HEDIS Evaluation

Louisiana Healthcare Connections is committed to maintaining the necessary data for accurately assessing and comparing our plan’s performance against adopted HEDIS measures. A cross section of key staff from multiple departments serve on our HEDIS Steering Committee in order to provide strategic recommendations and dedicated oversight of the implementation of interventions designed to ensure state benchmarks are met.

The Louisiana Department of Health (LDH) identified more than 30 HEDIS measures to calculate annually. From those measures, LDH selected eight HEDIS and incentive measures for Louisiana Healthcare Connections to focus on. These focus HEDIS measures include:

  • Postpartum Care - The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
    • Numerator:
      • Complete PPC Visit
      • Cervical cytology
      • Providers may be asked to submit supplemental data (medical records) as some codes for PPC are bundled with the delivery codes. Woman who delivered a live birth on or between 11/6/2016 through 11/5/2017
    • Denominator: Woman who delivered a live birth on or between 11/6/2016 through 11/5/2017
  • Adolescent Well Visit - The percentage of enrolled members 12 – 21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN practitioner during the measurement year.
    • Numerator: At least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during 2017.
    • Denominator: Members 12 – 21 years of age as of December 31, the measurement year.
  • Follow-up Care for Children Prescribed ADHD Medication Initiation Phase - The percentage of children 6-12 who were newly prescribed ADHD medication who had a follow-up care visit within 30 days of when the medicine was dispensed.
    • Numerator: Initiation Phase – Member should receive an outpatient or follow up visit with a practitioner with prescribing authority, within 30 days after the date the medication was prescribed.
    • Denominator: Initiation Phase – Members 6-12 who were newly prescribed a ADHD medication between March 1, 2016 through February 28, 2017.
  • Follow-up Care for Children Prescribed ADHD Medication Continuation & Maintenance Phase - The percentage of children 6-12 who were newly prescribed ADHD medication who had TWO follow-up care visits within 300 days after the date the medication was dispensed.
    • Numerator: Continuation and Maintenance Phase – Member should receive TWO outpatient or follow up visits with a practitioner with prescribing authority within
    • Denominator: Initiation Phase – Members 6-12 who were newly prescribed a ADHD medication between March 1, 2016, through February 28, 2017.
  • HIV Viral Load - Percentage of patients, regardless of age, with a diagnosis of HIV with an HIV viral load less than 200.
    • Numerator: Number of members in the denominator with an HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
    • Denominator: All members with a diagnosis of HIV (042).
  • Initiation of Injectable Progesterone Therapy in Woman with Previous Pre-term Births - The percentage of women 15-45 years of age with evidence of a previous pre-term singleton birth event (<37 weeks completed gestation) who received one or more progesterone injections between the 16th and 24th week of gestation.
    • Numerator: Women who had at least one progesterone injection between the 16th and 24th week of pregnancy.
    • Denominator: Women who had at least one progesterone injection between the 16th and 24th week of pregnancy.
  • Cesarean Rate for Low Risk First Birth Woman - The percentage of cesareans in live births at or beyond 37 weeks gestation to women that are having their first delivery and are singleton (no twins or beyond) and are vertex presentation (no breech or transverse positions).
    • Numerator: Patients with CPT-4 procedure code for cesarean section.
    • Denominator: Nulliparous members with CPT-4 procedure code for outcome of delivery and with a delivery of a newborn with 37 weeks or more of gestation completed.
  • Diabetes Short-Term Complications - The number of discharges for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 member months for Medicaid enrollees age 18 and older.
    • Numerator: All discharges with ICD-9-CM principal diagnosis code for short-term complications of diabetes (ketoacidosis, hyperosmolarity, coma).
    • Denominator: Total number of months of Medicaid enrollment for enrollees age 18 and older during the measurement year.

