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Overview of HPHC Reporting
Connecticut Medical Directors Meeting
Martha Hoefer, Manager, Provider Analytics
Wednesday, September 30, 2015
Agenda
 Purpose of orientation
– orient you to HPHC’s commitment to Medical Informatics
– demonstrate the array of reports, downloads, and dashboards
available to provider groups
 Reporting Framework
– Content areas: What?
– Delivery mechanisms: Where?
 Resources
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Challenges in CT Reporting – No PCP selection
 HPHC’s product in CT is Open Access HMO (OAH)
– No PCP selection is required
 PPO Attribution Methodology enables assignment of
patient to a PCP
– 24 months of claims history for professional services
– Most CT members have not yet amassed sufficient claims history
 Current Attribution Logic (modifications in 2016)
Step
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Specialty
Criteria
Primary Care (PC)
Primary Care (PC)
OBGYN
Primary Specialist dual (PS)
Eligible Specialist
Not Attributed
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Visit
Well Visit
Any Visit
Any Visit
Any Visit
Any 2 Visits
Other
Member Selection (Mass GIC only)
Reporting Overview –
Content Domains (what) & Access (where)
Secure Server
HPHConnect
LCU Reporting
(static pdf)
Provider Performance
Reporting Tools
Data Extracts
(interactive; Microstrategy)
Financial / Cost & Utilization
 Financial Capitation
 Lab Steerage
 CSU Dashboard [PAID]**
 PCMH Dashboard **
 Provider Util Reports
by Physician Group [PASS]
SFTP1 (by contract model)
 Hosp & Med Claims *
 Membership
 Capitation
 Pharmacy Claims
Clinical
 IP Discharge [IP-DC] **
 IP Census [IP-C]**
 Authorization /Notification
Report [ANR]**
 CMDM Participation [CMDM]**
 Gaps in Care Metrics
[EBIM/QMR]**
SFTP2
 Quality Mgmt Rpts *
 Gaps in Care Registries**
Pharmacy
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Overview/Prescriber Profile
Therapeutic Class
Top Drugs
Tier 1 (raw)
 Therapeutic Class Reports
(target 2015Q2)
** contains PHI
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Access to HPHC Reporting
 Physician Group must have Privacy and Security Agreement in place
(Contracting)
HPHConnect
Secure Server sftp
 User must have signed HPHConnect User
Agreement
(contains PHI)
 Requestor must complete User Access
Request available at
www.HarvardPilgrim.org/LCUReporting
 Submit form to:
[email protected]
 Provider eBusiness provides account code;
user sets password
MicroStrategy:
• HPHC Helpdesk provides Htrio Account
with MSTR Web Report License
• Provider Analytics establishes Htrio
account and associated CSUs in access
security table in EDW
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 User must complete form
 HPHC Provider Reporting
Support sends out SSH Tectia
client software
 Contracting establishes type of
Claims Downloads, per contract
model and updates user access
table
 NMM/Contracting establishes
access to Quality Management
Reports (HEDIS)
Domain 1:
Financial/Cost & Utilization Reporting
HPHConnect
LCU Reporting
(static pdf)
Secure Server
Provider Performance
Reporting Tools
Data Extracts
(interactive; Microstrategy)
Financial / Cost & Utilization
 Financial Capitation
 Physician Group Provider Roster
 Member Months (Matrix)
 Mo. Cap Summary
 Capitation Rosters
 Hosp/Med Expense Detail
 Commercial 1 Pool
 Commercial 2 Pool
 Profit & Loss
 Commercial 1 Pool
 Commercial 2 Pool
 CSU Dashboard [PAID]
 $ PMPM & Util trends
 Vital Statistics
 High Cost Claimants
 Expense Type Detail
 Service Category Detail
 IP DRG Detail
 OP Service Detail
 ReAdm & ReER**
 Amb .Sensitive Cond
Adm & ER
SFTP1 (by contract model)
Fully Insured Claims:
Pool 1 & 2
Medical ASO Claims
Membership: Weekly Chg
Membership File
snapshot a/o 1st of month
Capitation Roster File
 Packages Options –
with and without financials
Flash & Excel Output
Monthly Updates
* *contains PHI
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Monthly Updates
Monthly Updates
(overwrites last month)
Focus on: PAID Dashboard
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3 years of data trend
Compared to Physician
Group Linear
regression
Compared to top 25th
percentile in network
Can look at all CSUs
combined or
individually
Can look at
subpopulations by
product, funding, and
age
Vital stats on
membership and
leakage
High Cost claimants
drillable to patient ID
and cost over 100K
threshold
Readmissions/ReER
shows cases seen
within 30 days (all
cause) drillable to
patient level .
