Medicare Stars and HEDIS

I thought I would start putting together some of the ideas I've been talking about into more concrete forms. I know when I talk about about NCQA and Compliance I get some interesting looks. But the facts are they are tied together. Whether or not you tie in performance measurements to clinical or compliance they still impact you when reporting to the Federal government. Let's talk about HEDIS measures in the STARS program.

1. 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

2. MEASURE: Colorectal Cancer Screening NUMERATOR: % of denominator that had an appropriate screening for colorectal cancer DENOMINATOR: Number of enrollees aged 51 to 75

3. MEASURE: Cholesterol Screening NUMERATOR: % of denominator who had LDL-C test during year (and for diabetics the year prior) DENOMINATOR: Enrollees with either ischemic vascular disease or diabetes

4. 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

5. MEASURE: Access to Primary Care Doctor Visits NUMERATOR: % of denominator that had an ambulatory/preventive care visit during year DENOMINATOR: All enrollees

6. MEASURE: Diabetes Care – Eye Care NUMERATOR: % of denominator who had a retinal or dilated eye exam by an eye care professional DENOMINATOR: Diabetic enrollees

7. MEASURE: Diabetes Care – Kidney Disease Monitoring NUMERATOR: % of denominator who either had a urine microalbumin test during the measurement year, or who had received medical attention for nephropathy during the measurement year DENOMINATOR: Diabetic enrollees

8. MEASURE: Diabetes Care – Blood Sugar Controlled NUMERATOR: % of denominator whose most recent HbA1c level is greater than 9, or who were not tested during the measurement year. DENOMINATOR: Diabetic enrollees

9. 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

10. MEASURE: Diabetes Care – Cholesterol Screening NUMERATOR: MA enrollees 18-75 with diabetes (type 1 and type 2) who had an LDL-C screening test performed during the measurement year DENOMINATOR: MA enrollees 18-75 with diabetes (type 1 and type 2)

   

11. MEASURE: Controlling Blood Pressure NUMERATOR: % of denominator whose most recent chart notation of systolic BP was 140 or less and diastolic BP was 90 or less during the measurement year DENOMINATOR: Sampled MA enrollees with hypertension on or before June 30th of the measurement year.

12. MEASURE: Rheumatoid Arthritis Management NUMERATOR: % of denominator who received at least one prescription for a disease modifying anti-rheumatic drug (DMARD) DENOMINATOR: Enrollees diagnosed with rheumatoid arthritis during year

13. MEASURE: Osteoporosis Management NUMERATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year, and who subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the six months after the fracture. DENOMINATOR: Female MA enrollees 67 and older who suffered a fracture during the measurement year

 

14. MEASURE: Adult BMI Assessment [Checking to See if Members are at a Healthy Weight] NUMERATOR: Members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior the measurement year. DENOMINATOR: Members 18-74 years of age

15. MEASURE: Care for Older Adults – Medication Review [Yearly Review of All Medications and Supplements Being Taken] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list in the medical record. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older.

16. MEASURE: Care for Older Adults – Functional Status Assessment [Yearly Assessment of How Well Plan Members Are  Able to Do Activities of Daily Living] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one functional status assessment during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older.

17. MEASURE: Care for Older Adults – Pain Screening [Yearly Pain Screening or Pain Management Plan] NUMERATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older who received at least one pain screening or pain management plan during the measurement year. DENOMINATOR: Medicare Advantage Special Needs Plan enrollees 66 years and older

18. MEASURE: Plan All-Cause Readmissions [Readmission to a Hospital within 30 Days of Being Discharged]    (Lower percentages are better because it means fewer members are being readmitted) NUMERATOR: Senior plan members discharged from hospital stays who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason. DENOMINATOR: Plan enrollees 66 years and older

     All these measure are part of STARS and these are HEDIS.  So who owns them? Clinical or Compliance? The reality is both. Sure these are clinical measures that are monitored and coached upon but these are also results that get reported to Federal agencies.  Sure these get reported and audited and sent to NCQA but then they get used for medicare STARS scores which then affects how much money the HMO might receive.  The lines are blurring between many groups.  Also who actually pulls this information and puts them into a report??  It might be a group's IT department so maybe they own a chunk.  It's going to become an increasingly complex world with blurred lines of responsibilities. Many things will fall through the cracks and you really need to be forward thinking.

