The objective of this document is to provide a high level understanding of the Healthcare Effectiveness Data and Information Set (HEDIS), which is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. This document helps in understanding different components of the HEDIS in terms of the measure sets (what it is meant for health plans, changes to the previous year), different methods of collecting data for HEDIS and key requirements for reporting HEDIS
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Enhancing Competitive Advantage through Improved HEDIS Reporting and NCQA Ratings
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16 October, 2017 | Author : Vaibhav Rai| Healthcare Business Analyst
Enhancing Competitive Advantage through
Improved HEDIS Reporting and NCQA Rankings
CitiusTech Thought
Leadership
2. 2
The objective of this document is to provide a high level understanding of the Healthcare
Effectiveness Data and Information Set (HEDIS), which is a tool used by more than 90 percent of
America's health plans to measure performance on important dimensions of care and service
This document helps in understanding different components of the HEDIS in terms of the
measure sets (what it is meant for health plans, changes to the previous year), different methods
of collecting data for HEDIS and key requirements for reporting HEDIS
The process & timeline section helps in understanding key responsibilities of different
stakeholders involved over the time period starting from release of HEDIS measure specs to
posting of HEDIS ratings
The document concludes with the summary of advantages and importance of HEDIS for health
plans in terms of financial, clinical, operational and competitive advantage and also few key
recommendations and best practice for health plans
Objectives
3. 3
Agenda
Components of HEDIS
o HEDIS 2018 Measure Set and Difference from HEDIS 2017
o HEDIS Data Collection Methods
o Audit & Submission Requirements for HEDIS
Process and Timelines of HEDIS 2018
Business Proposition of HEDIS Measures
HEDIS Best Practices and Recommendations
4. 4
Healthcare Effectiveness Data and Information
Set - HEDIS® is the gold standard in healthcare
performance measurement, used by more than
90% of America’ health plans and many leading
employers and regulators on important
dimensions of care and service
HEDIS® is maintained by NCQA, a not-for-profit
organization committed to evaluating and
publicly reporting on the quality of physicians,
HMOs, PPOs and other organizations
Altogether, HEDIS consists of 95 measures across
7 domains of care (updated yearly)
NCQA collects the HEDIS data to compare health
plan performance to other plans and to national
or regional benchmarks
CMS also collects the Medicare HEDIS data in
order to provide HMO services for Medicare
enrollees under Medicare Advantage plan
Overview
Objectives:
Useful for evaluating current
performance and setting goals
Emphasis on physician
collaboration and patient
engagement
Focus on quality outcomes to
help members getting the most
from their benefits and helping
payers for better use of limited
resources
Close gaps in care and improve
overall quality
Stakeholders:
Health Plans
NCQA
5. 5
Components of HEDIS
Measure Set
Every year, NCQA releases a measures list which includes measures which are added, deleted and revised
Later in the year, NCQA releases the measure specification file which includes the details of inclusion /
exclusion criteria for each measure
Data Collection Methods
HEDIS data is collected through surveys, medical charts & insurance claims for hospitalizations, medical office
visits and procedures
Clinical measures use the administrative or hybrid data collection methodology as specified by NCQA
Administrative data are electronic records of services, including insurance claims and registration systems from
hospitals, clinics, medical offices, pharmacies and labs
Hybrid method is more costly, time-consuming and requires nurses or medical record reviewers who are
authorized to review confidential medical records
Reporting (Audit & Submission Requirement)
HEDIS results must be audited by an NCQA-approved auditing firm for public reporting
NCQA collects HEDIS survey results directly from health plans and PPOs through HOQ (Healthcare Organization
Questionnaire), and collects HEDIS non-survey results through IDSS (Interactive Data Submission System)
NCQA's web site (link) includes a summary of HEDIS results by health plan
6. 6
HEDIS 2018 Measures Set
Domains
Effectiveness of Care
Access/Availability of Care
Experience of Care
Utilization & Risk Adjustment
Utilization
Relative Resource Use
Health Plan Descriptive
Information
Measures collected using
Electronic Clinical Data Systems
Each measures specification file includes:-
Summary of Changes, Description, Calculations,
Definitions
Eligible Population Criteria – Includes details like
product line, age, continuous enrollment, allowable
