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Overview of 2007 Performance Measure Validation Findings and HEDIS Results

Overview of 2007 Performance Measure Validation Findings and HEDIS Results. Presented by: Wendy Talbot, MPH, CHCA January 16, 2008. Presentation Overview. Performance Measure Validation a. Process b. Findings and Recommendations c. Questions HEDIS Results

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Overview of 2007 Performance Measure Validation Findings and HEDIS Results

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  1. Overview of 2007 Performance Measure Validation Findings and HEDIS Results Presented by: Wendy Talbot, MPH, CHCA January 16, 2008

  2. Presentation Overview • Performance Measure Validation a. Process b. Findings and Recommendations c. Questions • HEDIS Results • Results and Recommendations by Dimension of Care • 2008 HEDIS Changes • Questions

  3. Performance Measure Validation Objectives • Evaluate accuracy of data collected • Determine the extent to which each measure calculated followed established specifications • Utilize process consistent with CMS protocol

  4. Validation Activities • NCQA-licensed audit organization • Pre-on-site call/meeting • BAT review • AHCA-specific measure set validation • Source code/certified software review • Primary source review • Convenience sample validation (if applicable) • Medical Record Review • Health Plan Quality Indicator Data File Review

  5. Validation Activities Findings • Used a certified software vendor: • 10 out of 12 HMOs • Convenience sample validation: • 4 HMOs had a convenience sample • 3 HMOs were exempt • Was not specified in final audit report whether one was required or performed for 5 HMOs • Medical record review validation • 11 HMOs • 1 HMO did not use the hybrid method • All other validation activities were fulfilled

  6. Audit Findings • R = Report • Reportable rate or numeric result for HEDIS measures • NA = Not Applicable • The HMO followed the specifications but the denominator was too small to report a valid rate (<30) • NB = No Benefit • The HMO did not offer the health benefits required by the measure • NR = Not Report • The HMO calculated the measure but the rate was materially biased or the HMO chose not to report the measure

  7. Audit Findings • Breast Cancer Screening • 42-51 Years • R = 10 HMOs • NA = 2 HMOs • 52-69 Years • R = 10 HMOs • NA = 2 HMOs • Combined • R = 10 HMOs • NA = 2 HMOs • Timeliness of Prenatal Care • R = 11 HMOs • NR = 1 HMO

  8. Audit Findings • Cervical Cancer Screening • R = 12 HMOs • Chlamydia Screening • 16-20 Years • R = 11 HMOs • NA = 1 HMO • 21-25 Years • R = 11 HMOs • NA = 1 HMO • Combined • R = 12 HMOs

  9. Audit Findings • Appropriate Medications for People with Asthma • 5-9 Years • R = 9 HMOs • NA = 3 HMOs • 10-17 Years • R = 8 HMOs • NA = 4 HMOs • 18-56 Years • R = 8 HMOs • NA = 4 HMOs • Combined • R = 10 HMOs • NA = 2 HMOs

  10. Audit Findings • Comprehensive Diabetes Care • LDL-C Screening • R = 10 HMOs • NA = 2 HMOs • LDL-C Testing • R = 10 HMOs • NA = 2 HMOs • Eye Exams • R = 9 HMOs • NA = 2 HMOs • NR = 1 HMO • Nephropathy • R = 10 HMOs • NA = 2 HMOs

  11. Audit Findings • Controlling High Blood Pressure • 18-45 Years • R = 7 HMOs • NA = 1 HMO • NR = 4 HMOs • 46-85 Years • R = 7 HMOs • NA = 1 HMO • NR = 4 HMOs • Combined • R = 7 HMOs • NA = 1 HMO • NR = 4 HMOs

  12. IS Standards • IS 1.0—Sound Coding Methods for Medical Data • IS 2.0—Data Capture, Transfer, & Entry—Medical Data • IS 3.0—Data Capture, Transfer, and Entry—Membership Data • IS 4.0—Data Capture, Transfer, and Entry—Practitioner Data • IS 5.0—Data Integration Required to Meet the Demands of Accurate HEDIS Reporting • IS 6.0—Control Procedures that Support HEDIS Reporting Integrity

