identifying barriers to achieving hedis goals peggy ketterer, rn, bsn, chca health services advisory...
TRANSCRIPT
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!