I'm going to suggest bring back the old Tripartite Pact just replacing them with Clinical, Compliance and IT as the three partners.  Anyone who works in the HIPAA world knows how important having IT and Clinical on board to be being successful.  But I'm going to take it one step further that in order to be successful in Health Care Compliance you need this pact in the 21st century.  Next I'm going to take a specific measure and break it down.

Compliance-- Recent events

Well after a some vacation time its back to blogging again on topics I enjoy. I'm going to ramble a bit on the next few posts about the ever changing world of Health Care Compliance and throw in a little HEDIS and NCQA for good measure.  Well since the Supreme Court punted on the Health Care Act and said it was Congress's responsibility it still doesn't really settle the issue. However in the world of compliance, funding may change but regulations and requirements don't... One thing is for certain is that Federal Dollars are going to be tighter and hard to get. In some ways the regulations that HHS have developed are cost saving benefits. If you don't have a 4 or 5 star Medicare rating you aren't going to get the maximum federal payout as the years go by.  As the populations gets older and the strain on the system is going to get heavier and compliance with federal guideline with get more stringent. Plans will need to show improvement with their HEDIS measures covered by STARS. Some measures will get new weight others less but these ranking will never go away.

Congress really doesn't get this deep into regulations and rules and allows this to be the responsibility of the governing federal agency. That's why the funding may change but the rules won't.  Or they might become an unfunded mandate(a nightmare for many entities).   Most of the people serving in congress do not have technical or clinical backgrounds and really have no idea what is being discussed. They rely on staff members to make recommendations with constituent feedback(hopefully). Throw in a whole bunch of lobbyists and you get the current mess we have. That's why congress punts most of the time on regulations and relies on the governing body to put those in place.

Let's take the topic of the ICD-10 conversion. It's scheduled to go live in October of 2013. However they might move to 2014 now. However that's only a proposed change so what do you do? Well you better assume that its going to be next year.  Compliance is about risk avoidance and good practices.  The safe path is to be ready for next year and if it changes you are already prepared and have less work to do.. Besides you'll get better identification and stratification by converting as the level of detail with ICD-10 is greater(unfortunately a bit more complex). I find it surprising that they  want to delay it again(there must be some lobbyist group putting pressure on HHS). At this rate you might as well convert to ICD-11...

Kudos to Health Ed

I follow this blog a bit and wanted to say kudos to them :)

This past week we received word that HealthEd has been named a finalist for the 2012 MM&M Awards in the category of Best Multichannel Campaign, Large Client Organizations for the Xeloda Multichannel Patient Adherence Campaign.
 http://healthed.com/
http://healthed.typepad.com/healthed-blog/

Great Idea from NCQA!!

It's good to see NCQA engaging its members in a interactive way!

Announcing: NCQA's New Accreditation Users Group

The National Committee for Quality Assurance (NCQA) is excited to announce the Accreditation Users Group (AUG). The AUG provides a new communication, learning and development platform for members to discuss updates to existing NCQA Accreditation and Certification products, and how they are applied. AUG members will also have the opportunity to contribute to the enhancement of future products. The AUG will cover the following accreditation and certification products:

• Health Plan (HP) Accreditation
• Disease Management (DM) Accreditation
• Managed Behavioral Healthcare Organization (MBHO) Accreditation
• Wellness and Health Promotion (WHP) Accreditation
• Accountable Care Organizations (ACO) Accreditation
• Case Management (CM) Accreditation
• Disease Management (DM) Certification
• Health Information Products (HIP) Certification
• Physician and Hospital Quality (PHQ) Certification
• Credentials Verification Organization (CVO) Certification
• Utilization Management/Credentialing (UM/CR) Certification
• Medicare Advantage (MA) Deeming
• Multicultural Health Care (MHC) Distinction

AUG members also receive the following benefits during the subscription year:

• A $200 voucher toward an NCQA Accreditation, Certification or HEDIS publication, or toward a license for the Interactive Survey System Survey Tool.
• A $200 voucher toward any NCQA educational seminar.
• A $100 voucher toward NCQA's Quality Compass.
• NCQA WebEx sessions that address key updates and user-expressed topics of interest.
• Access to the Users Group Member Download Center, which include recorded training sessions, presentations and other valuable user-only materials.
• Access to the monthly Users Group newsletter, which lets subscribers know about recent policies and issues that have the potential to affect their organization, and includes information about Webinar trainings, policy updates and publication release dates.

