HEDIS

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HEDIS
P0418 (10/09)

• HEDIS requirements for Anthem, MDwise and
  Managed Health Services
• A Combined Managed Care PresentationOctober
  20-22, 2009
• HEDIS is a registered trademark of the National
  Committee for Quality Assurance

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Agenda

• Introduction of Managed Care Representatives
• What is HEDIS
• HEDIS Measures
• Data Reporting
• Chart Reviews
• HEDIS Barriers
• Missed Opportunities Flyer
• Presumptive Eligibility and NOP
• Anthem
• Managed Health Services
• MDwise
• Questions Answers
• Drawing

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HEDIS Overview

• What is HEDIS?
• HEDIS Healthcare Effectiveness Data and
  Information Set
• National Committee for Quality Assurance (NCQA)
  uses these performance measures for commercial,
  Medicare, and Medicaid.
• HEDIS is the most used set of performance
  measures in the Managed Care industry, developed
  and maintained by NCQA.

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HEDIS Overview

• Majority of HEDIS is measures from administrative
  results-claims, but some of the measures are
  pulled from hybrid results-medical record review.
• Administrative data is calculated by a claim or
  an encounter submitted to the health plan.
• Hybrid reviews are a random sample of member
  medical records. Hybrid data can consist of
  administrative data and a sample of medical
  record data.
• Annual State mandated quality improvement
  initiative required of all Managed Care Health
  plans.
• Retrospective review of medical care and services
  from the prior year.

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HEDIS Overview

• Results from the HEDIS data collection serve as
  measurements for quality improvement processes
  and preventive health programs.
• HEDIS rates are used to evaluate the
  effectiveness of a health plans ability to
  demonstrate an improvement in preventive health
  outreach to its members.

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HEDIS Overview

• Data is reported to NCQA in June of the reporting
  year.
• Data reflects events that occurred during the
  measurement year (calendar year).
• Example
• HEDIS 2009 data is reported in June 2009.
• Data reflects events that occurred in January
  December 2008 (per specs)
• HEDIS 2009 2008 data

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HEDIS Overview

• Denominator Eligible members of the population.
• Numerator Members that meet the criteria of the
  measure.
• Anchor Date The specific date the member is
  required to be enrolled to be eligible for the
  measure.
• Continuous Enrollment The minimum amount of
  time a member must be enrolled to be eligible for
  a measure.
• Provider Specialty Certain measures must be
  performed by a specified provider specialty.

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HEDIS Score Barriers

• Claims not submitted due to members that have
  third party liability.
• Members that are assigned to the wrong Primary
  Medical Provider.
• Claims are submitted without the appropriate
  diagnosis or CPT codes that will count towards
  the measures.
• The provider specialty does not count towards the
  measure.
• The member is not continuously enrolled.
• The services are not all documented in the
  members medical chart.
• All components of the required measure were not
  provided.
• New member and previous medical records are not
  obtained or transferred when a member changes
  PMPs.
• Appointment availability when a member tries to
  schedule preventive services.
• Appointment availability for new members on the
  PMP panel.

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HEDIS Measures Hybrid Review

• Cervical Cancer Screening CCS
• Women 24 64 years of age who had a pap smear
  during the measurement year or the two years
  prior to the measurement year or have
  documentation of a hysterectomy. The claim must
  have the appropriate coding and with the
  appropriate provider specialty to count toward
  the measure.
• OMPP Incentive Measure

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HEDIS Measures Hybrid Review

• Comprehensive Diabetes Care CDC
• Members 18 75 of the measurement year who
  received an LDL C screening, and care of
  diabetes during the measurement year. The claim
  must have the appropriate coding to count toward
  the measure.
• Required testing and documentation
• Hemoglobin A1c (Test and Result)
• LDL C Lipid screening (Test and Result)
• Retinal Exam (Dilated eye exam/Retinopathy)
• Urine screening (ACE or ARB medication therapy)
  (attention to Nephropathy)
• Blood Pressure Documented (lt130/80) (lt140/90)
• OMPP Incentive Measure

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HEDIS Measures Hybrid Review

