Did NCQA just hand you the ultimate tool to prove your worth?

Here’s what you need to know about HEDIS 3.0

Case managers have struggled for years to prove the value of their interventions. Now, with the release of HEDIS 3.0 (Health Plan Employer Data and Information Set), the National Committee for Quality Assurance (NCQA) in Washington, DC, may have just handed case managers the measurement tool they’ve been waiting for, says Marcia A. Friesen, RN, BS, CCM, ABQAURP, plan manager for Medicaid/Medicare Managed Care Programs with Mutual of Omaha (NE).

"The indicators, measurement, and knowledge base for HEDIS implementation often lie at the feet of the health plan’s quality improvement director. However, case managers who also have a sound knowledge base of the goals HEDIS requires health plans to achieve can impact the outcomes that cause health plans to score well on HEDIS report cards," emphasizes Friesen. "And, health plans want to score well. Consumers and purchasers of health plans are taking notice of HEDIS report cards and using them to select health plans."

HEDIS 3.0 is the third set of measures released by NCQA to help gauge the effectiveness of managed care health plans. An early draft was released for public comment in July 1996, and the new data set stormed down the pike with the first reporting date looming just around the corner in June of this year. What makes this new data set different from earlier versions? NCQA spokesman Barry Scholl outlines the following changes:

New set is more outcomes oriented.

"Health plans are now expected to measure how well their patients function in their daily lives," Scholl says. "In addition, health plans will be asked to assess member satisfaction results with a single instrument, so that we can capture and compare members’ experiences across health plans."

New set addresses the full spectrum of health care.

"Previous sets did not measure how well health plans treat members who are acutely and chronically ill," Scholl says. "HEDIS 3.0 addresses the range of issues from prevention and early detection to acute and chronic care. It also looks at the care provided to special populations such as the elderly, adolescents, and AIDS patients."

New set brings together private and public sector efforts.

"It was important to us that we developed a data set that is relevant to all populations: public and private. We used to have separate measures for the public and private sector. The new set is all-inclusive but can be broken into subsets for study of special populations," he says.

New set provides standard measures.

HEDIS 3.0 attempts to address the full range of issues that are important to purchasers and consumers of health plans, including clinical results, access to care, satisfaction with care, and cost of care, and it provides standard measures for each issue, Scholl says.

New set provides for ongoing improvement.

"The new set includes testing measures that give health plans a clear signal about what is important for the future," he says. They give NCQA an opportunity to work with health plans, researchers, and consumers to refine additional measures before they become part of the reporting data set.

Knowledge is power

If it’s true that knowledge is power, then understanding the new HEDIS 3.0 measures can only help case managers plan interventions and services that improve the performance of their health plans and make them invaluable to the plan’s success, Friesen says. "There is no doubt that case managers will be involved in the data collection and assessment requirements of the new HEDIS 3.0 measures. We’ve done some preliminary training internally for our case managers on what HEDIS is and how it impacts the organization, but most health plans are in the very early phases of HEDIS 3.0 implementation since its recent availability," she notes.

The basic eight

HEDIS 3.0 measures focus on eight broad categories of health care delivery, and as case managers read through those eight categories, they should be able to identify several areas where they can have a direct impact, Friesen says. Those categories include:

Effectiveness: Is care achieving the gains in health expected?

Accessibility/availability: Is care available to those who need it, without inappropriate barriers and delay?

Satisfaction with the experience of care: Is the experience of care satisfying, as well as clinically effective?

Cost: Is the care of high value?

Stability of the health plan: Is the health plan stable, or will members experience change that could disrupt care?

Informed heath care choices: Is the health plan successful at helping members to be active and informed partners in health care decisions?

Use of services: How are resources used? Is there evidence of too much or too little care?

Description of the plan: How is the plan organized? What type of doctors participate, and how many?

Within each of the eight categories are multiple measures that provide better information on how good plans are at keeping members healthy and improving health when people are sick, Scholl says. For example, within the "effectiveness of care" category are wellness and prevention issues, such as:

• childhood immunization status;

• flu shots for at-risk adults;

• breast cancer screening;

• prenatal care in the first trimester;

• follow-up after hospitalization for mental illness;

• eye exams for diabetics;

• use of beta blockers after a heart attack.

HEDIS can be a ‘great complement’

HEDIS 3.0 allows purchasers and consumers of health plan services to compare apples to apples, say Friesen and Scholl. "The new HEDIS 3.0 data set allowed us to formalize our reporting. It gave us appropriate indicators of care to measure and focus on improving," Friesen says.

"Case managers have struggled for a long time to find a way to show our customers, or our employers, the value of case management. If case managers take the time to understand HEDIS 3.0, it will be a great complement to achieving the goal of providing high quality care," she adds.