Quality Tools
Provider Profiles
Introduction:
In order to assist busy clinicians in improving the quality of care, Illinois Health Connect will be sending each Primary Care Provider (PCP) a Provider Profile that summarizes each PCP’s performance on 20 clinical indicators. Provider Profiles will be sent semi-annually. In 2008, some PCPs may receive more than two Provider Profiles due to the initial implementation schedule.
The data reflected in the Provider Profiles is gathered from adjudicated claims data from the Illinois Department of Healthcare and Family Services (HFS). The use of claims data has some advantages. For example, if a patient receives a recommended immunization from the health department, that data can be captured and reflected in the Provider Profiles. On the other hand, claims data cannot always accurately reflect what happens in the clinical encounter. Accurate, complete and detailed submission of claims information will enhance the accuracy of the Provider Profiles.
A consensus process through the work of the Primary Care Case Management/Disease Management Quality Management (QM) Advisory Subcommittee selected the measures for the Provider Profiles. Participation in the QM Subcommittee is voluntary. The Subcommittee meets via teleconference quarterly. Anyone interested in participating in the QM Subcommittee can contact the Subcommittee Chairperson, Margaret Kirkegaard, MD, Illinois Health Connect Medical Director using our Online Contact Us form.
Provider Profiles will be posted on the Illinois Health Connect secure Provider Portal. In order to access the Provider Portal, providers or provider designees must obtain a digital certification through HFS’ Medical Electronic Data Interchange System (MEDI). The MEDI system links providers or provider designees to the IHC Provider Portal.
PDFs to download and review:
Provider Profile Summary Table:
The "Provider Profile Summary Table" was developed to assist PCPs in understanding the various clinical measures reflected on the Provider Profiles. Most of the measures are adapted from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). Expanded information about HEDIS measures can be obtained at http://www.ncqa.org/.
Explanation of "Provider Profile Summary Table":
- The first column of the table gives the definition of the clinical quality indicator.
- The second column is 2007 national comparison data for Medicaid patients from the NCQA. It shows, nationally across all Medicaid programs, what percentage of patients must receive the service to hit the national 50th percentile. While all of the measures are nationally recognized clinical standards of care, not every measure has a HEDIS definition and some of the measures on the Provider Profile have been slightly modified from the exact HEDIS format.
- The third column shows the CPT or ICD-9 codes that reflect the clinical criteria and allow the measure to be calculated from claims data. Practices are strongly encouraged to revise their charge sheets (superbills) to reflect these codes for consistent data collection.
- The fourth column provides some useful clinical references. Additional information about clinical standards and billing/coding can be found in the HFS Handbooks for Providers. The Handbook for Providers of Healthy Kids Services (Handbook Chapter 200-HK) is particularly useful for clinicians working with the pediatric population. Illinois Health Connect Provider Service Representatives can deliver a copy of the Handbook to your office (call 1-877-912-1999) or it can be downloaded from the HFS website (linked above).
Providers can obtain information about individual patients and whether they have received many of the clinical services reflected on the Provider Profiles by checking their Illinois Health Connect Panel Rosters. The Panel Rosters are mailed to each provider monthly and are available electronically via the Illinois Health Connect Provider Portal which can be accessed through HFS’ MEDI system. The electronic Panel Rosters are updated daily. Information on accessing the electronic Panel Roster through MEDI is available on the Illinois Health Connect website or you can contact the Illinois Health Connect Provider Relations Helpdesk for assistance at 1-877-912-1999.
Bonus Payment for High Performance 2008
The Illinois Department of Healthcare and Family Services is proud to announce its Illinois Health Connect Bonus Payment program for 2008. Under this program, qualifying Illinois Health Connect Primary Care Providers (PCPs) are eligible to receive annual bonus payments for each qualifying service under a bonus measurement.
What are the Bonus Measurements?
- Immunization Combo 3: Children who receive designated immunizations by age 24 months (benchmark 62.6%).
- Developmental Screening: Children who receive at least one objective screening by the age of 12 months (benchmark 35%), between the ages of 12 and 24 months (benchmark 25%), and between the ages of 24 and 36 months (benchmark 20%). A bonus will be available for each separate age group.