• Well Child Visits in the First 15 Months of
  Life W15
• Members 0 15 months of age must receive 6 or
  more well child visits with a PMP that document
  in the medical record the following
• health and developmental history (physical and
  mental) i.e. developmental questionnaires
  regarding sleep habits, feeding, motor skills,
  teething, interaction with others, walks alone,
  teething/chewing objects, and PCP observation.
• a physical exam i.e. general appearance, height,
  weight, heart, lungs, abdomen, head
  circumference, deformities, reflexes present,
  fontanels, and alertness.
• health education/anticipatory guidance i.e.
  injury prevention, circumcision care, thermometer
  use, choking prevention, bathing, car seat use,
  temper tantrums, and lead poisoning.
• The claim must have the appropriate coding and
  submitted with the appropriate provider specialty
  to count towards the measure.
• OMPP Incentive Measure

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HEDIS Measures Hybrid Review
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HEDIS Measures Hybrid Review

• Well Child Visits in the Third, Fourth, Fifth
  and Sixth Years of Life W34
• Members 36 years of age in the measurement year
  must receive one well child visit with a PMP
  each year that documents in the medical record
  the following
• health and developmental history (physical and
  mental) i.e. developmental milestones,
  disposition, communication with others,
  vocabulary, independence with dressing, and
  toileting.
• a physical exam i.e. general appearance, height,
  weight, heart, lung, abdomen, BMI percentile,
  vision, hearing, abuse/neglect, eyes/strabismus,
  and alertness.
• health education/anticipatory guidance i.e.
  balance meals with snacks, limit sweets, caution
  with strangers, second hand smoke, childcare
  planning, bed time, friends, and limit setting.
• The claim must have the appropriate coding and
  submitted with the appropriate provider specialty
  to count towards the measure.
• OMPP Incentive Measure

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HEDIS Measures Hybrid Review
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HEDIS Measures Hybrid Review

• Adolescent Well Care Visits AWC
• Members 12 21 years of age in the measurement
  year must receive one well child visits with a
  PMP that document in the medical record the
  following (school physical, preventive care
  visits with a Pap, or post partum visit)
• health and developmental history (physical and
  mental) i.e. developmental questionnaires
  regarding social and emotional development,
  school progress, physical activity, depression,
  menarche, and peer relationships.
• a physical exam i.e. general appearance, height,
  weight, heart. Lung, abdomen, tanner stage, BMI,
  head eyes, heart, lungs, acne, and pap smears.
• health education/anticipatory guidance i.e.
  balanced meals, sex education, safety, smoking,
  drug and ETOH avoidance, regular exercise, breast
  self exams, seat belt use, suicidal ideation, and
  partner selection.
• The claim must have the appropriate coding and
  submitted with the appropriate provider specialty
  to count towards the measure.
• OMPP Incentive Measure

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HEDIS Measures Hybrid Review
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HEDIS Measures Missed Opportunities

• A member comes in for a problem focused or sick
  visit and per the HEDIS measure is in need of
  preventive services well child visit,
  immunizations, or a screening, and these services
  were not provided at the visit.
• A member was in the office for a postpartum visit
  and per the HEDIS measure is in need of a pap and
  the service was not provided at the visit.

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HEDIS Measures Missed Opportunities
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HEDIS Measures Hybrid Review

• Childhood Immunization and Lead Screenings CIS
  and LSC
• The health plan is looking for all childhood
  immunizations and lead screenings to be completed
  on or before the childs second birthday.

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HEDIS Measures Hybrid Review

• Immunizations for Adolescents IMA
• The health plan is looking for a percentage of
  adolescents 13 years of age who had the following
  by their 13th birthday
• one dose of meningococcal vaccine given on or
  between the 11th and 13th birthday AND
• one tetanus, diphtheria toxoids, and acellular
  pertussis vaccine (Tdap) given on or between the
  10th and 13th birthday OR
• one tetanus, diphtheria toxoids vaccine (Td)
  given on or between the 10th and 13th birthday.

