NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards

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Impact of HEDIS on Health Plans
27 July, 2017| Author: Sheetal Sawardekar, Sr. Healthcare Consultant
CitiusTech Thought
Leadership
* HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

2. 2
Agenda
 Objective of NCQA Accreditation
 HEDIS rating scale for health plan
 Listing of health plan ratings at NCQA
 How is HEDIS data acquired?
 Business advantage of NCQA ratings
 HEDIS domains and comparison with previous version
 Incremental changes between HEDIS 2016 and 2017
 Implementation timelines for HEDIS 2017
 References

3. 3
Objective of NCQA Accreditation
 NCQA’s Accreditation process provides payers with a comprehensive framework to improve
quality of care and services.
 It allows members and employers to compare health plan performance across various plans and
against industry benchmarks.
 NCQA accreditation has 3 parts – HEDIS, patient experience CAHPS measures and NCQA
standards.
 Once accredited, NCQA publishes health plan ratings for public viewing.
HEDIS
(Weightage: 37%)
CAHPS
(Weightage: 13%)
NCQA Standards (Weightage: 50%)
+

4. 4
HEDIS Ratings Scale for Health Plans
 NCQA’s Health Insurance Plan Ratings lists down both NCQA accredited and non-accredited
private, Medicare and Medicaid health insurance plans based on their combined HEDIS, CAHPS®
and NCQA accreditation standards scores.
Lower performance Higher performance
 Starting 2015, NCQA used the new rating methodology which classified plans into scores from 0-
5 in 0.5 increments - a system similar to CMS Five Star Quality Rating System.
 With NCQA’s permission and licensure, consumer reports references the NCQA Health Insurance
Plan Ratings on its website.
 Like CMS Star computation methodology, weightage is assigned to a type of measure for
calculating the ratings:
• ‘1’ = Process measures (e.g. screenings, visits, etc.)
• ‘1.5’ = Patient Experience measures
• ‘3’ = Outcome measures (e.g. HbA1c Control, BP Control, etc.)
1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

5. 5
Listing of Health Plan Ratings at NCQA
 NCQA publishes ratings for each accredited health plan on its website as a ready reckoner
of plans performance.
 The summary report displays health plan rating over the assessment year along with a
detailed report.

6. 6
How is HEDIS Data Acquired?
Data Collection Methods:
 Clinical measures use the administrative or hybrid data collection methodology, as specified by
NCQA.
• Administrative Method: Data is derived from claims and encounters, and is submitted to
NCQA through the Interactive Data Submission System (IDSS).
• Hybrid Method: Data is selected from random sample of the population and allowed for
supplementation of administrative data. Supplemental data are sources other than claims and
encounters like lab reports, EMR records, immunization records, etc. (IDSS).
 For survey measures, data is collected directly from the certified survey vendor.
• Survey Method: Data is obtained from member and provider survey via the Healthcare
Organization Questionnaire (HOQ).
NCQA is also piloting a new option for health plan quality reporting in HEDIS – Measures Using
Electronic Clinical Data Systems (ECDS) – which expands the use of electronic data (EHRs, clinical
registries, HIEs, administrative claims systems etc. ) to encourage interoperability for quality
measurement.
Health Plans
(Medicare, Medicaid &
Commercial)
HEDIS Data Submission
Using HOQ & IDSS

7. 7
Business Advantage of NCQA Ratings
 Guidance for P4P Measures
 Part of CMS Star which can
impact health plans’
revenue; upto 5% for quality
bonus payments and upto
70% as part of rebates of
difference in plan bid and
benchmark
 Part of NCQA accreditation;
the industry’s gold standard
 Enhanced effectiveness of
care
 Improved clinical and quality
outcomes
 Ensures health plans are
offering quality preventive
care and service to members
 Increased insight on patient
disease, comorbidity and
care management
Financial & Clinical
 Ensured availability of care
 Focus on processes of care,
directly actionable for
quality improvement
activities
 Patient feedback turned
into actionable intelligence
 Enhanced care coordination
 Improved resource
utilization
 Actionable intelligence to
improve operational
performance
Operational
 NCQA Ratings published on
consumer reports
 Gateway to Health
Insurance Marketplace
 Plan-to-plan comparisons
by quality, national &
regional benchmarks apart
from price (Quality
Compass)
 Qualify plans to provide
HMO services to MA
enrolees
 Centrepiece of most health
plan "report cards"
 Higher member retention
Competitive
Advantage

