Medicare Payment Policy

eport HEDIS measures based on administrative data only. To
assure that all PPOs are compared on equal grounds based on
data collection methodologies, NCQA will not accept results
based on hybrid data from PPOs.” (National Committee for
Quality Assurance. PPO HEDIS Requirements for Health
Plan Accreditation 2010 Products Update – Draft Changes,
Appendix 4. Washington, DC: 2009. (NCQA public comment
document, obsolete after 4/1/09.))
13 Several HEDIS measures are reported only by SNPs, all of
which are based on medical record documentation. All these
measures showed statistically significant improvement in
average rates between 2011 and 2012: medication review,
functional status assessments, pain screening (the three
measures included in the star rating system), advance care
planning, and medication reconciliation postdischarge. The
three SNP-only measures in the star rating system are a factor
in determining the star rating of contracts that are exclusively
SNP contracts; they are also factors for determining the star
ratings of organizations that have both SNP and non-SNP
members under one contract.
14 As we have noted, plans have the option of reporting hybrid
measures using only administrative data, and an organization
with good electronic medical records, for example,
may choose to report a measure solely on the basis of
administrative records. To cite an example, for the measure for
colorectal cancer screening, which has a nine-year look-back
period to determine whether a beneficiary had a colonoscopy,
about 5 percent of plans appear to be reporting based on
administrative data, according to an analysis of the confidence
intervals for the reported results.
15 There is similar regional variation in health plan performance
in the commercial sector (National Committee for Quality
Assurance 2011).
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