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HEDIS Measures Hybrid Review

• Controlling Blood Pressure CBP
• Members 18 85 years old with a diagnosis of
  Hypertension (High Blood Pressure) on or before
  June 30th of the measurement year.
• Latest documented blood pressure during
  measurement year control of 140/90.
• The following information is pulled problem list
  and progress notes.
• If the member is pregnant during the measurement
  year, the member is excluded for the measure.

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HEDIS Measures Hybrid Review

• Cholesterol Management for Patients with
  Cardiovascular Conditions CMC
• Members 18 75 who were diagnosed with
  Myocardial Infarction, Coronary Bypass Graft,
  Coronary Angioplasty, Ischemic Vascular Disease
• Documentation of LDL drawn and LDL control lt 100

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HEDIS Measures Hybrid Review

• Body Mass Index BMI
• BMI is a screening tool for obesity that will
  assist in determining BMI for Age Percentiles
• Documentation for BMI percentiles for children
  lt16 years old and BMI value for children gt16
  years old.
• Documentation of Educational materials,
  Nutritional Counseling, Activity plans and
  education.

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HEDIS Measures Hybrid Review

• Adult BMI Assessment ABA
• The percentage of members 18-74 years of age who
  had an outpatient visit and who had their body
  mass index (BMI) documented during the
  measurement year or the year prior to the
  measurement year.

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HEDIS Measures Hybrid Review

• Weight Assessment and Counseling Children and
  Adolescents WCC
• There are 3 required components of this measure
• Age 3 17 years old.
• BMI percentile or percentile graph must be
  documented on all children less than 16 years
  old, BMI value for over 16 years old will be
  accepted.
• Counseling and Nutrition in the form of
  discussion on diet, anticipatory guidance for
  nutrition, or counseling on nutrition.
• Counseling for Activity in the form of discussion
  of current physical activities, counseling for
  increasing activity, or anticipatory guidance on
  activity.

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HEDIS Measures Hybrid Review

• Frequency of Ongoing Prenatal Care FPC
• Members who delivered a live birth on or between
  November 6 of prior year to November 5 of
  measurement year and were continuously enrolled
  42 days prior to delivery.
• Documentation of all prenatal visits.
• 81 percent of expected visits.
• OMPP Bonus Measure

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HEDIS Measures Hybrid Review

• Prenatal and Postpartum Care PPC
• Members who had a live birth in the measurement
  year who had their first prenatal visit within 42
  days of enrollment or during the first trimester.
• Postpartum Care
• Members who had their postpartum visit on or
  within 21 56 days of delivery.
• The claims must have the appropriate coding and
  submitted with the appropriate provider specialty
  to count towards these measures.
• OMPP Bonus Measure

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Presumptive Eligibility and Prenatal Measures

• For a limited time, a pregnant woman who has been
  determined by a Qualified Provider (QP) to be
  presumptively eligible may receive ambulatory
  prenatal services while her Hoosier Healthwise
  application is being processed.
• The Package is known as Package P.
• OMPP and the MCOs worked jointly to develop a
  universal assessment for pregnant women known as
  the Notification of Pregnancy (NOP) to do the
  following
• Identify health risk factors
• Monitor risk factors
• Increase the percentage of pregnant women
  assessed during the first trimester
• Increase average birth weights
• Reduce smoking rates
• Reduce the number of pre term deliveries

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Presumptive Eligibility and Prenatal Measures

• Providers are reimbursed 60 for submission of
  valid NOP.
• Reimbursement is limited to one form per
  pregnancy.
• A valid NOP must be submitted within 5 calendar
  days via the Web interChange.
• The pregnant member gestation must be LESS than
  30 weeks gestation for NOP reimbursement.

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HEDIS Measures

• Follow up Care for Children Prescribed ADHD
  Medication ADD
• Members 6 12 years of age who receive a new
  prescription for an ADHD medication (had a
  negative ADHD medication history for 120 days
  prior) must receive a follow up visit with a
  practitioner with prescribing authority during
  the 30 day initiation Phase.
• OMPP Incentive Measure

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HEDIS Measures

• Follow up After Hospitalization for Mental
  Illness FUH
• Members 6 years of age and older as of the date
  of discharge from an acute inpatient stay must
  receive an outpatient visit with a mental health
  practitioner within 7 days after the discharge.
• OMPP Incentive Measure

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Quiz

• What does HEDIS stand for?
• What are 5 of the OMPP bonus measures?
• What are 3 barriers that cause services not to
  count toward HEDIS measures?