8. 8
HEDIS Domains and Comparison with Previous Version
# Domains (2017) Description Number of measures
2017 2016 2015
1 Effectiveness of Care Quality of clinical care
Impact of care delivered
52
Retired: 1
Added: 2
51
Retired: 1
Added: 2
50
2 Experience of Care Member satisfaction survey 3 3 3
3 Access/Availability of Care Assess how many members use basic plan
services
6
Retired: 1
7 7
4 Utilization and Risk
Adjusted Utilization
Assess how a health plan manages and
expends its resources
15
Added: 1
14
Added: 3
18
5 Relative Resource Use Indicate how intensively health plans use
resources
Standardize total cost of care across
different clinical areas
5 5
6 Health Plan Descriptive
Information
Plan’s structure, staffing and enrollment
characteristics & ability to provide
effective care
6
Retired: 1
7 7
7 Measures collected using
electronic clinical data
systems
Assess the quality of depression care
This data is challenging to collect through
typical HEDIS reporting methods
2
Added: 1
1
Added: 1
0
TOTAL 89 88 85

9. 9
Incremental Changes between HEDIS 2016 and 2017
Category Changes
General Exclude members who use hospice services or elect to use a hospice benefit any
time during the measurement year, regardless of when the services began
Effectiveness of Care Retired: Human Papillomavirus Vaccine for Female Adolescents (Note: It has been
added as a new indicator in the Immunizations for Adolescents measure)
Added:
 Follow-Up After Emergency Department Visit for Mental Illness
 Follow-Up After Emergency Department Visit for Alcohol and Other Drug
Dependence
Revised: Added a requirement to not include denied claims in the numerator for 6
measures i.e. URI, AAB, LBP, APC, DDE, DAE, valueset updates, other minor updates
Experience of Care Revised: Minor updates
Access/Availability of Care Retired: Call Answer Timeliness
Revised: Minor updates
Utilization
and
Relative
Resource
Use
Utilization and
Risk Adjusted
Utilization
Added: Standardized Healthcare-Associated Infection Ratio
Revised: Minor updates
Relative Resource
Use
Revised: Added HIV Type 2 Value Set to required exclusions, minor updates
Health Plan Descriptive
Information
Retired: Weeks of Pregnancy at Time of Enrollment
Revised: Minor updates
Measures collected using
electronic clinical data systems
Added: Depression Remission or Response for Adolescents and Adults
Revised: Minor updates

10. 10
Calendar
Year
Current Year 2017
12-month
(Jan 1–Dec 31, 2016)
Evaluation
Period
Accreditation /
Certification
Period
Awarded in 2017 for
2017 Measure Set
By June 15, 2017
HEDIS 2017 Measure
set(released in Sep 2016)
Reporting Period,
Measurement Period
Submission Period Financial Year
Implementation Timelines for HEDIS 2017
HEDIS reflects health plan performance and their focus on quality outcomes thereby comparing
plan performances on all important aspects of care and quality.

11. 11
References
 http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-data-submission
 http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2016/HEDIS%202016%20List%20of%20Measures.pdf
 http://www.ncqa.org/hedis-quality-measurement/hedis-measures/hedis-2016
 www.ncqa.org/Portals/0/Policy%20Updates/HEDIS%20Measures%20and%20Points%20for%20Reporting%20Y
ear%202016.pdf
 http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDISDataSubmission.aspx#sthash.j5Zwxo
Ut.dpuf
 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/QualityInitiativesGenInfo/Downloads/2015-QRS-Measure-Technical-Specifications.pdf
 Measure Rotation Concept:
http://www.ncqa.org/Portals/0/PublicComment/HEDIS2016/14.%20General%20Guidelines%2012-16.pdf
 Relative Resource Use: http://www.ncqa.org/tabid/1276/Default.aspx#sthash.hYE2B6Dr.dpuf
 Health Insurance Plan Rankings: http://www.ncqa.org/report-cards/health-plans/health-insurance-plan-
rankings
 Health Plan ratings: http://www.ncqa.org/report-cards/health-plans/health-insurance-plan-ratings/ncqa-
health-insurance-plan-ratings-2015#sthash.M8vXDeYo.dpuf
 Accreditation Levels: http://www.ncqa.org/programs/accreditation/mco-accreditation/accreditation-levels
 Ratings 2017:
https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/Ratings2016FAQs_Final_3.17.16
.pdf?ver=2016-03-21-160657-990

12. Thank You
Author:
Sheetal Sawardekar
Sr. Healthcare Consultant
thoughtleaders@citiustech.com
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