- Asthma management: Patients with persistent asthma, ages 5-9 years (91.7%), ages 10-17 years (benchmark 88.8%) and ages 18-56 years (benchmark 85.4%) who fill an asthma controller medication prescription.
- Diabetes Management: Patients with diabetes, ages 18 to 65 years who receive at least one HbA1c test annually (benchmark 79.3%).
- Breast Cancer Screening: Women ages between ages 40 and 69 who have had a mammogram in the last two years (benchmark 49.2%).
Who is a qualifying PCP?
A qualifying PCP is an Illinois Health Connect PCP who meets or exceeds the 2007 HEDIS 50th percentile benchmark collectively for all the Illinois Health Connect enrollees on their panel roster for a particular measure, or, in the case of developmental screening, the benchmark target set forth above. A PCP may be a qualifying PCP for one or more measurement.
What is HEDIS?
HEDIS is the Healthcare Effectiveness Data and Information Set, which is a natfional reporting system administered by the National Committee for Quality Assurance (NCQA) to measure performance on a number of important measures of care and service. Most commercial health plans and state Medicaid programs utilize these measures. National benchmarks are reported annually which provide a summary of the various metrics. HFS is using the 50th percentile (meaning ½ of all Medicaid plans performs better than and ½ perform worse than the benchmark) as a minimal threshold of performance.
How we will measure whether you met the benchmark.
HFS will count the number of qualifying patients for each measure enrolled on each PCP’s Illinois Health Connect panel roster on December 1, 2008. We will then look to see which of those patients received the measured service during the measurement period. HFS claims data will be used to determine whether a service was rendered (for immunizations, Cornerstone data will also be used). Although providers have 12 months from the date of service to bill in order to be paid for the service, the bonus payment will be based on measurement year 2008 claims, after a three month run out (January through March of 2009). This means all claims for measurement year 2008 services must be submitted to HFS prior to April 1, 2009 to be counted. We will then determine and pay the bonus payments by June 2009.
PCPs do not have to report any special information to earn a bonus payment; they just need to submit a detailed claim for the services that are rendered as usual. A measured service is counted whether or not it was the current PCP or another provider who rendered the service during the measurement period. We will use the date of service for the measured service to determine if it was rendered in the measurement period. Ordering a service for a patient does not qualify for a bonus payment, the service must actually be received by the patient. A sheet is attached for each bonus measurement giving details on the billing codes measured, the time period measured and other details to maximize the opportunity for bonus payments.
For which services will bonus payments be made?
If a PCP meets or exceeds the benchmark for a particular measured service, a bonus payment will be made for each patient that received the measured service. If the PCP does not meet the benchmark, there will be no bonus payment made for any patients, whether they received the service or not.
How much are the bonus payments?
The bonus payments will be at least $20 per patient. They may be higher depending on the number of qualifying PCPs and the number of patients receiving a measured service from those PCPs. HFS will dispense at least $5 million in bonus payments for 2008.
For example, for the diabetes measurement, the HEDIS 50th percentile is 79.3% (meaning that half of the nation’s Medicaid programs had achieved a rate of 79.3% or higher for diabetic patients receiving at least one HcA1c test) then a PCP would need 79.3% or more of their Illinois Health Connect diabetic patients to have received at least one HbA1c test in the past 12 months to qualify for the incentive payment. The PCP would receive the incentive payment for each patient that met the criteria. If less than 79.3% of the Illinois Health Connect diabetic patients on the PCP’s panel roster did not have the test then no bonus would be available for any of their diabetic patients.
For specific information about each of the clinical measures, click on the links below:
- Immunization Combo 3
- Developmental Screening
- Asthma Management
- Diabetes Management
- Breast Cancer Screening
New Electronic Tools For Providers
Claims History Report
In order to assist clinicians with providing care, Illinois Health Connect will provide electronic access to a summary of the claims for any current HFS client. The Claims History contains all claims submitted to HFS for the past 2 years, including pharmacy claims, and contains at least four years for immunization claims. The immunization claims will be retained in the Claims History for seven years. Due to Illinois confidentiality laws, the Claims History does not contain claims information related to mental illness, drug and alcohol abuse treatment, domestic violence or HIV/AIDS care. The Claims History only reflects claims received by HFS so services paid by other payers are not included.