Benchmarks

The list below shows each HEDIS and incentive measure and the corresponding state benchmarks:

  • Postpartum Care – (PPC): 63.12%
  • Adolescent Well Care – (AWC): 40.69%
  • Initiation for Children Prescribed ADHD Medicine – (IP): 36.43%
  • Continuation and Maintenance for Children Prescribed ADHD Medicine – (C&M): 43.32%
  • HIV Viral Load Suppression: 54.34%
  • Initiation of Injectable Progesterone Therapy in Woman with Previous Pre-term Births – (17-P): 20.00%
  • Cesarean Rate for Low Risk First Birth Women: 26.47%
  • Diabetes Short Term Complications: 17.5%
  • Ambulatory Care – (ED): 68.41%

Intervention Strategies

The following intervention strategies were developed and implemented to meet state standards.

Member-Focused Efforts:

  • Established a HEDIS call center to conduct outreach for the primary focus of helping members see their Primary Care Provider (PCP), schedule appointments and arrange transportation if necessary.
  • Offered gift card incentives to members who attended specific appointments.
  • Hosted health fairs in GSA-A, B and C and offered providers incentives to hold health fairs at their clinics on weekends.
  • Held Back to School events and distributed school supplies.
  • Utilized programs for sending immunization reminders to adolescent well-care and well-child members.
  • Mailed monthly birthday cards and screening reminders to all adolescent well-care and well-child members.
  • Care Gap Education
  • Care Manager outreach including member assessment and case management
  • Educated members and providers about the CentAccount program and its rewards.

Provider-Focused Efforts:

  • Provided practices with performance score cards and a list of non-compliant members.
  • Reviewed denied claims for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and worked with Provider Relations to resolve issues.
  • Partnered with provider groups to assist with scheduling member appointments.
  • Educated providers on coding and billing.
  • Care gap education
  • Distributed information to providers about our PMPM/Pay for Performance program.
  • Included information on HEDIS and incentive measures in provider newsletters.
  • Developed a process for collecting non-standard supplemental data to increase compliance rate on postpartum care. NOTE: Louisiana Healthcare Connections is continuing its efforts to collect supplemental data for the postpartum care measure by retrieving medical records from providers who used incorrect billing codes or failed to submit claims for postpartum care in 2015.

In addition to intervention initiatives, Louisiana Healthcare Connections identified the following challenges to address in promoting future improvements.

Member Challenges:

  • Consistently missed appointments despite phone call reminders
  • Missed screening deadlines
  • Reluctance to discuss screening results
  • Proximity of Primary Care Provider (PCP) assignment to members’ homes
  • Refusal of assistance with appointment scheduling

Provider Challenges:

  • Complications with billing and coding for services performed
  • Ability to accommodate all appointments
  • Awareness of member panel capacity
  • Seeing patients after-hours
  • Accepting appointment scheduling assistance

Louisiana Healthcare Connections will use all data to help improve the performance of our plan and to support our network providers in achieving our goal of providing excellent care to our members. Louisiana Healthcare Connections will refine and analyze these measures in 2016 for ongoing progress.

2014 HEDIS Outcomes

Louisiana Healthcare Connections uses HEDIS data to identify areas for improvement and monitor ongoing initiatives. Below are the 2014 results of the state-selected measures.

HEDIS 2015 Medicaid Benchmark 2014 Met?
Well child Visits (Ages 3-6) 64.41% 60.82% No
Adolescent Well Care Visits 42.36% 50.24% Yes
Adult Access 82.95% 81.43% No
Comprehensive Diabetes Care 80.37% 81.86% Yes
Chlamydia Screening in Women 59.25% 57.78% No

Postpartum Program Overview

The purpose of postpartum care is to maintain the health of a pregnant woman and her baby by providing necessary screenings and care between 21 and 56 days after delivery. A complete postpartum care visit should include:

  • An OB/GYN appointment between 21 and 56 days after delivery AND any of the following:
  • Pelvic Exam
  • Breast and Abdomen Exam with Vital Signs
  • Pap smear

Louisiana Healthcare Connections requests supplemental data to retrieve postpartum care records from provider offices. This helps ensure our members are getting the necessary screenings. Providers who complete postpartum visits and provide appropriate documentation as listed above receive a $50 incentive per postpartum visit.