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MCO HEDIS Interventions
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Anthem

• HEDIS Summit conducted in January 2009.
  Successfully disseminated knowledge on all
  aspects of HEDIS, identified critical elements
  and best practices to improve HEDIS performance
• Successfully developed three HEDIS workgroups-
  member, provider, and data, focusing on
  strategies and building on existing programs.

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Anthem

• Provider focused strategies
• Aligned the Physician bonus program with the
  States P4P Program including OB providers.
• Working on providing real time HEDIS data to
  physicians through ManagedCare.com.
• Developed a plan to deliver members with gaps in
  care reports to providers in person, by mail, or
  by fax, and assisting with tracking mechanisms
  for preventive/well care appointments to capture
  missed opportunities
• Incorporating age appropriate forms into current
  practice guidelines

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Anthem

• Provider focused strategies
• Developed provider tool-Kits containing
  educational required materials, forms, and
  preventive care codes, to assist network
  physicians in utilizing best practices from
  around the country in order to improve care to
  members thus improving HEDIS performance.
• CRC field staff are receiving training to assist
  physicians and their office staff to access and
  utilize the ManagedCare.com reports.
• Developing provider trainings via webinar and
  face to face contact meetings
• Providing medical records feedback from current
  year HEDIS abstractions

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Anthem

• Member focused strategies
• Clinical Quality Health Services Team implemented
  member interventions for all incentive measures
  and several NCQA accreditation measures
• Outreach efforts include automated calls,
  mailings and home visits to members.
• For select measures such as ADHD and diabetes
  measures, the call center staff make appointments
  for members and ensures transportation to their
  appointment.

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Anthem

• Member focused strategies
• Data driven member interventions will be
  implemented using real time HEDIS reports.
• Implemented incentives for timely prenatal and
  postpartum visits.
• Developing marketing strategies to promote
  preventive visits/medical home
• Working with Indiana WIC to design the cover
  sleeve for the WIC checks to include information
  about the importance of preventive visits and
  keeping members contact information current with
  the State (so we can find our members).

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Anthem

• Member focused strategies
• CRC ER initiative capturing members seen in the
  ER with follow up phone calls and education
  toward true ER
• Member focus toward promoting Medical Home and
  importance of annual well care visits with
  unlimited transportation services to get members
  to those appointments

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Anthem

• Data focused strategies
• Accurate and periodic monitoring of HEDIS
  performance of Anthem, network physicians, and
  physician groups through ManagedCare.com.
• Develop reports of members with gaps in care to
  assist with member and provider interventions.
• Evaluate the effectiveness of member and
  physician interventions to identify best
  practices.

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Anthem

• Healthy Habits Count for You and Your Baby
  Prenatal Program Anthem
• The Healthy Habits Count for You and Your Baby
  Program, hereafter referred to as the prenatal
  program, provides members with a comprehensive
  program of prenatal and postpartum care. The
  program is designed to identify members who are
  pregnant, encourage early and on-going prenatal
  and postpartum care and provide case management
  for members with high-risk pregnancies while
  increasing members access to prenatal care.

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Anthem

• Healthy Habits Count for You and Your Baby
  Prenatal Program Anthem
• Key components
• Prenatal member education booklet
• Case management when appropriate
• Access to free prenatal care (first 30 weeks of
  gestation) and related health education
• Gifts for timely prenatal and postpartum care
• Referrals for social services including crib
  program
• Breastfeeding support line

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Anthem

• Healthy Habits Count for You with Asthma Asthma
  Education Anthem
• Analysis of Anthem claims prevalence report
  reveals that asthma ranks among the top
  diagnoses. Given the high rate of members with
  asthma, the Anthem Healthy Habits Count with
  Asthma (HHCA) program is designed as a
  multifaceted program encompassing health
  education, member outreach, case management and
  physician clinical support.
• Anthem collaborates with plan physicians and
  pharmacies to promote the diagnosis, treatment
  and management of asthma according to the most
  current asthma clinical practice guidelines set
  forth by the National Heart, Lung, and Blood
  Institute (NHLBI). The HHCA member and provider
  interventions were developed in accordance with
  the NHLBI asthma recommendations for asthma
  treatment and management.

