As one of the nation’s best HEDIS staffing agencies, CareNational is always committed to providing the finest service possible to our candidates and our clients. This includes continuing education through interactive conversations with contacts from both the client and candidate perspective. As the 2015 HEDIS (Healthcare Effectiveness Data and Information Set) season continues, CareNational is dedicating a series of blogs to help leaders and staff-level workers involved in the HEDIS process. Today we wanted to review how HEDIS scores and other quality measures impact the end user, meaning the general public as a consumer. We wanted to give a general understanding of what these metrics mean and share some related resources that can help the consumer select the best health plan.
The primary source for rankings of both federal programs (Medicaid and Medicare) and commercial insurance plans is the NCQA (National Committee for Quality Assurance). The purpose of this non-profit organization is to evaluate the quality of care provided by these health plans, based on established Quality Improvement criteria. They then conduct statistical analysis of the data and present their findings to the public. This can give the consumer insight on how well these plans serve their members’ needs. In addition to providing rankings, the NCQA serves as an accreditation body that certifies a variety of health providers and payers using a vigorous set of quality compliance requirements.
According to Consumer Reports, a leading resource for consumer information and value, the NCQA ranked over 1,000 plans on the following data points: Quality of Care, Commitment to Improvement, Consumer Satisfaction, and Disclosure of Information. The NCQA ranks each available health plan on a simple scale of 1-100 compared to other health plans offered in similar categories. Meaning that they look at “like for like” plans such as Medicaid, Medicare, or private health insurance plan types. They further distinguish those managed care plans by the structure of their provider network, such as HMO (Health Maintenance Organizations) or PPO (Preferred Provider Organizations), if applicable.
So how does all this relate to HEDIS? Well those scores are derived from information collected by the plans themselves. Nurses and other professionals submit the information used to compile HEDIS scores by abstracting source data from patient charts, billings, and other medical records. According to the NCQA, weights may differ when the data is collected, because specific medical treatments are sometimes more abundant from one plan to the next. For example, a Medicare plan, used by seniors over 65, will have a higher treatment rate for conditions related to the patient’s age, as compared to a private commercial HMO plan that deals with a larger population set and so a wider variety of diagnosed illnesses. It should be noted that overall health plan scores are only partially based on those performance measures from HEDIS. The consumer satisfaction portion is based on two other surveys: the HOS (Health Outcome Survey) and CAHPS (Consumer Assessment of Health Providers and Systems Survey).
Unfortunately scores are not available for every plan, either because of lack of statistical data to compare, or they simply have chosen not make the information available to the public at large. Another possible reason a plan may not be available for review is that it’s simply too new. This largely refers to those plans which were created to either tap into an expanding consumer marketplace, or to be in compliance with increased quality of care standards. Both factors are an outcome of the Affordable Care Act passed in 2010, sometimes referred to as “ObamaCare”.
For the most part though, a consumer should be able to find rankings for plans in their area. They can search first by state, and then customizing the search using tools available on the NCQA website to sort by scores and performance measures. Another resource for consumers is a very user friendly tool offered at this page on Consumer Reports. As long as the consumer knows what type of plan (HMO or PPO) they want, and whether they are seeking private or government assisted insurance, this tool can help narrow down the options. It is important to note that these tools give quality rankings, but do not give information related to the price of these plans. The health insurance exchanges website or a qualified broker/advisor can provide pricing comparisons, once you know which plans meet your quality expectations. Consumers should also pay attention to accreditation of plans, meaning they have established protocols and processes, and are committed to accountability. In fact, NCQA accreditation is considered so critical by health care reform experts that it is now mandated by law for all plans sold through health insurance exchanges to have been accredited.
As consumers of these healthcare services, it is important we seek those health plans that provide the best value, best quality of service, and best communication practices, and consider all factors collectively. HEDIS and other quality metrics provide a scorecard for how well a health plan is doing, and can influence you to make the best selection as an individual or group participant. For health plans the message is clear: aside from the reimbursement related to government programs, these scores directly impact the organization’s bottom line in terms of how many consumers will want to buy your product.
CareNational is an expert in Quality Improvement and HEDIS staffing / career search consultation in these specialized areas, but we do not perform the functions ourselves. So how did we do? Did you find this information useful? We love feedback!