gap, anchor gap, benefit, event/diagnosis which needs
to be considered for including a member in the eligible
population criteria
Administrative Specification - Outlines the collection
and calculation of a measure using only administrative
data, and describes the eligible population, the
numerator requirements and any optional exclusion
allowed for the measure
Hybrid Specification - Includes sampling requirements
for the denominator population, medical record
documentation requirements for the numerator and
any optional exclusion allowed for the measure
Exclusion criteria, Notes, Data Elements for Reporting
HEDIS (2018) consists of total of 95 measures across 7 domains of care
7. 7
Effectiveness of
Care
55 measures
Quality of clinical care
Impact of care delivered
Added 5 new measures - Transition of Care, Follow-Up after Emergency
department visit for people with high-risk multiple chronic conditions, Use
of Opioids at High Dosage, Use of Opioids From Multiple Providers, Medicare
Health Outcomes Survey
Retired 1 measure - Aspirin Use and Discussion
Utilization and
Risk Adjusted
Utilization
15 Measures
Assess how a health plan manages and expends its resources
Experience of
Care
3 measures
Member satisfaction survey
Retired one measure
HEDIS 2018 Measures Set and Difference from HEDIS 2017
8. 8
Health Plan
Descriptive
Information
6 Measures
Plan’s structure, staffing, enrollment characteristics and ability to provide
effective care
Retired one measure on weeks of pregnancy at time of enrollment
Access/
Availability of
Care
6 Measures
Assess how many members use basic plan services
Retired one measure - Call answer timeliness
Added one measure - Use of first-line psychosocial care for children and
adolescents on antipsychotics
Relative Resource
Use
5 Measures
Indicate how intensively health plans use resources
To standardize total cost of care across different clinical areas
Measures
collected Using
Electronic Clinical
Data Systems
HEDIS 2018 Measures Set and Difference from HEDIS 2017
5 Measures
Assess the quality of depression care
This data is challenging to collect through typical HEDIS reporting methods
Added 3 new measures on Depression Screening and follow-up for
Adolescents and Adults, Unhealthy Alcohol Use Screening and Follow-Up,
Pneumococcal Vaccination Coverage for Older Adult
9. 9
HEDIS 2018 Measures Set and Difference from HEDIS 2017
Domains (2018) Description 2018 2017
Effectiveness of Care
Quality of clinical care
Impact of care delivered
55
Retired: 1
Added: 5
51
Retired: 1
Added: 2
Experience of Care Member satisfaction survey
3
Retired: 1
4
Access/Availability of
Care
Assess how many members use basic plan services
6
Retired: 1
Added: 1
6
Retired: 1
Utilizatio
n and
Relative
Resource
Use
Utilization
and Risk
Adjusted
Utilization
Assess how a health plan manages and expends its
resources
15 15
Relative
Resource
Use
Indicate how intensively health plans use resources
To standardize total cost of care across different
clinical areas
5 5
Health Plan Descriptive
Information
Plan’s structure, staffing and enrollment
characteristics and ability to provide effective care
6
Retired: 1
7
Retired: 1
Measures collected using
electronic clinical data
systems
Assess the quality of depression care
This data is challenging to collect through typical
HEDIS reporting methods
5
Added: 3
2
Added: 1
TOTAL 95 91
10. 10
HEDIS Data Collection Methods
Administrative
Method
Claims and encounter data are used to identify the eligible population and numerator.
Most of the measure also allows to use supplemental data along with claims &
encounter data.
Hybrid Method
This method involves drawing of a systematic sample of members from eligible
population & retrieving medical charts from providers for the members who do not
meet the numerator criteria through administrative data.
Survey Method
For survey measures, data is collected directly from the certified survey vendor. Data is
obtained from member & provider survey via the Healthcare Organization
Questionnaire (HOQ).
Electronic Clinical
Data Systems
New initiative from NCQA for health plan quality reporting in HEDIS which expand the
use of electronic data (EHRs, clinical registries, HIEs, administrative claims systems etc.)
to encourage interoperability for quality measurement.
Data Collection Methods
Each measure specifies the data collection method(s) that must be used. If a measure includes both the
Administrative and Hybrid methods, either method may be used.
Supplemental Data Uses
When administrative or medical record data are not available, organizations may use other sources to collect
data about their members and about delivery of health services to their members. Examples include lab result,
pharmacy data, EHR, immunization data, data from provider portals, HIEs and provider abstraction forms.
11. 11
HEDIS Data Collection Methods: Hybrid Method
Medical Record Review
Out of 95 measures, there are 17 measures which can be collected using the hybrid method.
