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HEDIS® 101

Kristen Swift, MHAManager, Policy Measures

August 28, 2018

These slides are current as of 08/28/2018. NCQA reserves the right to change the content of the information, as appropriate.

These slides are only meant to be key speaking points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation.

These materials are copyrighted and may not be further used, shared or distributed without permission of NCQA.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Agenda

NCQA OVERVIEW

HEDIS BACKGROUND

MEASURE DEVELOPMENT PROCESS

HEDIS DATA COLLECTION AND SUBMISSION PROCESS

HOW HEDIS DATA IS USED

HEDIS RESOURCES

What is NCQA?

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HEDIS 101

Background of HEDIS

What is HEDIS?

Healthcare

Effectiveness

Data &

Information

Set

• Most widely used set of standardized performance measures in health care

• Approximately 92 process and outcome measures and standardized member satisfaction survey (CAHPS®)

• Used by commercial, Medicare, Medicaid and Marketplace plans

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HEDIS 2018 Publications

Volume 1 – Overview & Background

Volume 2 – Technical Specifications (non-survey measures)

Technical Specifications for Physician Measurement

Volume 3 – Survey Measures (CAHPS)

Volume 5 – HEDIS Compliance Audit

Volume 6 – Health Outcomes Survey (HOS)

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HEDIS 2019 Data Reporting

• Data reflect events that occurred during themeasurement year(calendar year)• MY = January 1 – December

31, 2018

• Data are reported to NCQA in June of the reporting year• For HEDIS 2019 results are

reported in June 2019

HEDIS 2019

BP Reading -December

2018

Eye Exam -June 2018

Mammogram - January

2018

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From Idea to a Measure

HEDIS 101

Desirable Attributes of a HEDIS Measure

Relevance

Scientific SoundnessFeasibility

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MAPs CPM BOD

Who Decides on HEDIS?

Measurement Advisory Panels (MAPs)

• Support measure development process

• Specific clinical and/or implementation expertise

Committee on Performance Measurement (CPM)

• Oversees entire measurement development process

Board of Directors

• NCQA’s Board has the final say on which measures are added to or retired from HEDIS

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HEDIS Measure Life Cycle

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HEDIS Domains and Measures

HEDIS 101

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HEDIS Domains

Effectiveness of Care

Access/Availability of Care

Experience of Care

Utilization and Risk Adjusted Utilization

Health Plan Descriptive Information

Measures Collected Using Electronic

Clinical Data Systems

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List of HEDIS Measures

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Collecting HEDIS Data

HEDIS 101

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Four HEDIS Data Sources

Administrative Medical records

Electronic Clinical Data (ECDS)

Claims Encounter Eligibility Provider

Surveys

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Data Flow ChainAdministrative vs. Medical Record Data

Service provided

Service documented

Data entered intohealth plan systems

HEDISClaim/

Encounter Form

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Data Sources

Medical Records

• Primary care• Behavioral health• Ancillary• Specialty care• Acute Facilities

Administrative• Membership data• Provider data• Claims/encounter

data• Hospital discharge

data• Pharmacy data• Carve-out data

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Administrative vs. Hybrid Data

Administrative• Data is less expensive• Easy to run on a more continuous basis• Easy to generate reminders

Hybrid • Data may be more accurate• It is better for data that isn’t in claims (i.e., lab results, BP

readings)• Resource-intensive, but can potentially reduce sample

size

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Anatomy of a HEDIS Measure

HEDIS 101

Summary of Changes, Description and Definitions

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Eligible Population Criteria

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Selecting an Eligible Population

• Age (DOB)

• Enrollment date and type

• Dates of service

• Diagnosis and procedure codes

• Provider specialty

• Required benefit

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Administrative Specification

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Administrative SpecificationValue Set Directory

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Hybrid Specification

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Calculating a HEDIS Rate

HEDIS 101

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The first step for both methods is the same

Identify the eligible population based on

patient demographicsN = Denominator

(1,000 members)

Step 1. Identify the eligible population

Calculating a Typical HEDIS Rate

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Step 2. Did the ‘care’ event occur?

Number of patients in the denominator that satisfy the measure (340 patients)

Entire eligible population(1,000 patients)

= 34.0%

Administrative Method

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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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A. Use administrative data to determine if the event occurred in sample population a = number of events found with administrative data = 140)

B. Audit charts only for members who do not satisfy criteria per administrative data (411 – 140 = 271)

C. Identify members who satisfy criteria in the chart audit (b = 205)

Step 2. Draw sample (n = 411)

Step 3. Did the event occur?

Hybrid Method

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a+bn = 140 + 205

411 = 345411

= 83.9%

Step 4. Calculate rate

Administrative Chart

Hybrid Method

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Interactive Data Submission System (IDSS)

HEDIS 101

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Feb March April May June

IDSS Timeline

HOQ launched; orgs provide necessary updates

NCQA processes updates

NCQA provides submission IDs to orgs

IDSS is opened

Orgs begin data submission for applicable measures

All data is due to NCQA by June 15

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IDSS: Data Elements TableOrganizations that submit HEDIS data to NCQA must provide the following data elements.

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HEDIS Compliance Audit

HEDIS 101

HEDIS Compliance Audit

• Data collection and calculation methods can vary across plans.

• A standardized audit methodology for verifying the reliability of HEDIS data collection and rate calculation processes.- It identifies, quantifies and converts errors and reduces bias.

• The audit outcome indicates whether or not a measure is reportable.

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Audit Outcomes

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Is an Audit Required?

Accreditation Yes

Medicare Yes

Quality Compass Yes

Some states Yes

Some purchasers (OPM) Yes

Most Medicaid programs Some

Special projects No

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How HEDIS Measures and Data are Used

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How HEDIS Measures and Data are Used

NCQA AccreditationNCQA Health Plan

RatingsNational Quality

Forum

Health plan operations and quality improvement

State or other regulatory requirements

NCQA Health Plan Ratings

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HEDIS Scoring for Accreditation

• HEDIS scores are worth 50 points– HEDIS measures = 37 points

– CAHPS Ratings/Composites = 13 points

• In general, the points are evenly distributed among the measures

• The following are exceptions and are worth double points– Comprehensive Diabetes Care

– CAHPS Rating of Health Plan

NCQA Health Plan Ratings

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HEDIS Reporting by State42 States Report HEDIS to NCQA and/or Use HEDIS for Other Purposes

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Additional HEDIS Resources

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NCQA Website

Policy Clarification Support

http://my.ncqa.org

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Frequently Asked Questionshttp://faq.ncqa.org/

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Thank you