Appendix 4. Calculating the Total HEDIS Score
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1 Appendix 4 Calculating the Total HEDIS Score
2 2013 HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
3 Appendix 4 Calculating the Total HEDIS Score 4-1 APPENDIX 4 CALCULATING THE TOTAL HEDIS SCORE SCORING EXAMPLE This example uses a fictional organization and data to illustrate how NCQA calculates the HEDIS portion of the overall accreditation score. While the example reflects calculations for a commercial plan, the same steps can be used to calculate the points for Medicare and Medicaid product lines. To calculate the Medicare and Medicaid product lines, use Tables 4A 5D on pages 4-11 through There are different sets of HEDIS and CAHPS measures for each product line. The following steps demonstrate how NCQA calculates the score for the commercial product line of the ABC Health Plan in Maryland. A. Calculate the total HEDIS measures score Step 1: Assign the health plan to the appropriate CMS region based on the plan s location. Because the ABC Health Plan is in Maryland, it is assigned to Region 3: Philadelphia. Step 2: Determine the overall number of NAs and NBs for HEDIS measures (refer to Tables 3A 3D). An organization with more than eight HEDIS measure NA results is scored on standards and CAHPS only. An organization that has more than four CAHPS NAs or that exceeds the 10 NA results between HEDIS and CAHPS for each product line is scored based on the standards score only. The highest status an organization can achieve on standards and CAHPS only and on standards only is Commendable. Step 3: Add 2 percentage points (subtract 2 percentage points for measures where smaller is better) for the sampling variation adjustment for each measure result. Refer to the Policies and Procedures for information on the adjustment-point phase. Compare the organization s HEDIS measure results to the regional thresholds and national benchmark and thresholds (refer to the current Accreditation s and s, posted on NCQA s Web site) and determine the highest percentile that each result meets or exceeds. Record each. The example includes the adjustment points added to each HEDIS measure result prior to scoring. Step 4: After the determination of NAs and the comparison to s and s (step 2 and step 3) has been made, use Table 1 to assign points to each result based on the highest regional percentile met or exceeded and points for the highest national percentile met or exceeded. Step 5: Average the regional threshold points and national threshold points for each measure. Use the combined average or the points from national benchmark, whichever is higher. Step 6: Add the points for all measures to calculate the aggregate score for the HEDIS measure results. Table 1 illustrates steps 1 6. Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
4 4-2 Appendix 4 Calculating the Total HEDIS Score B. Calculate the total CAHPS 5.0H score Step 1: For CAHPS 5.0H results, assign the health plan to 1 of 10 regions. Because the ABC Health Plan is in Maryland, it is assigned to Region 3: Philadelphia. Step 2: Determine the overall number of NAs and NBs for CAHPS 5.0H. Step 3: Add the sampling variation adjustment of 2.8 percentage points for the four CAHPS rating results and the Claims Processing and Customer Service results and 2 percentage points for Getting Needed Care, Getting Care Quickly and How Well Doctors Communicate composites. Refer to page 50 of the Policies and Procedures for information on the adjustment-point phase. Compare the organization s CAHPS 5.0H results to national benchmark and thresholds (refer to the current Accreditation s and s, posted on NCQA s Web site) and determine the highest national percentile that each result meets or exceeds. record each. The example includes the adjustment points added to each CAHPS result prior to scoring. Step 4: After the determination of NAs and the comparison to s and s (step 2 and step 3) has been made, use Table 2 to assign points to each result based on the highest percentile met or exceeded. Step 5: Add the points for all measures to calculate the aggregate score for the CAHPS 5.0H results. ABC s score is Table 2 illustrates steps 1 5. C. Calculate the overall score Add the aggregate points from the HEDIS measures and HEDIS/CAHPS 5.0H results. This is the total HEDIS score. ABC s score is: Total HEDIS measure points: Total HEDIS/CAHPS 5.0H points: Total HEDIS points: D. Determine the accreditation status level To determine the accreditation status level, add the total HEDIS score to the score from the health plan s performance on the accreditation standards and compare the overall score to the scoring ranges for each accreditation status level listed in the table below. Accreditation statuses are determined by the Review Oversight Committee (ROC), ABC s status is Commendable based on the following calculation. Commercial Product Total HEDIS points: Total standard points: Overall score: Accreditation status: Commendable 2013 HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
