Where do I begin? There were many levels of failure – from the member to the provider to the health plan – even as high as NCQA and their difficult specifications for some of the measures. Let’s start at the top.
The Technical Specifications for some of the measures contain gray areas. Rules are interpreted differently. One company says you can use a BP from any specialty as long as it is in the provider's chart while others say the BP must be from a provider who can manage BP.
Example: One company used the BP from an optometrist because it was in the PCP’s chart as the last BP of the year. Another company says only use the BP from a PCP, nephrologist, or cardiologist. Not everyone has/can read all the Q&A at NCQA to know all the answers.
Another problem I see with NCQA is Colorectal Cancer Screening – how can it be possible for a health plan to review TEN YEARS worth of records to find a colonoscopy? That would be a very time-intensive task. I don’t know about you but I DO NOT want to request ten years’ worth of records from any provider’s office.
THE HEALTH PLAN
Then there is the health plan with its’ many moving parts – internal staff, contractors, temps, clinical and non-clinical. How seasoned are these people? Does everyone know the HEDIS guidelines? I was over-reading charts for Colorectal Cancer Screening. I pointed out to an abstractor that she missed a mention of a colonoscopy in 2011. The documentation was dated correctly and worded correctly – she said to me “but we don’t have a copy of the colonoscopy.” As you know we don’t need the actual test itself – just the correct documentation. Does your HEDIS staff know all the rules? We were only over-reading 10% -- so I wonder how many were missed. I had another “temp” who did not capture any pain screenings unless it actually stated “pain screening.” I am sure a lot of these were missed since we were only reviewing 10%.
Another problem was the setting up of the initial HEDIS chart requests. We had requested sent to optometrists for mammograms or requested for HbA1cs at GI specialists. Our data “scrub” was not done by the people more familiar with the providers. By the time, it was noticed that the requests needed to go somewhere else – we were halfway into HEDIS season.