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Anthem

• Key components
• Member stratification into 3 risk levels low,
  medium high based on hospitalization and use of
  quick relief meds
• Condition monitoring
• Patient adherence
• Consideration of other health conditions
• Lifestyle issues
• Asthma member education booklet which includes
  asthma action plan and peak flow meter monitoring

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Anthem

• Childhood Obesity Program Office Toolkit for
  Providers
• In response to the increasing prevalence of
  childhood obesity, Anthem is facilitating
  standard screening for obesity and encouraging
  children and their families to eat healthy and be
  physically active. The 2009 Childhood Obesity
  Office Toolkit is designed to support a
  physicians office in providing care around
  healthy weight, nutrition, and physical activity.

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Anthem

• Childhood Obesity Program Office Toolkit for
  Providers
• Key components in the toolkit include
• Get Up and Get Moving Family Activity Book
• Body Mass Index (BMI) brochure for parents
• AAFP Childhood Obesity CME Bulletin
• Online BMI training for clinical staff
• Anthem Blue Cross and Blue Shield BMI wheel
• CDC BMI growth chart for age and sex
• Providers Family Counseling Guide to address
  childhood obesity

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Managed Health Services - HEDIS Initiatives

• OMPP NCQA Focused Performance Measures
• Educational Material MHS has developed and
  issued education material such as HEDIS Quick
  Reference Guide and Healthwatch (EPSDT) chart
  tool
• Provider Education Session HEDIS Education
  sessions offered throughout The State to assist
  our provider network in education regarding what
  is needed to achieve goals .
• Scorecard Mailing - Quarterly scorecard
  information to PMP network. Provides a snapshot
  of current metrics and listing of members
  identified as not receiving service to date and
  aid in patient outreach
• Billing/Claims assistance MHS team providing
  one on one education sessions with office to
  provide instruction on appropriate EPSDT and
  HEDIS billing procedures.
• Member Outreach Outreach calls and mailings
  issued to members identified as in need of
  services. Connections team available to assist
  provider with member contact.

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Managed Health Services - HEDIS Initiatives

• Preventative Health Action Committee Multi
  departmental workgroup set up to identify and
  develop clinical quality improvement activities
  encompassing HEDIS and Benchmark measures for
  appropriate delivery and management of healthcare
  interventions. Current initiatives include
• Smoking Cessation Intervention
• Chlamydia Screen
• Quarterly Health Initiative Focus (Women,
  Children, Respiratory and Diabetic Health)
• Educational Update/Material

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Managed Health Services - HEDIS Initiatives

• Member Outreach Programs
• Connections Takes the plan to the member to
  promote preventative health
• Birthday Postcards Postcards sent to members in
  need of well services two months before their
  birthday
• Preventative Reminder Calls Outreach calls to
  members in need of select preventative service
  reminding importance

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Managed Health Services - HEDIS Initiatives

• Coordinated Care Programs
• Start Smart For Your Baby
• Asthma
• Diabetes
• Lead
• Emergency Department Diversion

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Managed Health Services - HEDIS Initiatives

• Health Check Health Day MHS coordinated
  outreach event. MHS will do for you
• Encourages specialty type screenings for age-,
  gender- and disease state-specific members.
• Create and mail letter of invitation to targeted
  members.
• Call members to schedule appointment, arrange
  transportation and provide follow-up reminder
  calls.
• Provide specific billing details to ensure
  screening credit is received.
• Complete a scheduling form (dictated by you) and
  send (via fax) updates as new/changed/ canceled
  appointments arise
• Have a team on site to promote health messages,
  provide health-related giveaways and answer
  questions about MHS