5 Appendix 4 Calculating the Total HEDIS Score 4-3 The following tables illustrate calculation of the total HEDIS and HEDIS/CAHPS scores. Table 1 shows the calculations for HEDIS scoring. Table 2 shows the calculations for HEDIS/CAHPS scoring. Table 1: HEDIS Measure Results and s Note: The thresholds used in this example do not represent actual thresholds used to score health plans undergoing NCQA Accreditation. Actual thresholds are posted on the NCQA Web site ( Points are rounded to three decimal places for illustration only; for actual scoring, NCQA does not round or truncate decimals. (Commercial) HEDIS Measure ABC s Rate, Including the Adjus tment Regional Point Allocation National or Rate Point Allocation Averaged Points or National Rate (Whichever Is Higher) Adult BMI Assessment Antidepressant Medication Management (Acute Phase and Continuation Phase) Appropriate Testing for Children With Pharyngitis Appropriate Treatment for Children With Upper Respiratory Infection* Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Breast Cancer Screening Cervical Cancer Screening (Total Rate) Childhood Immunization Status (Combination 2) Chlamydia Screening in Women (Total Rate) Cholesterol Management for Patients With Cardiovascular Conditions (LDL-C Screening Only)* * * Colorectal Cancer Screening Comprehensive Diabetes Care (Eye Exam, HbA1c Testing, LDL Screening, Medical Attention for Nephropathy)** Comprehensive Diabetes Care HbA1c Poorly Controlled (>9.0%) * Indicates measures that may involve special scoring rules. Refer to the current s & s document for descriptions of special scoring. For this measure, plans with reported rates at or above the regional percentile receive 100% of the regional points. Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
6 4-4 Appendix 4 Calculating the Total HEDIS Score Table 1: HEDIS Measure Results and s (continued) Regional National or Rate Averaged Points or National Rate (Whichever Is Higher) (Commercial) HEDIS Measure ABC s Rate, Including the Adjus tment Point Allocation Point Allocation Controlling High Blood Pressure Flu Shots for Adults (Ages 50 64) Follow-Up After Hospitalization for Mental Illness (7-Day Rate Only) Follow-Up for Children Prescribed ADHD Medication (Initiation Phase and Continuation Phase) Medical Assistance With Smoking and Tobacco Use Cessation (Advising Smokers and Tobacco Users to Quit Only) Persistence of Beta-Blocker Treatment After a Heart Attack Pharmacotherapy Management of COPD Exacerbation (Dispensed a Systemic Corticosteroid within 14 days of the Event, Dispensed a Bronchodilator within 30 days of the Event) Prenatal and Postpartum Care (Timeliness Postpartum Care) Use of Imaging Studies for Low Back Pain Use of Spirometry Testing in the Assessment and Diagnosis of COPD Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (BMI , Counseling for Nutrition, Counseling for Physical Activity) Total HEDIS Measure Points * Indicates measures that involves special scoring rules. Refer to the current s & s document for descriptions of special scoring. For this measure, plans with reported rates at or above the regional percentile receive 100% of the regional points. ** Comprehensive Diabetes Care is worth twice the points of other HEDIS measures. Only the final column figure has been doubled. Note: Data presented are based on the 2011 Accreditation s & s ( figures meet or exceed values by region or national threshold, respectively. Values less than the next highest percentile range are grouped in the next lowest percentile range HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
