Highlighting HEDIS 2015

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1 Provider Remittance How to read your Facility Provider Remittance Ancillary Providers: Refer to this guide only when working with Facility providers. Highlighting HEDIS 2015 This booklet captures articles that were published in 2015 as part of the Highlighting HEDIS series in Partners in Health Update SM. This article series offers providers education and strategies to help them improve their HEDIS performance. Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.

2 Table of Contents Partners in Health Update SM edition Topic Page January 2015 Cervical cancer screening 3 February 2015 Pharmacotherapy management of COPD exacerbation 4 March 2015 Appropriate testing for children with pharyngitis 5 April 2015 Well-child visits in the first 15 months of life 6 May 2015 Well-child visits in the third, fourth, fifth, and sixth years of life 7 July 2015 Osteoporosis management in women who had a fracture 8 August 2015 Weight assessment and counseling for nutrition and physical activity for children/adolescents 9 October 2015 Breast cancer screening 10 Highlighting HEDIS

3 Highlighting HEDIS : Cervical cancer screening Cervical cancer screening: The percentage of women ages who were screened for cervical cancer using either of the following criteria: women ages who had cervical cytology performed every three years; women ages who had cervical cytology/human papillomavirus (HPV) co-testing performed every five years. QIPS alert This measure is a part of the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers. Cervical cancer can be detected in its early stages by regular screening using a Pap (cervical cytology) test. A number of organizations, including the American College of Obstetricians and Gynecologists, American Medical Association, and American Cancer Society, recommend Pap testing every one to three years for all women who have been sexually active or who are 21 and older. NCQA, HEDIS 2015 V1 Quick tips for improvement 99Develop a reminder system to help keep members up-to-date with when they are due for screening. 99Educate members about the importance of cervical cancer screening, and provide educational resources such as the National Cancer Institute website: 99Explain the screening procedure to help alleviate any anxiety or fear related to the screening. 99Encourage scheduling of a cervical cancer screening during the member s gynecologic visit. Percentage of U.S. women ages 18 and older who have had a Pap test in the last three years by race and ethnicity *The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is measure performance on important dimensions of care. QIPS is a reimbursement system developed by Keystone Health Plan East for eligible Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. January 2015 Partners in Health Update SM 3

4 Highlighting HEDIS : Pharmacotherapy management of COPD exacerbation Pharmacotherapy management of COPD exacerbation: The percentage of chronic obstructive pulmonary disease (COPD) exacerbations for members ages 40 and older who had an acute inpatient discharge or emergency department visit on or between January 1 November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported: 1. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event; 2. Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event. Note: The eligible population for this measure is based on acute inpatient discharges and emergency department visits, not on members. It is possible for the denominator to include multiple events for the same individual. Plan performance For this measure, the HEDIS 2014 rates for all Independence plans fall below the HEDIS 90th percentile benchmark, an industry indicator of excellence and desired target for each plan. Performance compared to the HEDIS 90th percentile is broken down by line of business and plan type below. Bronchodilator dispense rate Systemic corticosteriod dispense rate Source Commercial Medicare HMO PPO HMO PPO Independence 81.4% 74.1% 74.9% N/A HEDIS 90 th percentile 88.0% 89.0% Source N/A = The PPO Medicare plan did not meet the minimum required sample size for reporting. Commercial Medicare HMO PPO HMO PPO Independence 78.2% 70.5% 66.9% N/A HEDIS 90 th percentile 81.0% 78.0% While other major causes of death have been decreasing, COPD mortality has risen, making it the fourth leading cause of death in the U.S. The disease results in both direct and indirect costs, and exacerbations of COPD account for the greatest burden on the health care system, though studies have shown that proper management of exacerbations may have the greatest potential to reduce the clinical, social, and economic impact of the disease. Pharmacotherapy is an essential component of proper management. NCQA, HEDIS 2015 V1 * The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is HEDIS 2014 rates reflect data collected in Did you know? Independence Health Coaches can collaborate with you to support and guide patients through an acute or chronic episode to help achieve the medical treatment goals you establish. Please provide the Independence Health Coach phone number to your patients. Independence Health Coaches are available 24 hours a day, seven days a week and can support your patients as they make important decisions about their health. Ask them to call ASK-BLUE ( ) and say Health Coach when prompted. Stay informed! Request to receive a Daily Hospital Census Report from Independence by ing Specify which office the request is for and provide the fax number or secure address. February 2015 Partners in Health Update SM 4

