Prenatal Care

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

8
Prenatal Care

• Common data collection issues
• Global billing
• Resource intensive medical record review
• Others?

9
Prenatal Care

• Barriers to Improving Performance
• Plan doesnt 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

10
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

11
Postpartum Care

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

12
Postpartum Care

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

13
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

14
Postpartum Care

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

15
Cervical Cancer Screening

• Data sources
• Eligibility
• Claims/encounters
• Medical records
• Lab vendors

16
Cervical Cancer Screening

• Common data collection issues
• Capitated reimbursement for lab
• Inaccurate coding by providers
• Resource intensive medical record review
• Others?

17
Cervical Cancer Screening

• Barriers to Improving Performance
• Members are non-compliant
• Other barriers

18
Cervical Cancer Screening

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

19
Annual Dental Visits

• Data sources
• Eligibility
• Claims/encounters
• Dental vendors

20
Annual Dental Visits

• Common data collection issues
• Difficulty obtaining dental visit data from
  dental care vendors
• Difficulty identifying dental providers/provider
  type
• Others?

21
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

22
Annual Dental Visits

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

23
Other Measures

• Challenges
• Interventions/Improvement Efforts

24
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

25
THANK YOU FOR YOUR PARTICIPATION!