Assigning ownership to measures helps plan improve its scores
Assigning ownership to measures helps plan improve its scores
Staff are responsible for quality-of-care measures
An initiative that assigns "ownership" of HEDIS®* measures to various staff members has resulted in improved HEDIS scores and national acclaim for Keystone Health Plan Central, a wholly owned subsidiary of Capital BlueCross, independent licensees of the Blue Cross Blue Shield Association.
Management-level staff are assigned responsibility for each HEDIS Effectiveness of Care measure and are responsible for constantly monitoring the measure and creating quality improvement activities.
As a result of the initiative, HEDIS scores improved, and the plan’s HMO, Keystone Health Plan Central, was recognized by the National Committee for Quality Assurance (NCQA) as one of the top five best-performing commercial health plans in effectiveness of care in the Middle Atlantic region.
Effectiveness of Care measures indicate how well a health plan performs in making sure members are receiving necessary care for conditions that relate to significant health issues such as cancer, heart disease, smoking, asthma, and diabetes.
The health plan began its initiative to improve HEDIS scores several years ago, according to Elizabeth Barnett, BSN, JD, vice president for clinical management.
"When we got back our scores, we identified opportunities for improvement. We looked at both those far-ranging opportunities without losing track of the measures on which we were doing well," she says.
The health plan’s HEDIS scores have improved every year since the initiative began, Barnett reports.
"In some cases, we’re already into the 90% range, leaving a small margin for improvement. Each year, we target areas of opportunity and continue to work on all of the measures," she says.
The management team decided that the quality improvement goals were too far-reaching to be the responsibility of just two or three people. Instead, management-level staff were assigned responsibility for each HEDIS measure.
It was obvious who would be responsible for some of the measures, Barnett says.
For instance, the manager of disease management "owns" the measures related to diabetes. She and her team keep up with the latest clinical practice guidelines, pull data from the health plan’s database to see what is going on with patients, study the interventions the plan makes with members, and work with physicians to better manage care for members with diabetes.
The medical director with pediatric expertise was in charge of the pediatric immunization measures. The tobacco cessation educator was responsible for the tobacco cessation programs.
In the case of measures where the health plan didn’t have programs to improve those measures, the management team identified staff who might be able to develop programs.
"In some cases, we didn’t have people with the necessary skill sets, but we did have an organization need," Barnett says.
The first step in a quality improvement program is making sure that there is ownership of the measure because ownership is a year-round activity, Barnett says.
The responsibilities are twofold for people who own the measures. They make sure that the HEDIS measures are not adversely affected when the health plan makes changes from an organizational perspective.
They also are responsible for making recommendations for the program about how the process can be improved. They monitor what other health plans are doing and identify changes that would benefit their members.
The health plan has task forces that concentrate on preventive health, conditions and disease management, and service. The owners of the measures sit on the task force. When the HEDIS scores are calculated, each task force analyzes the data and looks at areas where the plan should focus during the next year.
"We look at our population, determining if the demographics have changed, if the primary disease conditions have changed, if the preventive measure rates have changed. We look at anything from our population that can affect our scores or indicate that an area should be a priority," Barnett says.
One initiative concentrated on obtaining laboratory values from the providers, rather than having to collect the information from the members’ individual charts.
"We want to know not just that the laboratory tests were performed but what the values were. Because we had a unique relationship with these providers, we were able to negotiate a way to capture that information and feed it into our care management process," Barnett explains.
Now, the laboratory data from the vendor are incorporated into the care management system, giving the nurse case managers access in real time to the lab values.
"It really helps our nurses manage and helps the HEDIS data overall," Barnett says.
Another project was aimed at improving rates of retinal examinations for diabetics.
"These rates are relatively low across the industry and represented a big area of opportunity," Barnett says.
The team determined that the requirement for a referral sometimes is an obstacle for members who need the examination and that some members avoid the exams because of the copay requirements.
The team designed an educational flyer that is sent to all members with diabetes, allowing them to have an examination without a referral and authorizing the provider to conduct the examination without collecting a copay from the member.
Rather than rotating the measures over time as NCQA allows, Capital BlueCross measures each element every year.
"This allows us to track improvements over time and to understand how we are managing these patients," Barnett says.
Disease management programs
When the NCQA announces new HEDIS measures, Capital BlueCross starts assigning staff for those measures and starts thinking about how to improve them even before they are part of the HEDIS scores.
The plan finetunes its HEDIS data to eliminate members who don’t meet HEDIS criteria and to capture data from all members who do.
"We work to really understand who are the members who fit into HEDIS criteria and who doesn’t," Barnett says.
For instance, a member may have been prescribed an inhaler for a one-time incidence of exercise-induced asthma but does not, in fact, have asthma. This member would be eliminated from the HEDIS data.
"As the disease managers interact with the members, they identify whether they are appropriate to be included in the HEDIS measures. We work with providers to determine which members may appear to be appropriate but who are not," Barnett explains.
For instance, a member who had a bilateral mastectomy may not be appropriate for a mammogram.
The health plan’s quality nurses go into the field and capture data from patient records at physician offices. The quality nurses are assigned regionally to a group of physicians and hospitals to work on credentialing and quality improvement measures, as well as HEDIS data collection.
If the administrative data do not show that an eligible member received the services that are included in HEDIS measures, the quality nurse goes to the physician office and reviews the chart.
The nurse talks with the physician staff to find out if there is another way the member might have received the service — for instance, from the OB/GYN instead of the primary care physician.
"Some plans have the doctor fax back the information or work with a data collection vendor. We have found it more effective to go on site," Barnett says.
For instance, if the information isn’t in the chart, the nurse already has an established relationship with the provider and the office staff who are willing to work with someone they know to track down the information.
Disease management programs represent Capital BlueCross’s best opportunities to improve quality of care and to create programs that make the plan attractive to employer groups, Barnett points out.
"Our broad range of disease management programs set us apart from other carriers because we manage the care for the high-end, high-cost members but also have preventive health programs targeted to the healthy and at-risk members," she says.
The health plan stratifies its population into healthy and at-risk categories as well as chronic and catastrophic categories so they can target the messages to the members.
With the healthy and at-risk populations, the plan concentrates on preventive health management.
The chronically ill are invited to participate in a wide range of disease management programs aimed at improving their quality of life and educating them to better manage their conditions, resulting in improved medical costs.
Case managers coordinate the care for the catastrophically ill or injured patients.
"People with chronic illnesses have higher medical costs than other members. Because employer groups are looking to cut medical costs, they appreciate the mechanisms we have in place to control overall costs and increase quality of care," Barnett says.
*HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
An initiative that assigns ownership of HEDIS®* measures to various staff members has resulted in improved HEDIS scores and national acclaim for Keystone Health Plan Central, a wholly owned subsidiary of Capital BlueCross, independent licensees of the Blue Cross Blue Shield Association.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.