HEDIS/STARS Measure LDL-C Control

MEASURE: Diabetes Care – Cholesterol Controlled
NUMERATOR: % of denominator whose most recent LDL-C level during the measurement year was 100 or less
DENOMINATOR: Diabetic enrollees


LDL-C Control <100 mg/dL
Identify the most recent LDL-C test during the measurement year. The member is numerator compliant if the most recent LDL-C level is <100 mg/dL. If the result for the most recent LDL-C test during the measurement year is ≥100 mg/dL or is missing, or if an LDL-C test was not performed during the measurement year, the member is not numerator compliant.

LDL-C Control <100 mg/dL
The most recent LDL-C level performed during the measurement year is <100 mg/dL, as documented through automated laboratory data or medical record review.
Administrative
Date of most recent LDL Screening
Results of the LDL Screening
The member is compliant if the most recent LDL-C level is <100 mg/dL.
If the results are missing or the results are ≥100 mg/dL then they are not compliant

Medical record
Documentation in medical record must include, at a minimum, a note indicating the date when the LDL-C test was performed and the result.

This is a pretty straight forward measure.  Get the screening and report the results. Either you passed or you didn't. items

Things that can impact the score.

• Not getting the lab results sent to the plans when the plan pays for them(Pretty rare in most cases since the plans usually get the results with the billing info)
• Not getting the results because the tests were done by a third party not connected to the plan. Supplemental Insurance, VA, Community Health Organizations.
• Bad Data sent to the health plans.

How can you improve upon these scores?

Outreach, Care Coordination and  patient education plain and simple.

If a practice or a health plan doesn't not have a serious outreach program to re-engage their patients once they leave the exam room they will miss the out on closing gaps. The practice will need help to reach these members and that's where care coordination comes into play. It maybe be the practice staff or another organization that works with the practice or plan to reach out and engage these members. The final piece is education.  You need to make the members understand that these preventative measure help them live longer, happier lives. Once they make these gaps closures part of their yearly routine the plans and the practices will save money and increase their reimbursement rates.  This is very hard to do. You will need a mature education program in place.

Breast Cancer Screening(BCS) HEDIS Measure

OK here's another measure

MEASURE: Breast Cancer Screening

NUMERATOR: % of Denominator that had a mammogram during the measurement year or the year prior to the measurement year.

DENOMINATOR: Number of female enrollees aged 42 to 69 

It's applicable for Commercial, Medicare and Medicaid 

It has a 45 day allowable gap in enrollment for the denominator. So if they don't have coverage with your plan for 46 days you can get them out of the population.

It does have exclusionary criteria:

Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies

The data elements are pretty straight forward

Year 
Collection 
Eligible population
Numerator events by population

Now this is another straight forward measure on the surface.  The provider needs to get the patient a mammogram screening every basically every two years and these records need to be verified.

The problem is that this can be an "uncomfortable" screening and compliance can be difficult to do.  Once again you might have to deal with dual coverages in the older populations and reporting can be difficult.  
Plus you may have several competing organizations offering these services that may not communicate. Below is an example

CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides access to breast and cervical cancer screening services to underserved women in all 50 states, the District of Columbia, 5 U.S. territories, and 12 tribes

 

It's a federal program but they may not communicate with your provider or the insurance company.  It's just an example of where something very simple can get a bit complex.  This is another example of where supplemental data can be used to provide additional information.  You need evidence of this service has taken place and this must pass your HEDIS auditor scrutiny. I can't emphasis enough that you should have very clear channels of communication with your auditor and provide detail information of how

 

Glaucoma Testing measure

Now that I'm done with vacation and happily(no more summer camp for a year) back at work let's get back to talking about HEDIS and Medicare. Let's talk about a particular measure, Glaucoma Testing. 

MEASURE: Glaucoma Testing
NUMERATOR: % of denominator who had at least 1 glaucoma exam by an eye Dr. during year or year prior
DENOMINATOR: Enrollees aged 67 or older without a prior diagnosis of glaucoma

This seems to be pretty straight forward but this can be very deceptive.  How many health plans get information from eye doctors? Most plans do pay for eye exams but a lot of members do pay out of pocket. Plus members may have supplemental insurance and programs that may be better than what the plan offers.  Plus not all the eye doctors take all insurance. So how the heck does a plan figure out how to increase this score?

You got a couple of different ways. You could have a proactive system where you engage the members get their eye doctors into your provider program.  You could just link up with a national eye insurance program and get them to send you their data.  The other option is HEDIS supplemental data.  This can be pretty tough for a Health Plan if they don't have a good outreach program in place.  If you are going to use supplemental you will need a clinician that will have to collect date, results, type of eye doctor and verify it has no exclusion.Plus you'll need to get this data collection signed off by your auditor.  Be prepared to have a lot of material available for review.

Medication Vacations

This is just more of a personal post and something I ran into last week. I have 2 boys in Cub Scouts and I volunteer every summer to be a Cub Scout Day Camp counselor for a week(It's a week away from work). I ran into something that I had never heard of before and hope to never to again. "Medication Vacation" is a term when parents take their kids off their medication for issues that they deal with during the school year for the summer.  The unfortunate consequence is that the unpaid volunteer at the camp has no idea why your child is bouncing off the wall, hitting other kids, or generally telling you to shove it. Then the poor camp nurse has to delve through the medical records to figure out if there is an issue and has to ask the child if he's been taking his medication. That's where I heard the term "Medication Vacation" So please don't take your kids off their medication for the summer and then do a dump and run on a unpaid volunteer to be a babysitter for your child from 730 to 5pm.  I'm fine with dealing challenging kids but have some consideration for the volunteer and talk to them about your child.  I have to make sure all kids have a safe environment to have fun in. Plus you keep doing this you won't have volunteers to run programs for your children.