In order to protect patient confidentiality, this Claims History will only be available to any HFS provider or provider designee who has obtained a digital certification through HFS’ Medical Electronic Data Interchange (MEDI) System.
To access the Claims History, providers or provider designees will access the Illinois Health Connect Provider Portal through the MEDI system. Once on the Provider Portal, access to the Claims History can be obtained by clicking on the "Claims History" link and providing at least three pieces of identifying information about a specific client including name, RIN, DOB or SSN. For more information or assistance in accessing this information, contact the Illinois Health Connect Provider Relations Helpdesk at 1-888-912-1999.
Drug Search Engine
HFS is pleased to announce that a drug search engine has been incorporated into its website that will allow providers to search for drugs by both generic and brand names to immediately determine if the drug requires prior authorization (PA). This web page also contains links to information regarding the PA process, PA forms and PA requirements so that prescribing for HFS clients can be streamlined. The web address is: http://www.hfs.illinois.gov/pharmacy/. Click on "Search for Prior Approval Status by Drug" on the left side of the page.
This search engine was developed and is maintained by the University of Illinois at Chicago College of Pharmacy (UIC). The Department would like to sincerely thank UIC for the hard work that they invested in the search engine.
For your internal distribution, please download the PDF version of the New Electronic Tools announcement.
Quality Improvement Resources
Originally known as the Ambulatory Care Quality Alliance, the coalition is now known as the AQA alliance because its mission has broadened to incorporate all areas of physician practice. The mission of this effort, a broad based collaborative of physicians, consumers, purchasers, health insurance plans and others, is to:
improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician or group level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians, and other stakeholders to inform choices and improve outcomes.
The National Committee for Quality Assurance is a private, 501(c)(3) not-forprofit organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the health care system, helping to elevate the issue of health care quality to the top of the national agenda.
State Medicaid agencies are required to provide quality assurance and fee for-service utilization review in the inpatient hospital settings for services provided to participants in the Medical Assistance program and Illinois contracts with a PRO/QIO to conduct this function. The department requires the PRO/QIO to assist the department in assuring that quality care is being provided to Medical Assistance program participants. Effective June 1, 2006, the department executed a contract with Health Systems of Illinois (HSI). HSI provides concurrent, retrospective prepayment and post payment reviews for services provided in the inpatient hospital setting for participants eligible for Medical Assistance. HSI provides quality of services review including medical necessity, reasonableness and appropriateness of care using telephonic, and web-based interactions. Please view HSI's Web site for additional information. Please view the Department of Healthcare and Family Services Web site for provider releases and policy updates.
The Illinois Foundation for Quality Health Care (IFQHC) is the Medicare contracted Quality Improvement Organization (QIO) for the state of Illinois. QIOs collaborate with Medicare consumers and each state's health care community to foster an environment in which every person receives the right care every time.
The American Health Quality Association represents Quality Improvement Organizations (QIOs) and professionals working to improve the quality of health care in communities across America. QIOs share information about best practices with physicians, hospitals, nursing homes, home health agencies, and others. Working together with health care providers, QIOs identify opportunities and provide assistance for improvement.
URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry.
DocSite® Registry for Population and Chronic Disease Management
DocSite Registry™ demonstrably improves care with minimal disruption to office workflow for a modest price, starting at only $50 per provider per month. DocSite Registry is an online patient-centric registry bringing evidence-based medicine to the point of care without stifling each physician’s individualized approach to practice.
Physicians use the registry to manage chronic, complex and preventive health needs for individual patients or entire patient populations. DocSite Registry summarizes relevant clinical information from the patient record and graphically highlights condition-specific clinical indicators that are due or out of range to save time during office visits, and supports proactive management of patient health needs.
And, there are many applications within the DocSite suite that will help you progress when you are ready. For more information, go to www.DocSite.com and view product tours, download brochures or find out more about DocSite. You can also send us an email at info@docsite.com, or speak with us at 919-256- 9500.