Identifying Barriers to Achieving HEDIS Goals

Peggy Ketterer, RN, BSN, CHCAHealth Services Advisory Group

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)

Today’s Session

• Discuss data sources for each measure

• Discuss common data collection issues

• Discuss barriers to improving performance

• Discuss best practices/improvement efforts

Ground Rules

• Everyone must say something!! I expect each plan to talk about either one challenge or possible intervention.

• If you don’t speak, I’ll call on you!!!

Lower Performing Measures

• Prenatal Care

• Postpartum Care

• Cervical Cancer Screening

• Dental Visits

• Other measures – based on individual health plan performance

Prenatal Care

Data sources:

• Eligibility

• Claims/encounters

• Medical records

• If available, other internal databases such as a prenatal care program

Prenatal Care

Common data collection issues:

• Global billing

• Resource intensive medical record review

• Others?

Prenatal Care

Barriers to Improving Performance:• Plan doesn’t 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

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

Postpartum Care

Data sources:

• Eligibility

• Claims/encounters

• Medical records

• If available, other internal databases such as a prenatal care program

Postpartum Care

Common data collection issues:

• Global billing – no incentive for physicians to submit separate bill

• Resource intensive medical record review

• Others?

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

Postpartum Care

Best Practices/Improvement Efforts

• Open discussion of potential interventions• Best practice resources

Cervical Cancer Screening

Data sources:

• Eligibility

• Claims/encounters

• Medical records

• Lab vendors

Cervical Cancer Screening

Common data collection issues:

• Capitated reimbursement for lab

• Inaccurate coding by providers

• Resource intensive medical record review

• Others?

Cervical Cancer Screening

Barriers to Improving Performance:

• Members are non-compliant• Other barriers

Cervical Cancer Screening

Best Practices/Improvement Efforts

• Open discussion of potential interventions• Best practice resources

Annual Dental Visits

Data sources:

• Eligibility

• Claims/encounters

• Dental vendors

Annual Dental Visits

Common data collection issues:

• Difficulty obtaining dental visit data from dental care vendors

• Difficulty identifying dental providers/provider type

• Others?

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

Annual Dental Visits

Best Practices/Improvement Efforts

• Open discussion of potential interventions• Best practice resources

Other Measures

• Challenges• Interventions/Improvement Efforts

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

THANK YOU FOR YOUR PARTICIPATION!