Stakes rise for HEDIS care with new NCQA rules
Stakes rise for HEDIS care with new NCQA rules
Practices can expect more HMO pressure
The National Committee for Quality Assurance (NCQA) for the first time has tied accreditation to scores on the Health Plan Employer Data Information Set (HEDIS), a move that signals greater pressure for health plans to participate in HEDIS.
NCQA's new Accreditation 99 program, in which HEDIS performance will make up 25% of NCQA accreditation scores, becomes effective July 1999. It is expected to carry even more weight in subsequent years.
Tougher national standards predicted
Health plans will be measured against benchmarks that initially will represent a blend of regional and national averages and national benchmarks of best performers. This will result in tougher national standards, according to a summary of the proposed standards.
Top performance on HEDIS can help health plans win an "excellent" rating from NCQA - a new accreditation category. Other plans will receive ratings of commendable, acceptable, or denial of accreditation. HEDIS data will be audited by third-party contractors who are certified by NCQA.
"Clearly, it's evolutionary," says Jeffrey A. Rideout, MD, MA, vice president and medical director for quality management of Blue Cross of California in Walnut Creek. "It's the obvious next step for NCQA to integrate its accreditation and performance monitoring."
HEDIS participation has been voluntary, and though some 90% of health plans collect and report HEDIS data, that information has not been audited. Performance has varied widely around the country and within regions.
While health plans scramble to improve their HEDIS scores, they will be forced to rely on physicians to help them. That may in fact empower physicians in their relationships with health plans, notes NCQA spokesman Brian Schilling.
Accreditation 99 standards also include some additional consumer protections, including a prohibition on providing financial incentives to case managers or utilization reviewers who limit or deny care.
Here is how Accreditation 99 is likely to affect physicians, according to those involved in health plan performance measurement:
· Health plans will expect physicians to improve their care related to HEDIS.
Already, many health plans offer awards or incentives for physician groups that show strong performance or improvement in HEDIS care, such as providing mammograms or immunizing children before their second birthdays.
Sample sizes used to calculate health plan HEDIS scores aren't large enough to compare medical groups. But plans often have other mechanisms for monitoring physician performance. For example, Blue Cross of California draws samples from medical groups to monitor mammography, Pap smear screening, and smoking cessation education.
Medical groups in competitive markets already have taken steps to conform to HEDIS requirements, such as using flow sheets or computerized reminder systems to target patients who haven't had their recommended screening tests or immunizations.
For example, Brown & Toland Medical Group, a multispecialty independent practice association based in San Francisco, raised its mammogram rate by compiling lists of women who hadn't received the screening and preparing letters that physicians could sign and mail to their patients.
Pressure to deliver appropriate HEDIS care ultimately benefits patients, says Richard E. Dixon, MD, FACP, medical director of the National Independent Practice Association Coalition in Oakland, CA, and a member of NCQA's Committee on Performance Measurement.
HEDIS: What physicians 'ought to be doing'
"HEDIS measures are, almost without exception, based on very strong science and wide spread clinical consensus," says Dixon. "They measure things we as physicians ought to be doing. So, to the extent they encourage physicians to do - and document - better immunization coverage, more complete use of appropriate cancer screenings, or better treatment of patients after myocardial infarction, the measures themselves are quite beneficial."
· Other clinical areas that need improvement may not receive adequate attention.
Quality improvement always has been an important aspect of NCQA accreditation. But with even greater emphasis on HEDIS, will other clinical areas of need be ignored? This is a concern voiced by some physicians and medical directors.
For example, colorectal cancer is the third leading cause of cancer deaths for both men and women, and guidelines recommend screening of patients over age 50. It is not yet a part of HEDIS, but as the baby boom generation enters its 50s, "that should be an area of concern" for health plans, says Rideout.
HEDIS will continually expand to encompass other clinical outcomes. For example, colorectal screening is in the "testing set," which means it may be added as a measure in future versions. Diabetes measures are also being developed that include glycosylated hemoglobin, a measure of diabetes control.
· Physician groups will face greater burdens related to HEDIS reporting.
Those health plans with the best claims databases may have the highest HEDIS scores. Low performers may be those who aren't doing a good job collecting the information, even though they are delivering the care, notes Dixon.
HEDIS reporting always has been a challenge, particularly in regions where capitated contracts are commonplace. Physicians will need to improve their coding so that HEDIS events are captured in the database, and they will need to be vigilant about submitting encounter data to plans when the care was covered under capitation.
Meanwhile, medical groups can expect a continued - and perhaps growing - parade of plan representatives or auditors pulling medical charts.
Health plans can obtain some information from existing databases. For example, they can pull HEDIS data from immunization registries in those states that maintain them. But some HEDIS specifications will be problematic, particularly if the continuous enrollment requirement is shorter than the period being measured.
The California Cooperative HEDIS Reporting Initiative (CCHRI) evolved as a collaborative of purchasers, health plans, and providers to streamline HEDIS measurement and reporting. But CCHRI participants worry about how the new rules will impact their sampling and auditing process.
For example, one health plan sent administrators at Cedars-Sinai Medical Care Foundation in Beverly Hills, CA, a list of patients and asked for additional chart reviews, beyond the sampling done for CCHRI. "If every health plan does this, the provider groups just can't survive," says chief administrative officer Mary Denton, RN. "It becomes a process that's overwhelming."
NCQA officials say they are aware of the reporting burdens faced by medical groups and have tried to lessen them.
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