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Managed Health Services - HEDIS Initiatives

• Health Incentive Program
• CentAccount Healthy Rewards program gives
  members a monetary incentive through a flexible
  spending account for completing annual well
  visits and health screenings.
• CentAccount MasterCard accepted at participating
  groceries and pharmacies, and is restricted to
  the purchase of health-related items, such as
  over-the-counter medicine. Can also be used at
  www.diapers.com to purchase items such as diapers
  and bottles,

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MDwise HEDIS

• MDwise developed a Network Improvement Program
  (NIP) Team to focus on the following
• OMPP Key Performance Measures.
• Analyze provider data and work on opportunities
  for improvement in the provider community.
• Work with the Quality Improvement Team to review
  medical records.
• Work with Provider Relations to conduct seminars
  and training opportunities.

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MDwise - HEDIS

• MDwise will provide the following to provider
  offices
• Group Comparison reports for providers produced
  from data out of ManagedCare.com
• Opportunity Reports
• Educational Tools
• Updates on the Web site
• 2009 Key HEDIS Measures Poster
• Well Child First Campaign/Mini Poster
• Utilization Reports

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MDwise - HEDIS

• The Network Improvement Program (NIP) Team will
  be conducting provider onsite visits to discuss
  HEDIS and Key Performance measures in short
  training sessions.
• Training Session can consist of the following
• Reports
• Educational Tools
• Forms and Documentation Guidelines
• Best Practices
• Provider Resources

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MDwise Educational Opportunities

• To ensure quality of care is provided to MDwise
  Hoosier Healthwise members.
• Assist Providers in gaining knowledge in the
  following
• HEDIS measures and requirements
• Components of each measure
• Forms and tools
• Opportunities for improvement
• Meet performance measure standards for the State
  and NCQA

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MDwise Member Outreach

• Newborn letters with well child visit schedule.
• Newborn list to each Delivery System.
• NURSE on call post card that focuses on well
  child care and womens screenings including
  mammograms .
• Member eligible lists to PMPs at each Delivery
  System.
• Education and weekly report of members with new
  ADHD scripts to PMPs.
• Outreach calls to parents of members with new
  ADHD scripts to schedule a follow up appointment
  within 30 days.

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MDwise Member Outreach

• Case Management follow up and education on the
  need for follow up after Hospitalization for
  Mental Illness.
• Education on the LDL measure to members and
  providers.
• Member and Provider Newsletters.
• ProviderLink (provider newsletter)
• Steps to Wellness (member newsletter)
• BLUEBELLEbeginnings program for Pregnant members.
• Member Services provides outreach calls to
  schedule post partum visits with members.

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MDwise Programs

• NURSEon-call Speak with a nurse 24 hours a day.
• RIDEwise MDwise members get free rides to and
  from doctor visits.
• WEIGHTwise Offers support to members who want to
  lose, gain, or stay at a healthy weight.
• TEENconnect Helps pre teens and teenagers get
  more involved in their health care.
• WELLNESSchats These are educational events.
  They take place in your community and are hosted
  by MDwise.

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MDwise Programs

• HELPlink Work with a member advocate who knows
  about health, school, and community services.
• SMOKE-free Get help kicking the tobacco habit.
• MS.BLUEBELLES club for kids Our kids club
  offers special activities and mailings that teach
  kids to make healthy choices.

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MDwise Programs

• BLUEBELLEbeginnings MDwise wants to improve
  birth outcomes. MDwise pregnant Members can call
  to join the program. MDwise representatives
  conduct a prenatal assessment and help the mom
  pick a doctor for her baby. It is very important
  for Hoosier Healthwise members to pick a doctor
  for their baby BEFORE the baby is born. MDwise
  will send out important information to the member
  about the pregnancy, being a parent, and a free
  gift for the baby.
• INcontrol This program provides information and
  education about chronic illness. Members learn
  to manage asthma, diabetes, or other chronic
  illness.

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Well Child First
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2009 Key HEDIS Measures
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HEDIS Questions and Answers
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Drawing