What is compliance?

  We hear this term kicked around a lot nowadays "We need to be compliant!", but what the heck do they mean. Unfortunately you ask 4 different people you are getting 4 different answers.  The irony is they probably are all correct.  In today's world increasing confused and complex world of health care compliance takes many forms.  You have legal compliance where you need to maintain HIPAA compliance along with Federal and State statutes.  You have accreditation compliance were you need need to maintain NCQA and URAC compliance.  You will also need to maintain compliance with your own internal policies and procedures.  I'm going to focus a bit on internal compliance because I don't think this gets enough consideration and truthfully in the long run this will save you a lot of heart ache.
   Internal Compliance to me is maintaining your internal policies and faithfully using them as your guidelines to how you do business.  A simple form of compliance would be using a standard set of documents for internal and external use.  It could be as complex as what your clinical guidelines are for Diabetes Care. A lot of companies don't really put much faith in documentation and established procedures. They find it time consuming and a waste of money.  The fact of the matter is that the type of regulation and oversight that is present in the aviation industry is coming to health care.  NCQA and URAC both expect internal policies and procedures to be present and followed, it just happen to be a lot of overlap when it comes to HIPAA. There is considerable expectation that these policies are reviewed on a annual basis. This can be hard for a lot of companies especially if the company culture doesn't support this. Also please realize that if you screw something up at the state or federal level those guys are going to ask what your internal policies are and how they are followed. Believe me you aren't going to get a good reaction if you can't prove you do what you say you do....
  The next question is what should be considered for internal compliance oversight.  Honestly everything should but that's completely unrealistic for most companies(Unless you are Google and have an extra 300 million to burn).  What internal policies and procedures could get you into trouble?.  IT policies on security, data, and usage should all be put into that bucket.  You better add in all your clinical guidelines that you use also. What about contractual agreements? Yup add those in also. See how the list is growing?  It's only going to get bigger with a few more minutes of thought. Let me know if there others that you think should get added to the list!  Alright I think I'm going to babble a bit on who should be doing the oversight in my next post

More HEDIS fun facts

Sorry I've gotten behind in my posting. I went away for a wonderful long weekend to Stowe Vermont with my wife(no kids). So now its back to posting some more HEDIS Fun Facts.

HEDIS Fun Fact #5 CDC what does it stand for? If you said Centers for Disease Control you are warm but not right.  It stands for Comprehensive Diabetes Care. It's actually a bunch of sub measures under main measure.
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following.

• Hemoglobin A1c (HbA1c) testing 
• HbA1c poor control (>9.0%) 
• HbA1c control (<8.0%) 
• HbA1c control (<7.0%) for a selected population
• Eye exam (retinal) performed 
• LDL-C screening LDL-C control (<100 mg/dL) 
• Medical attention for nephropathy 
• BP control (<140/80 mm Hg) 
• BP control (<140/90 mm Hg)

I personally find this one of the more interesting measures because of all the different  components.

HEDIS Fun Fact #6  How many different medicare programs are included for HEDIS reporting??  Correct answer is 6
HEDIS reporting is required for:

1. Medicare Advantage (MA) contracts 
2. Section 1876 cost contracts with active enrollment 
3. Medical Savings Account (MSA) plans 
4. Private Fee-for-Service (PFFS) plans 
5. Special Needs Plans (SNP) 
6. Certain demonstration projects.

 HEDIS Fun Fact #7 What is the  "Eligible Population"?  Coming from the definition from NCQA.  The eligible population for any measure is all members who satisfy all specified criteria, including age, continuous enrollment, benefit, event and the anchor date enrollment requirement.  The part to remember is that every individual measure has their own eligibility criteria.  It is very unwise to male a blanket decision for population. You will get burned in the long run.

HEDIS Fun Fact #8 What is "Continuous Enrollment"? No it is not the fee that you get charged monthly on your credit card you keep forgetting to cancel... Continuous enrollment specifies the minimum amount of time that a member must be enrolled in an organization before becoming eligible for a measure. Generally it is 12 months for HEDIS measures for the calendar year. However don't assume and check the specs

Ok that's all for Fun facts for today. Just remember "Don't assume, look up the darn spec!" 