  13. IS 1.0—Sound Coding Methods for Medical DataFindings IS 1.0 Issues – Two HMOs received a substantially compliant on this standard because they were not capturing CPT II codes and internal audits of claims examiners was not sufficient. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  14. IS 2.0—Data Capture, Transfer, & Entry—Medical DataFindings IS 2.0 Issues – Three HMOs received a substantially compliant on this standard due to issues with data entry processes and data transmissions. Two HMOs received a not report for this standard due to problems identified with their medical record process. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  15. IS 3.0—Data Capture, Transfer, and Entry—Membership DataFindings IS 3.0 Issues – One HMO received a substantially compliant on this standard because there were no policies and procedures in place for receiving Medicaid enrollment files. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  16. IS 4.0—Data Capture, Transfer, and Entry—Practitioner DataFindings IS 4.0 Issues - No issues, all HMOs were fully compliant with this standard. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  17. IS 5.0—Data Integration Required to Meet the Demands of Accurate HEDIS Reporting Findings IS 5.0 Issues - No issues, all HMOs were fully compliant with this standard. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  18. IS 6.0—Control Procedures that Support HEDIS Reporting IntegrityFindings IS 6.0 Issues – One HMO received a substantially compliant on this standard because NCQA specifications were not followed for sample size production and over-sample percentages. FC=Fully Compliant SC=Substantially Compliant NR=Not Report

  19. Recommendations—HMOs • Monitor all vendors who are contracted to work with data; specifically medical record vendors • Develop and implement policies and procedure for data entry validation, regardless of the amount of manual data entry performed • Develop procedures to ensure all data files are consistent and accurate

  20. Recommendations—AHCA • Require a predetermined file layout for submitting data • Consider using the NCQA IDSS data submission tool • Have HMOs submit Final Audit reports and Audit Designation reports to AHCA as soon as they receive them to eliminate confusion in the reporting process • Have auditors validate the actual data files being submitted to AHCA

  21. QUESTIONS?

  22. Florida Medicaid HEDIS 2007 Results

  23. Dimensions of Care • Women’s Care • Living with Illness

  24. Analytics Comparative • Florida 2007 weighted average compared to the national 2006 Medicaid 50th percentile • Florida 2007 weighted averages compared to Florida 2006 weighted averages (when applicable) Distribution • Range of MHP reported rates

  25. 100% Highest Rate 90% High 80% Outlier FL Weighted 70% Low Average 60% Outlier 50% 40% Lowest Rate 30% 20% 10% 0% Measure 1 Measure 2 Highest Plan Rate Weighted Average Lowest Plan Rate Distribution Graphs

  26. Florida 2007 Results Compared to National Benchmarks

  27. Women’s Care

  28. Women’s Care • 2007 Measures • Breast Cancer Screening • Ages 42-51 Years • Ages 52-69 Years • Combined • Cervical Cancer Screening • Chlamydia Screening • Ages 16-20 Years • Ages 21-25 Years • Combined • Prenatal and Postpartum Care • Timeliness of Prenatal Care

  29. Women’s Care • In 2006, only Breast Cancer Screening and Chlamydia Screening were reported by the HMOs. • Starting in 2007: • Breast Cancer Screening measure was reported in three cohorts and the lower age limit was raised to 40 years of age • The lower age limit for Cervical Cancer Screening was raised to 21 years of age

  30. Women’s Care Overall performance for the Women’s Care dimension continued to be below average to average.

  31. Women’s Care • Breast Cancer Screening—Ages 52-69 Years findings: • 10 HMOs reported a rate for this measure; two HMOs were unable to report rates due to insufficient sample sizes • Nine had rates below the national HEDIS 2006 50th percentile • Four of the HMOs had rates below the low performance level (LPL) • The 2007 Florida Medicaid weighted average decreased by 1 percentage point compared to the 2006 weighted average