5 Highlighting HEDIS : Appropriate testing for children with pharyngitis Appropriate testing for children with pharyngitis: The percentage of children ages 2 18 who were diagnosed with pharyngitis, dispensed an antibiotic, and received group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Pharyngitis is the only condition among upper respiratory infections (URI) where diagnosis is validated easily and objectively through administrative and laboratory data, and it can serve as an important indicator of appropriate antibiotic use among all respiratory tract infections. Overuse of antibiotics has been directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important to reducing the prevalence of antibiotic resistance. Pediatric clinical practice guidelines recommend that only children diagnosed with group A streptococcus (strep) pharyngitis, based on appropriate lab tests, be treated with antibiotics. Appropriate testing for group A strep pharyngitis includes a rapid strep assay and/or throat culture. NCQA, HEDIS 2015 V1 Plan performance The chart below shows a five-year trend where improvements in antibiotic prescribing have occurred; however, a substantial number of patients are still receiving inappropriate antibiotic treatment State of Health Care Quality (NCQA) QIPS alert Appropriate testing for children with pharyngitis is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers. Quick tips for improvement 99Only about 30 percent of all cases of pharyngitis in children are caused by bacteria. Be sure to follow the pediatric guidelines for appropriate treatment State of Health Care Quality (NCQA) 99Educate caregivers and patients on the risks of antibiotic resistance. 99The Poster Board Pledge: Recent studies have shown that displaying poster-sized commitment letters in exam rooms to avoid inappropriate antibiotic prescribing was a simple, low-cost, and effective method for improvement. JAMA Internal Medicine * The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. March 2015 Partners in Health Update SM 5

6 Highlighting HEDIS : Well-child visits in the first 15 months of life Well-child visits in the first 15 months of life: The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a primary care physician during their first 15 months of life: no well-child visits one well-child visit two well-child visits three well-child visits four well-child visits five well-child visits six or more well-child visits QIPS alert Well-child visits in the first 15 months of life is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers. The American Academy of Pediatrics recommends six well-child visits in the first year of life: the first within the first month of life, and then again at around two, four, six, nine, and twelve months of age. These visits are of particular importance during the first year of life, when an infant undergoes substantial changes in abilities, physical growth, motor skills, hand-eye coordination, and social and emotional growth. Regular check-ups are one of the best ways to detect physical, developmental, behavioral, and emotional health problems. NCQA, HEDIS 2015 V1 Plan performance The chart below compares the national average for six or more well-child visits in the first 15 months of life for commercial HMO/PPO plans vs. Independence s rates over a four-year period. Year National Commercial Independence HMO PPO HMO PPO % 76.9% 78.2% 83.6% % 76.4% 76.2% 83.0% % 76.1% 70.5% 61.2% % 72.8% 76.1% 75.2% Quick tips for improvement 99Schedule the entire suite of visits with or at the conclusion of the first visit. 99Inform caregivers on the importance of well-child visits. 99Be proactive make outreach calls to members who are not on track to complete the recommended six visits. As the chart demonstrates, Independence performs below the national average for HMO and above the national average for PPO. The goal for Independence is to reach the national 90th percentile benchmark, which is currently at 89.8 percent and 86.9 percent for HMO and PPO plans, respectively. Source: 2014 State of Health Care (NCQA) *The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. April 2015 Partners in Health Update SM 6

7 Highlighting HEDIS : Well-child visits in the third, fourth, fifth, and sixth years of life Well-child visits in the third, fourth, fifth, and sixth years of life: The percentage of members ages 3 6 who had one or more well-child visits with a primary care physician (PCP) during the measurement year. This measure looks at the use of routine check-ups for preschool and early school-age children. It assesses the percentage of children ages 3, 4, 5, and 6 who received at least one well-child visit with a PCP during the measurement year. Well-child visits during the preschool and early school years are particularly important. A child can be helped through early detection of vision, speech, and language problems. Intervention can improve communication skills and avoid or reduce language and learning problems. The American Academy of Pediatrics recommends annual well-child visits for children ages 2 6. NCQA, HEDIS 2015 V1 Plan performance The chart below displays the rates for one or more well-child visits for children ages 3 6 over a four-year period, comparing the national average for commercial HMO/PPO plans vs. Independence s HMO/PPO plans. Year National Commercial Independence HMO PPO HMO PPO % 70.3% 85.3% 77.1% % 69.9% 83.4% 78.7% % 69.8% 84.1% 75.0% % 67.8% 83.7% 77.8% QIPS alert Well-child visits in the third, fourth, fifth, and sixth years of life is included as a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers. As this chart demonstrates, Independence performs above the national average for both its HMO and PPO plans. The goal for Independence is to reach the national 90th percentile benchmark, which is currently at 87.4 percent and 84.9 percent for HMO and PPO plans, respectively. Source: 2014 State of Health Care Quality Report (NCQA) *The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. Quick tips for improvement 99Keep an active tracking system to monitor yearly visits for each member. 99Inform caregivers on the importance of well-visits. 99Consider providing off-hours and weekend appointment times. May 2015 Partners in Health Update SM 7