HEDIS Fun Facts

I'll profess right now all my knowledge comes from listening to a lot of people much smarter than me and reading NCQA's HEDIS technical specs.  If you take the time to read the specs you'll reap the benefits down the road. I've worked on databases that fed cinical data in and out of coaching systems but never really appreciated the work and thought that went into developing HEDIS measures.

 HEDIS Fun FACT 1: What the heck does HEDIS stand for???  I bet if you ask 6 people you'll probably get 6 different answers it actually stands for  Healthcare Effectiveness Data and Information Set. Hence the name HEDIS. However there is a mountain in Turkey named HEDIS(Hedis Dagi) also so once in a while you might see a blog posting in turkish about HEDIS. Don't worry the turkish healthcare system hasn't hijacked the standard..

HEDIS Fun Fact 2: When did HEDIS get started? It actually got rolled out in 1991 but its name back then was the HMO Employer Data and Information Set.  It was really created to compare HMO's against each other to see who had better ratings and how well it did in regional and national benchmarks. They changed the name to its current form back in 2007.

HEDIS Fun Fact 3: How many domains does HEDIS cover?

The Correct answer for 2012 is 5

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Relative Resource Use
• Cost of Care
• Health Plan Descriptive Information

There were 8
♦ Effectiveness of Care
♦ Access/Availability of Care
♦ Satisfaction With the Experience of Care
♦ Health Plan Stability
♦ Use of Services
♦ Cost of Care
♦ Informed Healthcare Choices
♦ Health Plan Descriptive Information

HEDIS Fun Fact 4: How many HEDIS measures are there
Currently in the 2012 Standards there are 76.

NCQA has been fairly logical in adding measures. Back in 2007 there were 71.  As new ideas and products come into the market to their credit NCQA has been fairly responsive to the changes. A good example of this is the Human Papillomavirus Vaccine measure that became effective for 2012. Measure do get retired also such as Relative Resource Use for People With Acute Low Back Pain. in 2012 also.

So now you too can win HEDIS Jeopardy! More to come :) I'm truly a dork because I published this on my birthday(May 16th)!

HEDIS and Outreach Part 4

Hedis and Outreach
 Michael’s comment sparked a few neurons for me so I’m going to digress a tiny bit. PCMH (Patient Centered Medical Homes) is a very popular buzzword. NCQA has this program that can be accredited. It’s a pretty good program to be honest. It really tries to get practices to use technology to improve health care. It focuses a lot on EHR’s (Electronic Health Records). They really want practices to think about population health and management.　 They do the typical quality improvement language (Quality measures) which will transmit into HEDIS measures being used. The one weakness with this is that the population will have multiple HMO coverage’s (there are very few single HMO practices out there as far as I know). So you could have 3 different patients with different coverage’s. All these plans could have different requirements…. It’s really a mess the practice to keep it straight. Plus who the heck is going to do the quality metrics for these practices?? The medical billing coder?　 This is where the DM companies need to work hand in hand with the practices.　 They need tie the practice outreach with the DM outreach.　 This is a huge opportunity for the DM companies. Do you really think the HMO is going to do this??They already are doing the metrics, they have the outreach capability.　 Just how do you tie this together?　 You need to tie the EHR, the doctor and the disease management together. You need the doctor to feed the EHR, the EHR to feed the DM and the DM to feed the EHR. Sounds easy, doesn’t it?There are very few companies that I know of that can do this at this moment. 　
I got some really nice email feedback from some readers.　 So I’ll do some running posts about HEDIS in general. A bit of a 101 type on Thursday.　