Hybrid method requires organization to draw sample from the eligible population
Out of this 17 Hybrid measures,
• 9 measures have membership-dependent denominators – means the eligible population will
be determined by membership data only
• 8 measures have claim-dependent denominators- means the eligible population will be
determined by membership & claims data
Once the eligible population is determined, sample of 411 or 548, as provided by NCQA needs to
be drawn from that population
Organizations then review the administrative data to determine if members in the systematic
sample meet the numerator criteria or not
For members who do not meet the numerator criteria, medical charts are retrieved from the
providers
Retrieving medical chart is a exhaustive process known as Medical Record Review, organization
needs to identify what charts needs to be retrieved and from which provider they need to be
retrieved
Record update process done through medical charts is known as Abstraction process which is
verified during the audits
12. 12
Audit Requirement for HEDIS (1/2)
Offsite Audit
To promote accurate, reliable and publicly reportable data, NCQA requires health plans to
validate HEDIS data by an independent NCQA Licensed Compliance Audit Organization
Offsite Audit Process
Roadmap completion- responding to the list of questions from audit vendor
Survey Sample frame validation- A Certified Auditor validates the survey sample frame before
drawing the final sample and administers the survey
Core Set Measure selection- Auditor will review all measures not included in the certification
program and any measure that failed certification which will be reported by the organization
Source Code Review- Prepare set of data with known results for validating algorithm
calculation of source code
Medical Record Review (MRR) Validation- Auditor ensure sample is created correctly or it has
passed the measure certification process and MRR data entry or uploading process for adding
MRR data is correct
The organization collects measure data, while the audit team schedules and conducts the following
activities which are part of two step process – Offsite Audit and Onsite Audit.
13. 13
Onsite Audit
A concurrent audit lets the auditor detect errors in the data collection process while there is
time for the organization to correct its methods and minimize the possibility of biased rates
Onsite Audit Process
During the site visit, the auditor
• Conducts interviews, reviews systems, processes and measure-specific-data collection
• Performs queries for specific data flows to validate beginning-to-end accuracy; and
assesses the level of the organization’s data completeness.
The length and content of onsite visits depends on the size and structure of the organization
and the number of delegated vendors or offsite facilities relevant to measure reporting
The team concludes the onsite visit with a closing session, where it shares initial findings
Audit Requirement for HEDIS (2/2)
14. 14
Submission Requirement for HEDIS
HEDIS results (in NCQA defined formats) need to be submitted to NCQA for health plans to receive final rankings
from NCQA and to be included in Quality Compass* for comparative health plan performance analyses
HEDIS non-survey data is submitted through IDSS (Interactive Data Submission System). HEDIS survey results are
retrieved directly from health plans and PPOs through HOQ (Healthcare Organization Questionnaire)
*tool used for selecting a health plan, conducting competitor analysis, examining quality improvement and benchmarking plan performance.
File Type Submitted
to
Description
IDSS file XML NCQA
Consolidated XML file including results for each measure
Health plan needs to submit separate XML files for each
product line (Commercial/Medicaid/Medicare/Marketplace)
NCQA Patient-
Level-Detail
(PLD) file
Fixed-width
text file
HEDIS
Compliance
Auditor
Patient level data including details for each measure
(applicable/not applicable, compliant/not compliant)
Health Plan need to submit separate PLD files for each product
line (Commercial/Medicaid/Medicare/Marketplace)
It is a method of validating that the counts of individual
members match the measure totals in the Interactive Data
Submission System (IDSS)
CMS PLD file
Fixed-width
text file
CMS
CMS Plan All-
Cause
Readmissions
(PCR) file
Fixed-width
text file CMS
Apart from submitting PLD files to CMS mentioned above,
health plans also need to collect ‘Plan All-Cause Readmissions
(PCR)’ measure result as a separate file and should be
submitted in the same manner as PLD files
File Formats for Submission
15. 15
Process and Timelines of HEDIS 2018
Jul ’17
Oct ’17
Nov ’17
Dec ’17
Jan ’18
Feb ’18
Apr ’18
May ’18
Jun ’18
Aug ’18
Sep ’18
Oct ’18
Release of
technical
specifications
Start of
measure
cert.
testing
Certification
of survey
sample frame,
hybrid
measures and
sampling
methodology
Posting of
XML
templates,
validations
and data
dictionaries
Release of
2018 HOQ
Submission
of final
HOQ for
IDSS access
Release of 2018 IDSS for
loading and validation
Distribution of survey
measure submission IDs
Provision of
preliminary
rates (XML
format) to
Payer
Submission of
member level
data
Demonstration of
XML file
uploading
Sending of plan
confirmation via
HOQ
Confirmation on
State, enrollment
and accreditation
info.
