Stakes rise for HEDIS with new accreditation rules

Physician help needed to attain top scores

For the first time, the National Committee for Quality Assurance (NCQA) has tied accreditation to scores on the Health Plan Data Information Set (HEDIS), a move that signals greater pressure for health plans to participate in HEDIS.

As Physician Relations Update went to press, NCQA announced its Accreditation 99 program in which HEDIS performance will comprise 25% of NCQA accreditation scores effective July 1999. It is expected to carry even more weight in subsequent years. To date, HEDIS participation has been voluntary, and though 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.

"Clearly, [Accreditation 99] is evolutionary," says Jeffrey A. Rideout, MD, MA, vice president and medical director for quality management at Blue Cross of California in Walnut Creek. "It's the obvious next step for NCQA to integrate its accreditation and performance monitoring."

Health plans will be measured against benchmarks that initially will represent a blend of regional and national averages, as well as benchmarks of top performers. That blending will evolve into 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.

While health plans scramble to improve their HEDIS scores, they will have no choice but to rely on physicians to help them. That may, in fact, empower physicians in their relationships with health plans, says 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.

NCQA is accepting comment on the stand-ards until May 15, and final standards will be released in August. (For more information about Accreditation 99, see list, above.) 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.

For example, Blue Cross of California offers an incentive of up to 60 cents per member per month for medical groups that perform well in a range of areas, including a field audit, member satisfaction surveys, grievance tracking, and three HEDIS measures. Groups that fare poorly are asked to take corrective action.

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 rates for mammography and Pap smear screening and advising smokers to quit.

Some physicians are gearing up now

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.

Increased 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 measures are, almost without exception, based on very strong science and wide-spread clinical consensus," he says. "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, and 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 has always been an important aspect of NCQA accreditation. But with even greater emphasis on HEDIS, will other clinical areas of need be ignored?

That is a danger voiced by some physicians and medical directors.

"There's already a lot of teaching to the HEDIS test," says Rideout. "HEDIS is required by most major purchasers. If you integrate HEDIS into accreditation, that can be positive as long as you don't leave all the non-HEDIS areas behind."

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 patients from the baby boom generation enter their 50s, "that should be an area of concern" for health plans, Rideout says.

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, Dixon explains.

HEDIS reporting has always 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 vigilant about submitting encounter data to plans when the care was covered under capitation.

Get ready for intense scrutiny

Meanwhile, medical groups can expect a continued - and perhaps intensified - 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.

"A child only needs to be continuously enrolled for a year in a health plan, but you're looking over a two-year period for immunizations," says Alison South, a director at Medstat in San Francisco who is certified to conduct HEDIS compliance audits. A plan may need to pull charts to determine if care occurred while the patient was covered by a different health plan.

"The physician is definitely feeling the impact today [of that dilemma]," she says. "There are more charts that need to be pulled."

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 and administrative 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.