1 HEDIS ® 101 Kristen Swift, MHA Manager, 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). 2
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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
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.