Confirmation
on rating and
accreditation
info.
Sending of projected
ratings
Legend
Activity –
NCQA
Activity –
HealthPlan
Activity –
HEDIS
Vendor
Drawing of
samples (for
hybrid measures)
Availability of CAHPS
survey results
Submission of final
HEDIS results
Freeze on ratings
data
Posting of
final health
plan ratings
Provision of
supplemental data
impact reports
and final XML files
to Payer
16. 16
Business Proposition of HEDIS Measures
Guide P4P Measures
Part of CMS Star which can
impact health plans revenue
by up to 5% for Quality Bonus
Payments and up to 70% as
part of rebates of difference in
plan bid and benchmark
Part of NCQA accreditation;
the industry’s gold standard
Ensures effectiveness of care
Improved clinical and quality
outcomes
Ensures health plans are
offering quality preventive
care and service to members
Increased insight on patient
disease, comorbidity and care
management
Financial & Clinical
Ensures availability of care
Focus on processes of care
and are directly actionable
for quality improvement
activities
Patient feedback is turned
into actionable intelligence
Enhanced care
coordination
Improvement in resource
utilization
Actionable intelligence to
improve operational
performance
Operational
NCQA ratings published on
consumer reports
Gateway to health
Insurance Marketplace
Allows plan-to-plan
comparisons by quality,
national & regional
benchmarks apart from
price (Quality Compass)
Can qualify plans to
provide HMO services to
MA enrolees
Centrepiece of most health
plan "report cards"
Higher member retention
Competitive
Advantage
17. 17
HEDIS Best Practices and Recommendations (1/2)
Readiness
Evaluate previous season performance for key areas of improvement
before starting for new season
Keep track of annual changes to HEDIS measurement, timelines &
reporting requirements
Process
Improvement
Reduce burden of provider by efficient & intelligent chart chasing –
analyzing provider chart submission pattern, configurable intelligence to
chase provider with highest likelihood of success, avoiding duplicating
request
Identify claims submitted without proper ICD or CPT codes that count
towards the measure
Data
Completeness
Have better relationships with provider network to ensure timely
acquisition of electronic data resulting in more efficient data acquiring
than manual chart review
Invest in data: Enrich data lake by adding more layers of data by capturing
data from different sources (EHR, Lab, Provider Portals, HIEs)
18. 18
HEDIS Best Practices and Recommendations
Technology
Enable continuous monitoring of quality results – real-time actionable
information, target measures with the greatest impact by leveraging a
modern CQM engine
Introduce technology enabled engagement programs focused on members
mobile lifestyle
Focus on workflow-driven technology solution investments reusable
across other areas, e.g., chart chase solutions that span across HEDIS, HCC
improvement, pended claims etc.
Right
Workforce
Information sharing between all teams is most important for teams to
work efficiently
Chart retrieval & abstraction teams should be well trained in prioritization
of outreach as well as interpreting charts to make sure to capture accurate
chart information
Focusing on the above parameters can easily help any health plan tackle the key challenges
faced in HEDIS improvement like managing different interconnected teams, inefficient chart
chasing, quality tracking etc.
19. 19
References
Summary of Table of Measures, Product Lines and Changes
http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2018/HEDIS%202018%20Measures.pdf?ver=20
17-06-28-134644-370
HEDIS Measures for Accreditation Scoring in 2018
https://www.ncqa.org/Portals/0/Policy%20Updates/Corrections/2018/HEDISMeasuresandPoints
forReportingYear%202018.pdf?ver=2017-05-15-204422-673
Measure Specs
http://store.ncqa.org/index.php/catalog/product/view/id/2816/s/hedis-2018-volume-2-hard-
copy/
Health Insurance Plan Rankings
http://healthinsuranceratings.ncqa.org/2016/Default.aspx
Accreditation Levels
https://reportcards.ncqa.org/#/health-plans/list
Ratings 2017
https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/Ratings2016FAQs_
Final_3.17.16.pdf?ver=2016-03-21-160657-990
http://www2.citiustech.com/NCQA-HEDIS-2017-Volume-5
20. 20
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Author:
Vaibhav Rai
Healthcare Business Analyst
thoughtleaders@citiustech.com
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