Tag Archives: qualified reporting

Using administrative claims data for quality reporting

Developing healthcare quality metrics based on administrative claims data has become increasingly common over the past several years. The National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set (HEDIS) measures have been a standard for health plan quality reporting for over two decades, and more recently, newer programs such as the Centers for Medicare & Medicaid Services (CMS) Pioneer Accountable Care Organization (ACO) program and Oregon Coordinated Care Organization program have included claims-based quality measures as requirements for program participation.

Most claims-based measures are process-based, evaluating if appropriate services are provided for specified groups of patients, or identifying potential overutilization of services, but claims data are not the sole source of quality measurement. Survey data are often used for patient satisfaction and operational measures, and there is increasing use of lab results and electronic health record (EHR) data to expand the clinical components of quality that can be measured—a topic for another posting.

Despite the expansion of claims-based quality measures, some still question their merit. Those citing concerns point out known limitations associated with analyzing claims data, including:

• Potential errors or inconsistencies in coding.
• Availability of required data sources may be constrained if components of benefits are administered by multiple sources.
• Lack of complete clinical information.
• No diagnostic coding for blood pressure, laboratory results, or pathology results.
• Clinical information is limited to conditions for which the patient was treated and submitted a claim. A noncompliant diabetic may have no claim history of the disease.
• Timeliness of data is impacted by claim lag.

However, the advantages of analyzing claims data greatly outweigh the limitations noted above. The advantages include:

• Data are commonly available and relatively inexpensive to analyze
• Data are available for very large populations, allowing for more robust sample sizes
• Coding accuracy has improved dramatically over the past 20 years
• For some types of measures, claims may produce a more accurate picture than even chart reviews

An example of this last point would be measures focusing on patient compliance with medications. A physician may regularly write refill prescriptions for a patient’s hypertension medication, and those refills may be well documented in the patient’s chart, but those data provide no real evidence that the patient filled those prescriptions. Tracking actual claims for prescription refills is a much better measure. Granted, submitting a claim for a hypertension medication does not prove that the patient actually took the medication at the appropriate frequency, but a regular, ongoing refill pattern is a better proxy of medication adherence than chart review information.

Days supplied is commonly available on claims data, making it easy to calculate “possession ratios” to monitor patient compliance from pharmacy claims. A simplistic way (additional conditions can be added to the calculation) to measure possession ratios is demonstrated in Table 1 below. For patients continuously enrolled during a 180-day period and previously diagnosed with hypertension, the possession ratio for each patient is the sum of all days supplied on their prescriptions during the study period, divided by 180 days.

Although claims data are not perfect for clinical reporting, they will continue to be a valuable and important source of data for quality reporting for a selected set of metrics.

This article first appeared at Milliman MedInsight.

Access to my data: The provider portal

Changes in reimbursement frameworks have increased the need for doctors to access meaningful, timely physician profile reporting.

There are many variations in what gets presented in physician profile reporting as well as how and when it is delivered. In July 2012, the American Medical Association (AMA) launched its Physician Reporting Guidelines in an effort to provide a physician perspective in profile reporting. The guidelines called for the need to be easy to understand, to be easy to access, and to provide an opportunity for review of detailed data. While the AMA reporting guidelines also called for standardized reporting, that remains a significant work in progress.

Technology and data availability continue to improve and have given rise to sharing information through provider or physician portals. There is a great deal of work on the front end to gather data, select measures, and validate all this data before release. Today, we scratch the surface of physician portals and share some examples and considerations in their design.

The critical elements in the design and implementation of a physician portal require early inclusion of physicians in the planning and design process. In accordance with the AMA Reporting Guidelines, it should also address ease of use, availability of actionable information, and ability to drill into member detail.

Dashboards are a popular method for sharing information through a portal. They provide for an accessible, visual, and portable look for physicians. This type of display can begin at a higher level such as the medical group and then allow for drill-down to individual providers and then to their members. Depending on the tool and data sources, the provider portal can include claims and electronic health records (EHR) data reporting. Retrospective data is very valuable in providing insights into opportunities for change. The claims-based examples below allow for review of the retrospective performance as well as provide transparency and insight into prospective issues, using risk assessment results and other mainstream methodologies.

Lastly, providing the option to submit feedback is a critical element for provider portals. Through the portal, the physician can be given access to submit requests to update or revise the data, and related results, based on additional information. The workflow of this process should be a significant consideration in the planning process to define standard reasons.

There is a great deal of planning involved in determining the specific metrics and the data visualization option but with early physician engagement and thorough data governance rules, the physician portal is a valuable tool in broadening the engagement of physicians.

This article first appeared at Milliman MedInsight.