Download General Questions What does “EXC” mean in Quality

General Questions
What does “EXC” mean in Quality Compass?
How does NCQA create a quality index?
How is the indexed ratio calculated?
Please explain the intent of the indexed ratio. How is this
calculation different from the RRU ratio?
Please define the medical ratio.
Do expected total costs include all product types?
EXC stands for “excluded.” For the Quality Index, EXC
indicates there was not enough information to calculate the
index. This can happen for a number of reasons. For
example, there may be too many missing values (NAs, NRs
or NBs) among the individual quality measures making up
the Quality Index to calculate the result.
For the RRU Index Ratio, an EXC is displayed if the
denominator is less than 400 for that condition and/or if
the calculated indexed ratio is less than 0.33 or greater
than 3.00.
If a plan receives an EXC for the Quality Index component,
then the corresponding RRU component will automatically
display EXC.
The quality index is calculated by taking the average of the
quality rates of designated HEDIS Effectiveness of Care
quality measures for a specific condition. A detailed
explanation of how Quality Index values are calculated can
be found in the document “How NCQA Calculates a Quality
Index” which is available at www.ncqa.org/rru
The indexed ratio is calculated by dividing the plan’s
observed-to-expected ratio by the average national
observed-to-expected ratio or regional observed-toexpected ratio adjusted by the plan’s peer group.
The indexed ratio compares a plan’s result to the mean
performance of all health plans in a given product line. The
index ratio is created by indexing all the plan O/E ratio
means to 1.0. This step allows NCQA to display plan
performance in Quality Compass despite inherent
differences in plan population sizes and severity of
condition.
The O/E ratio is determined for each RRU cost and service
component using a plan-specific benchmark (expected) that
informs the individual plan how it is performing compared
to others in its immediate peer group.
The Total Medical index is an aggregate of the Inpatient
Facility, Surgery and Procedure, Diagnostic Laboratory,
Diagnostic Imaging and Evaluation and Management (E&M)
service categories. This is the value that is displayed on the
scatterplots with the Quality Index.
Expected total costs are collected and reported separately
for each product type (line of business). For example, a
commercial HMO plan is compared with all commercial
HMOs that submitted only RRU data. NCQA does not
compare commercial plans with Medicaid or Medicare
plans.
Standardized Pricing Tables do not seem to reflect the
actual values of services paid for. Why is this?
Because of the significant variation in actual prices paid for
healthcare services across the country, RRU measures
utilize standard prices for each service to ensure that the
relative resource volume is used to compare plan
performance, rather than a total service cost that is unduly
affected by market, regional and other competitive factors.
Data Capture
Must a plan be approved, accredited or audited by NCQA Only audited data are accepted by NCQA and included in
before it may submit RRU data?
the RRU calculations; however, it is not necessary for a plan
to be NCQA Accredited in order to submit these data.
How should mental health inpatient services be handled Mental health services (MHSA diagnosis codes) that can be
in the RRU measures?
mapped to a service on the Standard Pricing Tables (SPT)
should be included in both the cost and frequency
reporting categories. Inpatient mental health stays should
be included in when counting services for the inpatient
frequency counts.
Do the cost categories in the RRU measures result from
The RRU measures look at all services for members with the
condition-specific discharges and pharmacy use, or from identified condition and are not specific to diagnosis at time
all inpatient discharges and medications, regardless of
of discharge. The standardized prices are aggregated across
reason?
services and members, to compute overall resource use for
each measure. For example, the RRU for People With
Asthma (RAS) measure includes all services for which the
plan has paid, or expects to pay, for the eligible population
(i.e., members with persistent asthma during the
measurement year).
If a plan receives multiple claims for the same service
When calculating service frequency, multiple claims for the
from different providers, is the intent that the service be same service should be counted only once. In your
counted multiple times? For example, if a member had
example, only one MRI should be counted, even though
one MRI performed and two different providers billed
two claims were generated for the technical and
separately for the technical and professional component professional components. However, when calculating costs,
of the MRI, should that be counted as two MRIs?
include all claims submitted for services, even if there are
separate claims for the same service.
If plans cannot report an Effectiveness of Care measure,
how will a RRU measure be handled if data are
submitted?
Should observation room stays be removed from the
Total Service Frequency by Service Category reporting
tables?
Should medical supplies (e.g., syringes) be excluded from
pharmacy services in standard cost calculations?
If Inpatient Facility services are not available, should we
disregard the category and only report E&M, Surgery—
Outpatient and Pharmacy services?
Are there special rules for subpopulations like disabled
or dual eligibles (and so on) for RRU measures?
Plans that cannot submit an EOC quality measure required
in the RRU technical specifications will not have any RRU
results reported by NCQA in Quality compass.
Yes. Only inpatient facility discharges and ED visits should
be reported in the Total Service Frequency tables.
Yes. Exclude medical supplies (e.g., syringes) from
pharmacy standard cost calculations.
