2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Quality Improvement ProgramNCQA originally designed HEDIS ® for privateemployers so that they could compare health planservices before making purchase decisions. Theuse of HEDIS ® data has expanded to include publicpurchasers, regulatory agencies, and consumers.NCQA conducts surveys to assess a health plan’sability to meet specific standards and guidelines forquality improvement, utilization management,credentialing and recredentialing, member rightsand responsibilities, and member communicationsusing the internet.When a health plan is accredited by NCQA, it isrequired to prepare and submit an annual HEDIS ®report as a way of continuously measuring qualityof care. The HSD requires HEDIS ® reporting forhealth plans contracted to provide Medicaidbenefits.What quality performance measures are included inthe reports?Effectiveness of care measures look at clinicalquality of care, such asChildhood immunizationsBreast and cervical cancer screeningChlamydia screeningControl of high blood pressureCholesterol managementDiabetes careUse of appropriate asthma medicationsFollow-up after hospitalization for a mentalillnessAntidepressant medication managementColorectal screeningAccess and availability of care measures look athow members access services from their healthcare system, such asAdults’ access to preventive/ambulatoryservicesChildren’s access to primary care practitionersPrenatal and postpartum careAnnual dental visitsSatisfaction with the experiences of caremeasures look at the members’ experiencewith their health plan, such asRating of all health careRating of the health planRating of personal practitionerRating of specialist seen most oftenClaims processingCustomer serviceGetting care quicklyGetting needed careUse of services measures look at information abouthow health plans manage the care provided to theirmembers, such asFrequency of ongoing prenatal careFrequency of selected proceduresInpatient/outpatient utilizationMental health utilizationWhere does HEDIS data come from?HEDIS ® data is collected from a sample of healthcare claims and encounters, enrollment forms,surveys, and medical records. Most of the dataincludes information from the previous calendar12-122014 Practitioner and Provider Manual - Ver. 3