The AUG membership fee is $950 per year, which follows NCQA's standards year (July 1 to June 30).

If you are seeking NCQA Accreditation or Certification for any of the products listed above; provide guidance to organizations covered under the scope of the products; or purchase services from an NCQA-Accredited or NCQA-Certified organization, we invite you to consider joining the AUG.

To sign up for the Accreditation Users Group, click here. If you have any questions about the AUG, please contact Veronica Locke at locke@ncqa.org.

Compliance warning sign

There always comes a time when a compliance professional needs to give his organization a reality dose. When your organization decides the compliance team needs to maintain documentation that's owned by another group because they don't have the time to keep up with it that's a major problem. The compliance team is job is to make sure that all departments keep their documents up to date and reviewed at least annually. Once you take on the role of setting up the reviews and assign work you open yourself to doing this for all departments.  This will become time consuming and drag your group's resources away from their main goal of compliance. There are a lot of fine document management systems out their. Have you company invest in one.

Compliance - Clinical

When it comes to clinical compliance I'm going to look at it from the policy and procedure  point of view.  As a compliance professional you do not have to be clinical to make sure it gets done.  You have to make sure your clinical group gets it done.  Your clinical group really has the ownership of the materials and policies.  They need to recognize the fact these need to get reviewed and updated at least on a yearly basis. As a compliance officer your job is make sure they do theirs.  Nobody really wants to get hounded to do things but sometimes you do need to explain why it is important to do things in a timely manner. Like the Aviation field health care is going to get the same level of scrutiny as that field does. Once you accept that fact as an organization you will be much better prepared.                                                                                                                         What does need to get reviewed on at least an annual basis? Anything clinical that can change on at least a yearly basis. Sounds pretty broad doesn't it? Well it is, and the reason it is you should never assume anything. For example let say you do health coaching for diabetes as a company.  You'll need to review what you coach on. That means you'll need to review changes in diabetes care, changes in diabetes medication, changes in diabetes health, fitness programs for diabetes, etc, etc. This might be a pain but  as a health organization you have to do this.  URAC and NCQA expect this, so do the feds and the state folks also. Besides isn't it best practice to review these items anyways?
Compliance isn't about making people miserable internally, compliance should really be about making people externally healthier by making sure you provide the best care possible.

What is compliance? Internal Oversight

I ended my last post about internal oversight so I'm going continue with that. Who owns compliance? The reality is that it is everyone. However if you ask 10 employees nobody will say they have a part in it.  Usually they'd say legal owns it or the compliance dept or maybe their manager. It's sad but its the situation for most companies.  When looking at internal compliance it really gets worse.  Most companies really don't have the time or budget to review all internal policies let alone spend the effort to make sure they are enforced.  It's a thankless job. Nobody likes to be scrutinized and even worse being told they aren't doing their job. It's like being in Internal Affairs police officer. You gotta have them but nobody wants to hang out with them. 
The mindset in Health care really should be how the FDA does their process and oversight. That's really the model that its going to.  Products that are developed need to trace to the business specifications traced to the business requirements to functional requirements, etc.  Policies will all need to trace up and trace down.  This also means the administrative workload will increase to ensure compliance(adherence).  Most Health Care companies are going to need to build out their compliance departments from just usually legal to having members with clinical and IT background also. Auditors aren't just going to accounting guys anymore. Companies are going to have to defend how they do business from the top to the bottom level.  Companies need to take a proactive approach to internal compliance.  You need to make folks realize that they do process as a way being more efficient. On the flip side you also need to be open and receptive that if process isn't working you need to fix it. It's a two way street and managers need to understand that.  It's a way to help promote reliable and consistent service to the members that use your health services.  Think of it as eliminating unwarranted variation at the corporate level :)