8 Highlighting HEDIS : Osteoporosis management in women who had a fracture NCQA s * HEDIS measurements for high quality care on important dimensions of services. Osteoporosis management in women who had a fracture: The percentage of women ages who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the six months after the fracture. National average The chart below displays the national average for HMO and PPO performance in this measure from Source: 2014 State of Health Quality This measure assesses how well the organization manages women who are at high risk for a second fracture. It studies whether female members who suffered a fracture had evidence of either a BMD test or prescription for a drug to treat osteoporosis in the six months after the fracture date. Morbidity and mortality related to osteoporotic fractures are major health issues. Ten million Americans have osteoporosis, and another 18 million are at risk due to low bone mass. Eighty percent of people with osteoporosis are women. Women who suffer a fracture are at increased risk of suffering additional injuries. Treatment of osteoporotic fractures is estimated at $10 $15 billion annually in the U.S. The aging U.S. population is likely to increase the future financial cost of osteoporosis care. NCQA, HEDIS 2015 V1 New incentive opportunity Independence is offering an incentive opportunity through a new program for Medicare Advantage HMO and PPO members who have been identified to be at-risk for osteoporosis to receive a BMD test. We will mail a list of identified members to affected providers, and incentives can be earned if the member: receives a DEXA scan at the provider s capitated (HMO) or any in-network (PPO) radiology site; receives a quantitative ultrasound BMD study in his or her home through Mobile Medical Examination Services, Inc. (MedXM), an independent company. In addition, each member will receive an incentive for the completed test. If you have questions or concerns about this program, please Independence at QIPS and Stars alert Osteoporosis management in women who had a fracture is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers and is also a Medicare Stars measure. * The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS ) is QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. Stars is a program developed by the Centers for Medicare & Medicaid Services to measure quality health care. Ratings are published annually to help educate consumers prior to enrollment decisions. July 2015 Partners in Health Update SM 8

9 Highlighting HEDIS : Weight assessment and counseling for nutrition and physical activity for children/adolescents NCQA s * HEDIS measurements for high quality care on important dimensions of services. Weight assessment and counseling for nutrition and physical activity for children/adolescents: The percentage of members ages 3-17 who had an outpatient visit with a primary care physician or OB/GYN and who had evidence of the following during the measurement year: Body Mass Index (BMI) percentile documentation Counseling for nutrition Counseling for physical activity One of the most important developments in pediatrics in the past two decades has been the emergence of a new chronic disease: obesity in childhood and adolescence. The rapidly increasing prevalence of obesity among children is one of the most challenging dilemmas currently facing pediatricians. The Centers for Disease Control and Prevention (CDC) states that overweight children and adolescents are more likely to become obese adults. For example, one study found that approximately 80 percent of children who were overweight at years of age were obese adults at age 25. Another study found that 25 percent of obese adults were overweight as children and that if overweight begins before age 8, obesity in adulthood is likely to be more severe. NCQA, HEDIS 2015 V1 *The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is an NCQA tool used by more than 90 percent of U.S. health plans to Body mass index-for-age percentiles The chart above, which was developed by the CDC, shows an example for a 10-year-old boy. BMI Percentile is the percentile ranking based on the CDC s BMI-for-age growth charts, which indicate the relative position of the patients BMI number among others of the same gender and age. The boys and girls growth charts from the CDC can be found at: August 2015 Partners in Health Update SM 9

10 Highlighting HEDIS : Breast cancer screening Breast cancer screening: The percentage of women ages who had a mammogram to screen for breast cancer. This measure looks at whether female members are being screened for breast cancer. It assesses the percentage of women between ages 50 and 74 who had a mammogram to screen for breast cancer. Breast cancer is the second most common type of cancer among American women, with approximately 178,000 new cases reported each year. It is most common in women older than 50. Women whose breast cancer is detected early have more treatment choices and better chances for survival. Mammography screening has been shown to reduce mortality by percent among women 40 and older. A mammogram can reveal tumors too small to be felt by hand; it can also show other changes in the breast that may suggest cancer. NCQA, HEDIS 2015 V1 National screening rates The following chart shows the national average for commercial and Medicare breast cancer screening rates for HMO and PPO plans from Do you know your rates? We are committed to keeping you informed. To learn more about your screening rates by provider office for Independence members, please send an to Quick tips for improvement 9 9 Develop a reminder system to help keep members up to date with screening. 99Educate members about the importance of breast cancer screening and provide educational resources such as the National Cancer Institute website: 99Provide members with information about screening procedures to help alleviate any anxiety or fear related to the screening. QIPS and Stars alert Breast cancer screening is a performance measure in the Quality Incentive Payment System (QIPS) program for measurement year 2015 for participating providers and is also a Medicare Stars measure. Source: 2014 State of Health Quality * The National Committee for Quality Assurance (NCQA) is the most The Healthcare Effectiveness Data and Information Set (HEDIS) is QIPS is a reimbursement system developed by Keystone Health Plan East for participating Pennsylvania primary care physicians that offers incentives for high-quality, accessible, and cost-effective care. Stars is a program developed by the Centers for Medicare & Medicaid Services to measure quality health care. Ratings are published annually to help educate consumers prior to enrollment decisions. October 2015 Partners in Health Update SM 10

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