HEDIS outcomes may not be the only ones you need to benchmark

Employers are pushing patient experience measurements

Not everyone is happy with the Health Plan Employer Data and Information Set (HEDIS) for outcomes reporting, and this dissatisfaction could mean you must use another set of benchmarks to secure managed care contracts.

Many large employers doubt the usefulness of "process-oriented" outcomes such as HEDIS. They have asked their hospital systems and disease management companies to use the patient-centered measurement sets published by the Portland, OR-based Foundation for Accountability (FACCT).

FACCT represents scores of large companies employing more than 70 million people. It has published a number of measurement sets — including ones for breast cancer, diabetes, and most recently, asthma — which have been adopted by managed care plans across the country.

While some plans have been compelled to use the FACCT measures by large corporate employers dissatisfied with the National Center for Quality Assurance’s (NCQA) HEDIS 3.0 data sets, other plans have begun using them voluntarily to evaluate the performance of physician groups and disease management companies.

"There are a number of business coalitions around the country now that are just beginning to implement the FACCT measures," says Louise Dunn, director of accountability projects at FACCT. "We also have hospitals and plans that would obviously be interested in complying with business purchasers’ requirements." Dunn adds that some plans and other health care providers have begun using the FACCT data sets "because they think they’re a good set of measures to judge how to do quality of care."

While NCQA and FACCT have worked together on the latest HEDIS 3.0 release, employers still complain that HEDIS does not supply the kind of information consumers need to make good health plan decisions. GTE, for example, a Stamford, CT-based telecommunications company, formerly used HEDIS 2.0 data to analyze and compare costs and quality of the health maintenance organizations (HMOs) with which it contracted. The company stopped because it considered HEDIS’ process-outcomes focus "insufficient in helping consumers make meaningful choices about the type of care they want to receive," says Dwight McNeill, manager of health care for GTE in Boston.

"NCQA, via the HEDIS measures and accreditation, has defined what quality is in this country for health plans," says Daniel Malloy, PhD, senior director for HCIA-Response, an outcomes technology firm based in Boston. "But people comment that that’s not really quality or outcomes. It’s not what they’re experiencing. It’s a question now of whether plans are willing to embrace types of performance measures that don’t meet a regulatory requirement or an accreditation requirement but are what the consumers ultimately want and need, and actually, what the plans themselves need to understand if patients’ experiences are positive within their systems."

Although he supports NCQA’s work with HEDIS, Malloy points out that HEDIS data are not intended primarily for the general public, and they don’t help consumers anticipate the events likely to occur in their interactions with health plans.

Nevertheless, NCQA claims that, with the advent of HEDIS 3.0, the committee is moving toward a better mixture of process and outcomes measures to "give the public ever more comprehensive and meaningful information on plan performance." Barry Scholl, an NCQA spokesman, points out that, unlike previous versions, HEDIS 3.0 includes selected FACCT measurements.

Although NCQA is interested in coordinating efforts with FACCT, Scholl says, it’s still unclear how the relationship will work. "There are simply not enough resources being devoted to issues related to performance measurement for us to be wasting any of them in the development of dueling measurement systems," he says.

NCQA officials worry particularly about the possibility that multiple competing measurement systems could hamper efforts to standardize outcomes measurement, Scholl says.

"The potential result is a lot of added burden on health plans and other organizations and providers that are being asked to create data. Is there a danger? We think there is, if we stray from the idea of standardization and revert to a time when health plans had to respond to dozens of different requests for information," he explains.

Meanwhile, NCQA is having problems making sure its participating plans gather comparable data. In April, it implemented new audit standards in response to issues raised about the integrity and comparability of HEDIS data. (See "NCQA implements new outcomes audit standards," p. 84.)

Name of the game is disclosure

NCQA’s attempts to become more consumer-friendly represent one more reason health care providers should get away from the idea that outcomes are relevant only "to your own group for your own self-improvement," McNeill says. "In market competition, we want disclosure. We want the market to recognize the best providers and to make that public. If you really think you’re doing good work, then stand behind it."

Malloy claims performance measurement is at a crossroads, "where the industry is trying to format and present information that they think consumers need. To some degree, they’re realizing they may not be specifying things that patients and purchasers care about."

Indeed, a study called "Employers and Individual Consumers Want Additional Information on Quality," prepared last year by the federal Government Accounting Office in Washington, DC, showed that individual health care consumers did not trust the quality data provided to them by managed care companies, calling the data "self-serving" and "one-sided." The study concluded that managed care organizations should ensure their data are independently audited and compared to benchmarks to enhance credibility.

Patient’s reality, not processes

To be an effective decision-support tool both for providers and consumers, performance measurement must shift away from "this continued overemphasis on process measures and start looking at what patients’ experiences are," Malloy says.

"The fact is that consumers have very little information that will help them understand what they will probably experience when they begin some disease state management program or they have a disease and have to seek treatment through a health plan," he says.

By relying primarily on patient survey data, FACCT’s work "is probably more pertinent and useful for consumers as well as providers who have to channel people through a system," Malloy says. "For example, FACCT’s breast cancer tools open the door to actually look at some of the experiences of people with breast cancer, not just at whether certain events have occurred on certain dates that can be verified against billing records," he says. "[The focus is] actually on what someone experienced in their treatment process."

Unlike NCQA, which uses its report for certification purposes, FACCT does not take cost into account in its measurement sets. "The financial stuff doesn’t have anything to do with our mission," Dunn says. "We’re really working on patient-centered outcomes and results. So, how the organization is financed and those types of things aren’t really of interest to us."

Bottom line: Quality costs less

Nevertheless, FACCT’s outcomes data can be used as one indicator of cost, McNeill says. "According to our data on health plans, quality costs less."

In examining premium costs for the various health care plans with which it contracts, GTE found that premium costs for high-quality HMOs were less than premium costs for lower-quality HMOs. "I’m delighted to be in a position to push for quality in health care and get costs down at the same time," McNeill adds.

Because purchasers are placing greater emphasis on quality as opposed to price alone, McNeill says, health care plans could find it in their financial best interest to disclose their clinical outcomes and patient satisfaction rates.

GTE contracts with 139 health plans nationwide and covers more than 300,000 employees, family members, and retirees. A founding member of FACCT, GTE long has required plans to provide information on health care quality and outcomes. The company defines quality as accessibility to health care, adequacy of benefits provided, cost-effectiveness, and patient satisfaction.

GTE and its employees use these data to make plan selections. In turn, plans increasingly are using outcomes data to evaluate physician groups and disease management companies when assigning contracts, McNeill says.