Plans should make every attempt to obtain inpatient facility
services data. If these data are not reported to NCQA, the
organization will not have any results displayed in Quality
Compass nor will it have a Total Medical Index calculated.
It will only receive the individual category information that
was provided to NCQA in its IDSS report.
No. Disabled and dual-eligibles are treated the same as the
general population in RRU measures.
Are members who were excluded from the
Comprehensive Diabetes Care (CDC) measure through
the chart review process also excluded from the RRU
Diabetes measure? For example, if it is determined that
a member is not diabetic (or is excluded for another
reason), can the member be excluded from the diabetes
RRU measure?
How do we handle services for members who are
insured on a capitation basis? Are the services incurred
by these members (reported as encounters, not as paid
claims) included in the measure, or excluded?
How are services that are carved out or delegated via a
per member per month fee, such as behavioral
healthcare, reported for the RRU measures?
Please define “dominant medical condition.” Does
“dominant” mean “principal diagnosis” or does it mean
any diagnosis on the claim?
If a member has two different E&M codes on the same
day, should only one be counted, or both?
No. Do not exclude members based on medical record
chart review findings in this measure.
Count capitated encounters, just as you do for other HEDIS
Utilization measures, paying particular attention to data
completeness to determine the measure’s reportability.
If a service is carved out, data completeness is the only
consideration. If the service is delegated by the plan,
encounter data should be obtained from the delegated
entity and included in cost and frequency estimations.
The term "dominant medical condition" is not the same as
“principal diagnosis.” The term refers to members who
have one or more of the following conditions: active
cancer, organ transplant, ESRD or HIV/AIDS. These
members are excluded from the RRU calculations because
of the disproportionately high-cost resources required to
treat these conditions.
Count both E&M codes and assign the standardized price
for each service. When you count frequency of services,
count each unique service once.
Using RRU Results
How do investments in health promotion and wellness
programs affect RRU results for a plan that focuses
resources on these types of activities?
RRU methods are not sensitive enough to account for
additional care for secondary health issues addressed
because of high quality.
RRU measures focus on chronic conditions. Wellness and
health promotion interventions are not captured directly in
the measure cost calculation, although it is reasonable to
expect that successful wellness programs would have a
positive effect on resource use, especially for high-cost
Inpatient and Surgical Service categories.
The current Risk Adjustment protocol takes into account
the number of different diagnosis on a member’s record to
assign them to an appropriate comparison (severity) group
for measurement on both the resource use and quality
dimensions.
How does NCQA address the problem that outpatientintensive plans may be unfairly targeted as inefficient
because of increased resource use in that environment?
While plans that use more outpatient services will likely
have higher costs in the outpatient E&M and Surgery areas,
they will probably have lower inpatient and total medical
costs (additional outpatient services would keep people out
of the hospital and that would reflect in the inpatient cost
categories and the total medical cost). For this reason,
plans that have higher outpatient costs are not targeted as
‘inefficient.’
It is important to look at all of the results, not just a single
result in isolation.
How do we account for a wide variation in associated
costs because of the disproportionate amount of
members with multiple comorbidities in some plans?
The HEDIS 2012 RRU specifications feature a HCC-RRU risk
adjustment model that accounts for potential differential
severity among chronic disease populations in different
health plans.
Do RRU results allow researchers to calculate a chronic
disease cost saving per patient, per year? For example,
reducing HbA1c by only 1% results in a saving of $1,205
per patient, per year. If the same diabetic has
concomitant heart disease and hypertension, the saving
is $4,116. By ensuring that every diabetic receives an
annual retinal eye exam, the saving is $2,162 per patient,
per year, and reduces the onset of blindness, which will
eventually save $14,296 per year for every affected
person.
RRU measures are not intended to report dollar savings per
patient, per year. NCQA produces an annual State of
Healthcare Quality Report that provides the national mean
average and 10th and 90th percentiles for the current year,
as well as previous years' national averages for selected
measures.
Viewing RRU Results
When I look at the scatter plot graph, the value at the
center of the graph is 1.00. What does this mean?
When I view a scatter plot graph, I see some plans
represented on the graph as a diamond. Why is that?
Why does the RRU + Quality Index (Commercial) license
contain fewer submissions than what is reported in the
Commercial license?
All values for Quality and Resource Use are indexed to a
mean of 1.00 in order to facilitate the comparison of one
plan to another in a specific product line.
A plan result outside the range of 0.5–1.5 is displayed as a
diamond-shaped pattern at the appropriate (upper or
lower) limit of the graph to denote that the actual value for
the plan falls outside the plot’s constant value range. A red
diamond represents the health plan that was selected to be
viewed while a gray diamond represents other plans in the
same HHS region.
Not every plan that reports HEDIS measure data to NCQA
also provides RRU information. Currently about 80% of
plans are also submitting RRU data to NCQA who also
submit some HEDIS data. Quality Compass includes all the
plan RRU data that met the public reporting requirements.