7 Appendix 4 Calculating the Total HEDIS Score 4-5 Table 2: HEDIS/CAHPS 5.0H Commercial Results Note: The thresholds in these example do not represent the actual thresholds used to score plans undergoing NCQA Accreditation. Actual thresholds are available on the NCQA Web site ( Points are rounded to three decimal places for illustration only; for actual scoring, NCQA does not round or truncate decimals. (Commercial) CAHPS 5.0H Survey Result ABC s Rate, Including the Adjustment National or Rate ( Exceeds) Points Claims Processing Customer Service Getting Care Quickly Getting Needed Care How Well Doctors Communicate Rating of All Health Care Rating of Health Plan* Rating of Personal Doctor Rating of Specialist Seen Most Often Total CAHPS 5.0H Survey Points Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
8 4-6 Appendix 4 Calculating the Total HEDIS Score Point Allocations for Organization With NA Tables 3 5 provide the points for organizations with one or more NAs for a HEDIS or HEDIS/CAHPS measure. Table 3A: Commercial HMO/POS/PPO HEDIS Point Allocation With a Reportable Rate on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only or on standards only *Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table. Table 3B: Commercial HMO/POS/PPO HEDIS Point Allocation With NA on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only or on standards only *Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
9 Appendix 4 Calculating the Total HEDIS Score 4-7 Table 3C: Commercial HMO/POS/PPO HEDIS/CAHPS Point Allocation With a Reportable Rate on Rating of Health Plan* CAHPS Rate the Scored on standards only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than 8 HEDIS measures or 4 CAHPS NAs, or which exceed 10 NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Table 3D: Commercial HMO/POS/PPO HEDIS/CAHPS Point Allocation With NA on Rating of Health Plan* CAHPS Rate the Scored on standards and HEDIS only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than four HEDIS measures or four CAHPS NAs, or which exceed six NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
10 4-8 Appendix 4 Calculating the Total HEDIS Score Table 4A: Medicare HMO/POS/PPO HEDIS Point Allocation With a Reportable Rate on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only * Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table. Table 4B: Medicare HMO/POS/PPO HEDIS Point Allocation With NA on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only * Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
11 Appendix 4 Calculating the Total HEDIS Score 4-9 Table 4C: Medicare HMO/POS/PPO HEDIS/CAHPS Point Allocation With a Reportable Rate on Rating of Health Plan* CAHPS Rate the Scored on standards only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than 8 HEDIS measures or 4 CAHPS NAs, or which exceed 10 NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Table 4D: Medicare HMO/POS/PPO HEDIS/CAHPS Point Allocation With NA on Rating of Health Plan* CAHPS Rate the Scored on standards only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than four HEDIS measures or four CAHPS NAs, or which exceed six NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
12 4-10 Appendix 4 Calculating the Total HEDIS Score Table 5A: Medicaid HMO/POS/PPO HEDIS Point Allocation With a Reportable Rate on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only *Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table. Table 5B: Medicaid HMO/POS/PPO HEDIS Point Allocation With NA on Comprehensive Diabetes Care* HEDIS Rate the Scored on standards and CAHPS only *Comprehensive Diabetes Care is worth twice the points and counts as two measures (plus 1) as indicated in the table HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
13 Appendix 4 Calculating the Total HEDIS Score 4-11 Table 5C: Medicaid HMO/POS/PPO HEDIS/CAHPS Point Allocation With a Reportable Rate on Rating of Health Plan* CAHPS Rate the Scored on standards only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than 8 HEDIS measures or 4 CAHPS NAs, or which exceed 10 NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Table 5D: Medicaid HMO/POS/PPO HEDIS/CAHPS Point Allocation With NA on Rating of Health Plan** CAHPS Rate the Scored on standards only * Rating of Health Plan is worth twice the points indicated in the table. Plans with more than four HEDIS measures or four CAHPS NAs, or which exceed six NAs, are scored based on the standards score only and the accreditation status is capped at Commendable. Effective for Surveys Beginning On or After July 1, HP Standards and Guidelines
14 HP Standards and Guidelines Effective for Surveys Beginning On or After July 1, 2013
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