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Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement

Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement. Presented by: Wendy Talbot, MPH, CHCA Associate Director, Audits. Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement.

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Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement

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  1. Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement Presented by: Wendy Talbot, MPH, CHCA Associate Director, Audits

  2. Analysis of Rates Submitted by HMOs and PSNs Revealed Several Opportunities for Improvement The following observations are intended to inform and serve as recommendations to enable a more efficient and effective method of reporting Performance Measure data

  3. SomePlans Not Included in Reports Several HMOs/PSNs were not included in reports this year for various reasons. They should plan to report valid rates for next year if they meet the reporting criteria.

  4. HMOs • AHF-Positive Healthcare • Preferred Care Partners • Simply Healthcare • United Healthcare-Evercare at Home • PSNs • Access Health Solutions • Integral Quality Care Plans Excluded from Reports

  5. Submission of Wrong Measures One HMO submitted a retired measure (PBH-Persistence of Beta Blocker After Heart Attack)while excluding a current measure (CWP- Pharyngitis- Appropriate Testing Related to Antibiotic Dispensing) for both Reform and Non-Reform populations. While the auditor should have caught that, the plans should both validate the submitted rates, and also ensure the correct measures are being reported.

  6. Specifications for TRT and TRA Measures Inconsistency among plans in calculating eligible populations, denominators and numerators, causing large variances in reported rates

  7. Inaccurate Calculation of Rates For several plans, the reported rates for various measures did not match the rates calculated from numerators and denominators

  8. Inaccurate Calculation of Rates Example 1: For TRT -Transportation Timeliness:Reported rate is 98.82%. However, the rate from numerator and denominator is 1368/1413 = 96.8%, a difference of about two percentage points.

  9. Inaccurate Calculation of Rates Example 2: For FPC- Frequency of Ongoing Prenatal Care: Reported rate is 29.17%. However, the rate from numerator and denominator is 19/72 = 26.4%, a difference of 2.8 percentage points.

  10. NA vs. NB Some plans, particularly for the Annual Dental Visit (ADV) measure, used the designation “NA” (Not Applicable) when the benefit for that measure was not offered to members. In those situations, “NB” (No Benefit) should be used instead

  11. HAART Measure Lack of clarity in specifications regarding exclusions. Some plans reported different denominator value than the eligible population value, indicating either a mistake or an exclusion.

  12. Missing Eligible Population values when <30 For agency-defined measures where denominator is less than 30, eligible population for some plans were not populated in reporting spreadsheet.

  13. Different Eligible Populations for Related Measures Eligible population for CIS Combo 2 and Combo 3 were different. When eligible populations for related measures are different, the data should be validated again to check for data entry errors.

  14. Different Eligible Populations Across Related Measures For Example: Lead Screening in Children (LSC), Childhood Immunization Status (CIS) Combo 2 and (CIS) Combo 3 should have the same eligible population, theoretically.

  15. Same Eligible Populations for Measures that are Mutually Exclusive For Example: FHM-Follow-Up after Hospitalization for Mental Illness (30 day follow up) and RER-Mental Health Readmission Rate eligible populations should not be the same, as the readmission within 30 days is one of the exclusion criteria for FHM-30 days measure.

  16. Sum of Numerators for Sub-measures Greater than Denominator For Example: W15 (Well-Child Visits Within the First 15 Months of Life). One plan’s sub-measures’ numerators, when added together (39), were more than the Denominator (38).

  17. Benefits of giving attention to these issues: Clearer expectations assist HMOs and PSNs to report more accurately. Agency-defined measures can be included in HEDIS Aggregate Report with confidence of completeness and accuracy. Aggregating of data can be more useful for identifying strengths, areas for improvement and trends.

  18. Upcoming Dates • The next HMO/PSN Collaborative PIP call is scheduled for February 13, 2012 • The HEDIS Aggregate report will be finalized on March 2, 2012. • The next Quarterly Meeting (Webinar) will be held during the week of March 26, 2012 • The HMOs/PSNs will receive their FY 11-12 PIP Validation Reports on May 25, 2012 18

  19. Questions? Wendy Talbot, MPH, CHCA Associate Director, Audits 602.801.6846 wtalbot@hsag.com

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