  32. Women’s Care • Cervical Cancer Screening findings: • 12 HMOs reported a rate for this measure • All 12 HMOs’ rates were below the national HEDIS 2006 50th percentile • 10 of the HMOs reported rates below the LPL • The 2007 weighted average of 55.8 percent was below the LPL of 59.7 percent

  33. Women’s Care • Chlamydia Screeningin Women—Combined findings: • 12 HMOs reported a rate for this measure • Four HMOs reported rates above the national HEDIS 2006 50th percentile • Two HMOs reported rates below the LPL • The 2007 weighted average was 1.5 percentage points below the 2006 weighted average

  34. Women’s Care • Timeliness to Prenatal Care findings: • 11 HMOs reported a rate for this measure; one HMO reported an NR for the measure • All 11 of the HMOs reported rates below the LPL • The 2007 weighted average of 63.4 percent was below the LPL of 74.2 percent

  35. Women’s CareRange of 2007 Rates

  36. Women’s Care • Improvement efforts to be considered for the Breast Cancer Screening measure include: • Increase efforts to target younger women for mammograms • Educate on the importance of early detection • Work to ensure complete administrative data

  37. Women’s Care • Improvement efforts to consider for the Cervical Cancer Screening and Chlamydia Screening measures include: • Educate women on the importance of screening • Identify barriers to accessing care and services

  38. Women’s Care • Improvement efforts to consider for the Timeliness to Prenatal Care measure include: • Ensure complete data through the use of medical record review, especially for plans that utilize global billing for maternity services • Educate on the importance of prenatal care

  39. Women’s Care • Missed opportunities could be examined to identify barriers to improvement and target specific interventions • High performing HMOs should share best practices with other HMOs

  40. Living with Illness

  41. Living with Illness • 2007 Measures: • Use of Appropriate Medications for People with Asthma • Ages 5-9 Years • Ages 10-17 Years • Ages 18-56 Years • Combined • Comprehensive Diabetes Care • LDL-C Screening • LDL-C Controlled • Eye Exams • Medical Attention for Diabetic Nephropathy • Controlling High Blood Pressure • Ages 18-52 Years • Ages 46-85 Years • Combined

  42. Living with Illness • In 2006, only Use of Appropriate Medications of People with Asthma was reported by the HMOs • Starting in 2007: • Controlling High Blood Pressure measure was reported in three cohorts and the lower age limit was decreased to 18 years of age • There were changes to several indicators in the Comprehensive Diabetes Care measure

  43. Living with Illness The overall statewide results in the Living With Illness dimension were average to below average, with the exception of Comprehensive Diabetes Care—Medical Attention for Diabetic Nephropathy, which was above average.

  44. Living with Illness • Appropriate Use of Medications for People with Asthma—Combined findings: • Nine HMOs reported a rate for this measure; three HMOs had an insufficient sample size to report the measure • Four HMOs reported rates above the national HEDIS 2006 50th percentile • One HMO reported a rate below the LPL

  45. Living with Illness • Comprehensive Diabetes Care findings: • LDL-C Screening • No HMOs reported rates above the national HEDIS 50th percentile • Eight of the 10 HMOs reported a rate below the LPL • LDL-C Testing • One HMO reported a rate above the national HEDIS 50th percentile • Two of the 10 HMOs reported a rate below the LPL

  46. Living with Illness • Comprehensive Diabetes Care findings continued: • Eye Exams • No HMOs reported a rate above the national HEDIS 50th percentile • Two if the nine HMOs reported a rate below the LPL • Medical Attention for Diabetic Nephropathy • Eight of the 10 HMOs reported a rate above the HPL • One HMO reported a rate below the LPL

  47. Living with Illness • Controlling High Blood Pressure—Ages 46-85 Years findings: • Seven HMOs reported a rate for this measure; one had an insufficient sample size to report the measure, and four reported an NR • None of the HMOs reported a rate above the LPL

  48. Living with IllnessRange of 2007 Rates

  49. Living with IllnessRange of 2007 Rates, cont.

  50. Living with Illness • Improvement efforts to consider for Appropriate Medications for People with Asthma include: • Ensure pharmacy data are complete • Educate providers on the guidelines of asthma treatment

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