Measuring Performance

More than 90 percent of the health plans in the U.S. use the Healthcare Effectiveness Data and Information Set (HEDIS) to measure performance on important dimensions of care and service. And because there are many health plans collecting HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. Additionally, the health plans use HEDIS data internally to compare to their own results to see where they need to improve.

The performance measures developed for HEDIS have been culled from best practices for various procedures and treatment guidelines from across the country. These best practices are derived from the standards of care for that particular condition, and standardized for all patients who present similarly.

For instance, there are HEDIS measures in place for the following conditions, and the standards of care for each were used in their development:

 

HEDIS (Healthcare Effectiveness Data and Information Set)      Allow comparison of health plans and improvement within a health plan   Examples of SoC used to develop HEDIS measures:      Asthma medication use      Persistence of beta-blocker treatment after a heart attack      Controlling high blood pressure      Comprehensive diabetes care      Breast cancer screening      Antidepressant medication management      Childhood and adult weight/BMI assessment

 

HEDIS

To ensure that HEDIS guidelines stay current, each year the National Committee for Quality Assurance (NCQA) determines if each particular guideline needs to evolve. The NCQA’s Committee on Performance Measurement, a broad-based group representing employers, consumers, health plans and others, discusses the current content and makes collective decisions as to how each standard should change for the coming year. Individual standards are field tested to assure appropriateness and accuracy, and then implemented. It’s also important to note that HEDIS includes the Consumer Assessment of Healthcare Providers and Systems or CAHPS 5.0 survey which measures health plan member’s satisfaction with claims processing, customer service and the perceived speed of getting care when needed.

 

HEDIS information may also be used by consumers to view comparison information for participating health plans. This can be helpful when shopping for health insurance, and is an “available for purchase” option for health plans through the NCQA.

Annual review by NCQA (National Committee for Quality Assurance)   Includes the CAHPS Survey (Consumer Assessment of Healthcare Providers and Systems)   Can be used by consumers to compare participating health plans

Development and Adoption of Standards of Care

To achieve standardization, options are reviewed:   What achieves best results? Thorough evidence-based review   Field tests are performed Feasibility, reliability, validity   SOC put into practice and endorsed by professional societies or consumer groups

Developing a standard of care is a multistep process that begins with a need. When government agencies like the Centers for Medicare and Medicaid Services (CMS) or the Agency for Health Care Research and Quality (AHRQ), or private nonprofits like the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or the National Committee for Quality Assurance (NCQA), or for-profit companies see a medical condition whose treatment could benefit from standardization, they look at the options currently available. From there an evaluation of medical literature is performed with an eye towards what achieves the best results (improved outcome or patient experience, lower cost or some other measure). If enough compelling evidence exists for one method of care over another, field tests are performed. If the field testing matches expectations and provides support for the feasibility, reliability and validity of the new standard, it is approved by the organization and put into their practice.

An example of this might be that research has found administering a beta blocker as soon as possible to a patient who is experiencing a heart attack can reduce the risk of death. This protocol was researched and tested, then developed into a clinical practice guideline.

Once a standard is put into practice other professional societies or consumer groups will endorse the measure. Some groups, like the AHRQ (Agency for Health Care Research and Quality) will meet with their stakeholders, including health care professionals, consumers, payers (such as insurance companies), employers, or hospitals to review new measures and decide if they meet their criteria. Measures endorsed by organizations like the nonprofit National Quality Forum (NQF) are generally recognized as reflecting a thorough scientific and evidence-based review. If the measure meets their criteria and is successful in field testing, it receives their endorsement and is generally put into widespread use.