Ambulatory Sensitive
Conditions (ASC)
shows cases with IP
and ER activity that are
best managed in
ambulatory setting
Focus on: PAID Dashboard
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Expense Type detail
provides deeper view
Heat map shows
PMPM (size of box)
and change from prior
year (color)
Can narrow time slider
Can drill down for IP
DRG information, OP
Services (including
ancillary), and Rx
Report (class/drug/
prescriber, patient)
Exportable:
• Button to export dashboard to interactive Flash format, which retains all the interactivity off-line, so can be sent as
attachment (Flash will not support data drilldowns of PHI , as you must be on live system and pass security checks
• Excel icon in upper right produces tabbed excel file with all data points used in dashboard
• Drill down outputs on live system can be exported to Excel output for further analysis/work flow management.
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Domain 2
Clinical Reporting
Secure Server
HPHConnect
Provider Performance
Reporting Tools
LCU Reporting
(static pdf)
Data Extracts
(interactive; Microstrategy)
Clinical
Daily updates
Authorization & Notification [ANR]
 IP Discharge *
 IP Census*
 Authorizations Report*
Monthly updates
Care Management [CMDM]
 CMDM Participation*
Quality Measures [EBIM/QMR]
- Retrospective 12 months
- Prospective: 1/1- this month
* contains PHI
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** in development
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Monthly updates
SFTP2
 Quality Mgmt Rpts *
 Gaps in Care Registries**
Focus on: Authorization & Notifications (ANR)
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Data from HPHC Care
Management System,
updated daily by CMs
Discharges within user
defined time window
IP Census of any
cases IP during user
defined time window
Authorizations in
system, past or
upcoming
Similar data on each
report (hospital,
attending, begin/end
dates, diagnoses,
procedures while IP,
etc.)
All hospitals where
HPHC has been
notified
Exportable to Excel
Frequent downloading
of report enables
detection of frequent
flyers
Focus on: Quality Measures Reporting (QMR)
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Data sourced from Optum
Impact Pro tool’s EMB suite
Flat file, exportable to Excel
RETROSPECTIVE VIEW
(rolling 12 months, to enable
overall practice performance;
28 measures)
PROSPECTIVE (Cal YTD to
find defects before year end;
17 measures)
HMO/POS and PPO
(Attributed)
Adding more over time (e.g.,
Choosing Wisely)
Metrics compares Physician
Group performance to Prior
Year HEDIS, HPHC Plan
wide average, Regional 75th
an d 90th Percentiles,
National
Focus on: Quality Measures Reporting (QMR)
Member Detail Report
• PCP information
• Member Contact
Information
• Compliance Flag
(1=Compliant)
• Excel Format output
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Domain 3:
Pharmacy
HPHConnect
Secure Server
Provider Performance
Reporting Tools
LCU Reporting
(static pdf)
Data Extracts
(interactive; Microstrategy)
Pharmacy

Tier 1 (raw)
 PAID Drilldown: Rx **
- Drug Class
- Drug
- Prescriber
- Patient
* contains PHI
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** in development
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 Pharmacy Claims (SFTP1)
 Multiple Prescriber Reports
Secure Server/sftp
SSH Tectia Client
Claims Download files
Harvard Pilgrim Health Care
Integrated Product Download Program
User Documentation
Caritas currently receives this information - No Financials & No NPI
File
Pool 01 Claims
File
Pool 02 Claims
Medasompxx.txt*
When it’s
available
The 15thof the
month.
The 15th of the
month.
The 15th of the
month.
Medasoypxx.txt*
Weekly Changes
File
Membership File
Capitation Roster
File
Every Thursday
The 2nd working
day of the
month.
Around the 21st
of the month.
What it contains
Partial Pool 1 Claims, which were paid in the
previous month. i.e. In February, the claims
file will contain claims paid in the month of
January. Pended and payable claims are not
included.
The Medmy1XX.TXT will contain Year to Date
claims data.
Partial pool 2 Claims, which were paid in the
previous month. i.e. In February, the claims
file will contain claims paid in the month of
January. Pended and payable claims are not
included.
The Medmy2pXX.TXT will contain Year to Pool
Date claims data.
Self insured claims, which were paid in the
previous month. i.e. In February, the claims
file will contain claims paid in the month of
January. Pended and payable claims are not
included.
The MedasoypXX.TXT will contain Year to
Date claims data.
A download of the members who had a
change since the last run of the change file.
A snapshot of current eligible members as of
the 1st of the month.
The aca096xx.txt download file that contains
the member level detail of your capitation
payment. It includes one record per member
for each month capitated. This file will save
lots of paper and allow providers the ability to
create reports by age/sex, drug eligibles,
employer group, etc. The aca098xx.txt will
contain Year to date claims data.
Name of file
on the bulletin
board
Medcmmp1xx.
Medcmyp1xx.
Medcmmp2xx.
Medcmyp2xx.
Medasompxx.txt
Medasoypxx.txt
ACA033XX.txt
ACA005XX.txt
ACA096XX.txt
ACA098xx.txt
*XX represents the Care Sub Unit Number of your file. Each sub care unit will have its o
own file created.
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Download
files can Pilgrim
be accessed
on the
HPHC SFTP Server defined for each user. Consult HPHC for
© 2011 Harvard
Health
Care
username, password, and directory information.
www.harvardpilgrim.org/LCUReporting
Live Link:Triage point for
questions/issues
Within Network
Medical
Management
web page
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