First, it is important to understand what we are doing and why we are doing it. As you may know, HNE is accredited by the National Committee for Quality Assurance. Twenty-five percent of a health plan’s NCQA accreditation score is based, in part, on Health Plan Employer Data Information Set (HEDIS) performance measures, such as diabetes management, immunization rates, access to care and member satisfaction with the health plan and the doctors. Additional points are based on disease management programs and demonstrated significant improvement. HNE approaches this in two ways; member-focused interventions and provider-focused interventions. The panel report is one intervention targeted to physicians who serve patients identified for these programs.

The ability to collect data through administrative means (claims, encounter forms) is often difficult and not always complete. This leads HNE to the HEDIS hybrid methodology, which uses data collected from medical record audits to augment the incomplete administrative results. Health plans do not have any flexibility when using HEDIS parameters. This methodology is quite strict and only certain CPT4 codes are included. An example is the measurement of cholesterol. HEDIS recognizes the following CPT4 codes:

Although we understand that cholesterol may be included in a care panel, we are unable to utilize it in the actual measure. To complicate matters, CPT4 codes may change each year. Understanding how confusing all this can be, we began using panel reports to identify patients within each physician’s panel who meet the program criteria, whether it is diabetes, asthma, or secondary prevention of cardiovascular disease. When a value is missing, we request that the office check the member’s medical record and provide the information in the record and return to HNE. Once we receive updates to the panel reports we enter what we call a “pseudo claim” in our system. This value will then appear on future panel reports. The panel reports can also be used as a tool within your office to contact a patient who has not been in and is due for a checkup or screening.

We understand that the use of claims data is limited, and that this is a source of frustration for you. It is also a source of frustration for us; however, it is what we have to work with. If you would like additional information about the panel reports please contact Lynn Ostrowski at 787-4000, ext. 3383.

April 2003 HealthScript is a quarterly newsletter designed to update HNE providers on any procedural changes, product developments or innovative disease management programs underway at HNE. PDF Format

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