HEDIS: Patient Eligibility, Medical Group Attribution & Reportability Thresholds, and Hybrid Measure Sampling
Patient Eligibility
All HEDIS measures have their base in claims data. Health plans apply the HEDIS measure specifications to their member data pool and supply MNCM with denominator and numerator information.
- While MNCM currently works with nine health plans that service the state of Minnesota, we do not receive data from all health plans that offer coverage to patients in the region. Additionally, while the majority of participating health plans contribute data on all measures, not all plans contribute for all measures.
- Those nine health plans provide MNCM with measure specific data for patients that were enrolled in commercial, Medicare managed care and Medicaid managed care programs. MNCM does not receive data on those served by Medicare/Medicaid fee-for-service programs. Also, the measures don't include uninsured patients.
- Individual measure specifications may limit eligible populations to only certain insurance programs/products (only commercial and Medicaid, for example).
- As HEDIS measures are at their heart designed to measure health plan performance, all HEDIS measure specifications include some form of 'continuous enrollment' criteria as part of the process to determine patient eligibility for measure inclusion for the given health plan. This ensures that a patient is fairly attributed to the health plan. For example, in the Immunization for Adolescents measure, commercial members have to be enrolled with the given health plan for the 12 months prior to their 13th birthday in order to be included in the eligible population by that health plan.
Hybrid Sampling, Medical Group Attribution, and Reportability Thresholds
- Some HEDIS measures reported to MNCM by health plans have data collected utilizing the hybrid method, which is a combination of claims data, chart reviews, and (where applicable) state registries. The measures utilizing this method of data collection are sampled rather than a submission of the entire eligible population. Based on that sampling, results are weighted after aggregation.
- Health plans do not take medical group attribution into consideration when they select their sample of patients for reporting, rather they select a random sample within their eligible member pool by product (for example, a sample from eligible commercial members and an additional sample from eligible Medicaid members).
- Hybrid measures that utilize this sampling process have a medical group reportability threshold of 60 patients. HEDIS measures utilizing the administrative or electronic data collection method (claims or electronically obtained clinical data only) have a medical group reportability threshold of 30 patients.
- Once health plans determine the eligible population for a measure based on the measure specifications and have identified their sample populations, they attribute the sample patients to medical groups registered with MNCM using an attribution methodology developed by MNCM. Generally, this attribution process includes counting specific types of claims by TIN and attributing to a medical group/TIN based on the largest number of those claims. If an eligible member didn't have any of those specific visit claims within the measurement year, they are not attributed to a medical group.
Medical Group Hybrid Measure Reportability Example
Eight of nine participating health plans reported having members eligible for the measure that could be attributed to the medical group: a total of around 400 eligible patients. From those 400 patients across nine health plans, 42 were randomly selected by those health plans for inclusion in their measurement samples, putting the medical group below the reportability threshold of 60.