New regulations as a result of healthcare reform and reimbursement reform, economic pressures and patient expectations are changing healthcare in America. Health plans and physicians are being challenged to collaborate much more closely than ever before. Information gaps affect the quality of care delivered and optimum reimbursement to both payers and providers.
Health plans and physicians are being called on to close gaps in care and improve overall quality. Multiple quality programs directly impact payer and provider success:
- HEDIS®: The Healthcare Effectiveness Data and Information Set (HEDIS) consist of 81 quality measures across 5 care domains (Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Relative Resource Use and Health Plan Descriptive Information). The measures allow consumers to make “apples to apples” comparisons of various health plans. Many health plans also report HEDIS data to employers or use the data to make improvements in the services they offer. HEDIS is used by 90% of American health plans to measure the performance on important dimensions of care and service.1 HEDIS reporting is required for NCQA (National Committee for Quality Assurance) accreditation, CMS Medicare Advantage (MA) Plans and Consumer Report health plan rankings. HEDIS results are included in a “Quality Compass” comparison tool that allows individuals to view plan results and benchmarks.
- CAHPS®: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a program of the U.S. Agency for Healthcare Research and Quality (AHRQ®). The program is designed to support and promote the assessment of consumer’s experience with health care. CAHPS surveys are similar to patient satisfaction surveys but go beyond simple ratings and probe at the patient’s experience with health care services. Surveys address health plans, practices, Patient Centered Medical Homes (PCMH) and hospitals. CAHPS also provides benchmarking tools to participating providers to compare their results with peers at the local, regional and national levels.
- Medicare Star Ratings: Medicare uses a Star Rating System to measure how well Medicare Advantage (MA) and Prescription Drug Plans perform. Star ratings emphasize patient care and satisfaction and include measures from HEDIS, CAHPS, HOS (Hospital Outcome Survey), Complaint Tracking Module, Independent Review Entity and Prescription Drug Event Data. These ratings are used to compare MA/Prescription Drug Plans and equally important, are used by CMS to determine reimbursement. For example, CMS is directly connecting reimbursement for Medicare services to patient outcomes. By not closing gaps and improving overall quality, Commercial payers and Medicare Advantage plans place a significant portion of reimbursement at risk in 2015.
- NCQA Accreditation: The National Committee for Quality Assurance (NCQA) is a private, not-for-profit organization dedicated to improving healthcare quality. NCQA Accreditation is a “seal of approval” to indicate that an organization is well-managed and delivers high quality care and service. NCQA Accreditation covers health plans, provider organizations and health plan contracting organizations. NCQA Accreditation, while voluntary is used by many employers to gauge the plan’s ability to leverage its resources to improve health and health care. NCQA Accreditation standards are also used by the majority of states as a role model for their own requirements. HCQA Accreditation is also required for MA plans. NCQA Accreditation is based on 3 components: Annual results of HEDIS clinical measures, CAHPS member experience survey and triennial results of the NCQA onsite survey.
- HOS: The Medicare Health Outcomes Survey (HOS) is the first patient-reported outcomes measure used in Medicare managed care (including MA Plans). The goal of the survey is to collect valid and reliable clinically meaningful data. HOS results are used to target quality improvement activities, monitor health plan performance and reward top-performing health plans. The results are that beneficiaries have better information to make informed choices and health outcomes measurement is facilitated.
I am sure there are additional quality programs underway as well. As healthcare and regulatory reform continue to evolve, these programs will be critical in meeting the upcoming regulatory, employer and consumer demands.