HEDIS and Outreach - DM Programs- Part 3

HEDIS and Outreach

Disease Management is not dead… Contrary to some beliefs.  Disease management companies will be back stronger than ever. Why do you ask? Simply HEDIS performance improvement.  In order to show improvement you need to reach members to get those screenings, tests, and medication persistence.  A lot of companies ditched their DM vendors and in sourced their services as a way to save money and still keep their NCQA accreditation.  In the short term it made sense. There wasn’t much “value”  in just keeping a company around for QI8.  What a lot of plans don’t realize is that DM vendors provide tremendous value in moving HEDIS scores. They have the knowledge, infrastructure and programs already in place to touch those critical HEDIS concerns.  To be totally frank the NCQA DM program is basically a blue print on how to improve HEDIS scores. Here’s a little tidbit NCQA DM Performance measurements is linked to HEDIS, there a reason why they did this.  Think about it….  More on this later

HEDIS and Outreach Part 2

I think I'm going to talk a bit about stratification and HEDIS.  NCQA requires that members are stratified according to risk levels(HIGH, and other(Medium and Low depending on how you assess risk) for Health Plans and DM companies. Now you are suppose to outreach to these members based on their stratification. Common sense says you outreach to those High members based on the fact that they are usually the most unhealthy of your population. The conundrum is with HEDIS that stratification isn't a concern most of the time. It looks at chronic high risk members the same as low risk chronic members for a significant number of HEDIS measures. You could be diabetic or asthmnatic in very good health but still have considerable gaps.  Take me for example I have asthma, I use an inhaler as needed but hate taking a controller. I also usually forget my flu shot. But otherwise I'm in good health(my wife thinks I could lose a few). I'd be showing as having a few gaps much to Cigna's chagrin.  How do you convince me to close those gaps?  With a lot of HMO's since I'm low risk I probably wouldn't get much attention. But with HEDIS measures now the challenge is how to get me to change behaviors and close those gaps???  It's a challenge because if I'm not living at PCP practice who is going to remind and should they?  The way the market is appearing to move its looking at more preventative and screening as a way to get people healthier. Makes sense to be honest you want to catch things before they get worse.  Is it ideal?? In my opinion not really I don't think the standards really take into account how good your doctor is and how well they treat you.  I think some good practitioners out there may feel handicapped because of what they may be forced to do to get good ratings. The system isn't perfect and it is involving. Wellness is going to be a factor down the road... prepare for it.

HEDIS and effective outreach Part 1

HEDIS and effective outreach Part 1
How do you close those pesky HEDIS Gaps??? Like the rest of the Health Care Market there isn't a perfect solution. However with a little persistence, a really good outreach program and some decent analytics you can get yourself in good shape. However HEDIS changed all that when they looked at populations and chronics as a whole. Population stratification while important isn't a big factor when it comes to HEDIS. For most of the screening and preventive gaps stratification doesn't count but age might buts its not consistent. So what do you? Start sending out reminders? Computer Calls? Health Coach Calls?  What time? What day? As a HMO you might want to start hiring a staff to do this.... Or you could outsource it..  You could ignore the issue and blame the provider that will only get you so far and then the providers will start refusing your insurance. Just the start of my thoughts on this...  More to come

Why is HEDIS so hard for many organizations?

Why is HEDIS so hard for many organizations?
I think many companies are having a rough time coping to the changes in the market.  Change is slow especially in Health Care and with Affordable Care Act passing a few years back changes hit the market at lightning speed(for Health Care).  Everybody knew it was coming but I don't think companies understood how important HEDIS was to become. These numbers are now how many HMO's live and die by.  So much emphasis has been put on these by HHS and CMS that now all companies talk about is this and how to make numbers better.  The problem is there is no easy silver bullet to good HEDIS numbers.  A lot of HMO I think shot themselves in the foot when they scaled by on outreach services in order to cut costs. Then they turned around and dumped the responsibility onto the provider practice to move the scores.  While it made sense in the short term for costs in the long run it will cost them.  You won't be able to move those numbers and get better ratings unless you invest in outreach and analytics.  You need to attack the problem from multiple angles of intervention and have different programs based on your populations.

NCQA Accreditation Pitfalls Part 5: Document submission

Document submission Part 5

Do not leave this to the last minute!!!  The ISS tool while it does work pretty well most of the time can have the occasional hiccup. Nothing is more stressful than having something go wrong at the 11^th hour and make a call to NCQA in a panic.  IT support is pretty decent but it can take a bit to reach them.  I highly suggest having everything ready a week early and submit the day before its due just to be safe. Also bookmark your pdf documents to help the auditor find what they need. Do not overload the auditor with documents. They really just want the exact documents they need to verify and nothing more. It’s a red flag if you try to blitz them with documentation.