Hybrid Methodology
The NYQA follows the NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) Administrative Measure methodology in calculating the quality measure results. For some measures, health plans follow what is called a “hybrid” method, first identifying members whose care meet the measure standard based on billing data; and for those members who do not pass based on billing data, health plans conduct a sample review of the medical record.
The current Consortium measures that call for the hybrid method include:
For those QARR/HEDIS measures that employ the hybrid method, the consortium will employ an adjustment factor that estimates the proportion of failing records attributable to data issues and adjust physicians’ scores accordingly.
The score for a measure is the percentage of eligible patients whose records comply with the measure standard. For example, the diabetes A1C screening measure requires that patients with diabetes have a blood test for A1C level at least once a year.
The score is:
Number of Patients with Diabetes who had an A1C Test / Number of Patients with Diabetes
In calculating the NYQA adjustment factor, it is assumed that measure-compliant records are accurate (true positives) and that non-compliant records include both records of patients who are not compliant with the standard (true negatives) and records of patients whose care is compliant with the measure but for whom data is missing or in error (false negatives). The adjustment factor is an estimate of the number of false negatives specifically related to non-compliant member records.
The adjustment factor (AF) is then:
AF= (PQ-PC)/(1-PC)
Where PQ is the plan’s hybrid score and PC is the plan’s claims based score.
HOW IS THE ADJUSTMENT FACTOR APPLIED TO A PHYSICIAN’S SCORE?
If DC = the % of a “doc’s” patients with diabetes who had their eyes examined based on claims data, then the “doc’s” adjusted score (DA) is:
DC+((1-DC)*AF)
Because a physician will have patients from multiple health plans in his or her panel, the adjustment factor will be calculated for each plan for each measure and applied to the patients from that plan in the measure.
The current Consortium measures that call for the hybrid method include:
• Comprehensive Diabetes Care - Eye Numerator
• Comprehensive Diabetes Care - HBA1c Testing
• Comprehensive Diabetes Care - LDLC Testing
There are a number of reasons why claims and administrative data may be less complete and accurate than chart review. As a result, the hybrid method scores for a given measure are almost always higher than the score would be for that measure if only billing data were used. Due to the inability to conduct chart reviews as part of this project, we must rely on less than perfect billing data to calculate measures.• Comprehensive Diabetes Care - HBA1c Testing
• Comprehensive Diabetes Care - LDLC Testing
For those QARR/HEDIS measures that employ the hybrid method, the consortium will employ an adjustment factor that estimates the proportion of failing records attributable to data issues and adjust physicians’ scores accordingly.
The score for a measure is the percentage of eligible patients whose records comply with the measure standard. For example, the diabetes A1C screening measure requires that patients with diabetes have a blood test for A1C level at least once a year.
The score is:
Number of Patients with Diabetes who had an A1C Test / Number of Patients with Diabetes
In calculating the NYQA adjustment factor, it is assumed that measure-compliant records are accurate (true positives) and that non-compliant records include both records of patients who are not compliant with the standard (true negatives) and records of patients whose care is compliant with the measure but for whom data is missing or in error (false negatives). The adjustment factor is an estimate of the number of false negatives specifically related to non-compliant member records.
The adjustment factor (AF) is then:
AF= (PQ-PC)/(1-PC)
Where PQ is the plan’s hybrid score and PC is the plan’s claims based score.
HOW IS THE ADJUSTMENT FACTOR APPLIED TO A PHYSICIAN’S SCORE?
If DC = the % of a “doc’s” patients with diabetes who had their eyes examined based on claims data, then the “doc’s” adjusted score (DA) is:
DC+((1-DC)*AF)
Because a physician will have patients from multiple health plans in his or her panel, the adjustment factor will be calculated for each plan for each measure and applied to the patients from that plan in the measure.