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Hybrid Methodology

Health plans follow NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) Administrative Measure procedures in calculating the quality measure results. For other 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, the health plans conduct a sample review of the medical record. The current Consortium measures that use the hybrid method include:
• Comprehensive Diabetes Care - Eye Numerator
• Comprehensive Diabetes Care - HBA1c Testing
• Comprehensive Diabetes Care - LDLC Testing
• Comprehensive Diabetes Care – Nephropathy
• Cervical Cancer Screening
• Childhood Immunization Status – Combination 3
• Lead Screening in Children
• Cholesterol Management for Patients with Cardiovascular Conditions
• Postpartum Care
There are a number of reasons why billing 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.

For those QARR/HEDIS measures that employ the hybrid method, an adjustment factor will estimate the proportion of failing records attributable to data issues and adjust physician’s 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 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.

Have questions? Contact My Quality Counts! at (716) 541-0289.