EmblemHealth maintains assessment methods and performance criteria used to evaluate the performance of network practitioners in meeting the objectives of the Quality Improvement Program.
We make available (on a periodic basis and upon practitioner’s request) the information, profiling data, and analysis used to evaluate their performance. Each practitioner is given the opportunity to discuss the unique nature of their professional patient population, which may have bearing on the practitioner’s profile and the evaluation of their performance.
EmblemHealth uses a variety of data sources and software to measure quality improvement processes and outcomes, determine and overcome barriers to improvement, and identify ways to improve quality. Data sources include, but are not limited to:
- Applicable case management and disease management.
- Behavioral health.
- Epidemiological, demographic, and census about EmblemHealth’s membership.
- Grievance and appeals.
- HEDIS®/QARR (Quality Assurance Reporting Requirements).
- Medical records.
- Member and provider surveys, including but not limited to, CAHPS®, Access and Availability surveys, and Health Outcomes Survey.
- National and regional benchmarks from sources such as Quality Compass®, NCQA, and CMS.
- Population-based member information.
- Quality improvement projects/studies.
- Telephone response.
- Utilization review.
EmblemHealth uses standard measures of clinical quality and customer experience to allow individuals to compare health plans and make informed choices when choosing a health plan for themselves and their family members. EmblemHealth uses the following key measure sets:
- Healthcare Effectiveness Data and Information Set (HEDIS®)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
- Health Outcomes Survey (HOS)
HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS®)
We use HEDIS® to measure clinical quality and customer service performance. HEDIS® is coordinated and administered by the NCQA and used by CMS for monitoring the performance of managed care organizations.
Each year between January and May, all NCQA-accredited managed care organizations like EmblemHealth perform HEDIS® reviews. It is a retrospective review of services and performance of care for the prior year. Data is collected either through claims (administrative), medical record collection and claims (hybrid), or surveys.
You play a critical role in HEDIS® scores. We look to you to promote healthy behaviors and provide the appropriate care within the appropriate time framesto members. You can improvethe health outcomes of your patientsby:
- Ensuring they receive their routine preventive services and screenings.
- Helping them manage chronic conditions such as arthritis, high blood pressure, and diabetes.
- Prescribing safe medications and only when necessary.
- Ensuring patients are continually taking their medications, especially those with chronic diseases.
- Coordinating patient care with medical and behavioral health services.
- Accurately coding claims. Coding accuracy may also reduce the number of records we need to request during the medical record collection phase of HEDIS®.
EmblemHealth-contracted providers and practitioners are required to provide medical records requested for HEDIS® data collection in a timely manner. HIPAA allows data collection for HEDIS reporting, thus no special patient consent or authorization is required to release the information.
CAHPS is a program of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.