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HEDIS Quality Performance Measures Assist Consumers, Insurers

Consumers are able to use HEDIS to compare different health plans since more than 90 percent of US healthcare payers include HEDIS when collecting data and measuring their overall performance.

By Vera Gruessner

- Healthcare payers attempting to improve their plans and coverage would be wise to address the quality performance measures set forth in the Healthcare Effectiveness Data and Information Set (HEDIS), which was developed and currently managed by the National Committee for Quality Assurance (NCQA).

HEDIS Quality Performance Measures

Consumers are able to use HEDIS to compare different health plans since more than 90 percent of US healthcare payers include HEDIS when collecting data and measuring their overall performance.

There are a variety of areas where the quality performance measures make a difference to patient care. Analyzed on a year-to-year basis, HEDIS measures cover childhood immunization, breast cancer screening, diabetes care management, asthma medication adherence, antidepressant medication care, and high blood pressure management.

Often, health payers report their HEDIS data to employers and also use the information to improve their overall performance over the next annual cycle. Both consumers and employers can use HEDIS data to determine which particular health plan best suits their needs.

Via an auditing process, NCQA auditors have a role in ensuring the quality performance measures are accurate and reveal key details about a health plan.

“The National Committee for Quality Assurance (NCQA) assumed responsibility for management of the evolution of the Healthcare Effectiveness Data and Information Set (HEDIS®) in 1992, with one clear goal - by devising a standardized set of performance measures that could be used by various constituencies to compare health plans, we could help drive quality improvement in the market,” the NCQA website stated.

“In order for HEDIS to reach its full potential, NCQA and others concluded that an independent audit of HEDIS collection and reporting processes, as well as an audit of the data which are manipulated by those processes, would be necessary in order to verify that HEDIS specifications are met.”

NCQA has also developed a process in which the quality performance measures are updated in order to stay current on a yearly basis. For example, when more attention was paid to elderly medical care, HEDIS began including measures related to glaucoma diagnostics and osteoporosis treatment within health plans.

HEDIS measures are based on five main areas of care including access to care, effectiveness of services, relative resource use, health plan descriptions, and experience of network providers.

When the NCQA has to develop HEDIS quality performance measures, it takes a good amount of time due to the complexities of this evaluation system. Creating these measures is not an easy task and requires more than two years’ time, according to an NCQA graphic.

First, the organization must identify the medical care areas in which a HEDIS measure may be missing. Then technical subgroups need to be developed and the initial, proposed measure must be drafted.

As the development process continues, professionals from NCQA develop field testing protocols and conduct field testing along with analysis. Once this is finished, it takes an additional year for the quality performance measures to be revised, presented, and open for public comment before being reviewed and adopted into the final HEDIS set.

“NCQA’s oversight programs are developed using a collaborative model. Input is sought from all interested parties about each of our programs, and a representative advisory committee helps inform development from start to finish. The industry and the public are always invited to comment on our programs as well. These comments often lead to important changes and improvements to our programs,” the NCQA reported on its website.

Consumers looking for a suitable health plan that meets their needs are often referred to HEDIS measurement data. Health payers are advised to work on improving their health plan offerings by boosting their scores on the HEDIS quality performance measures. 


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