Health Plan Employer Data Information Set Research Articles

Medicare Part D Enrollees' Use of Out‐of‐Plan Discounted Generic Drugs, Revisited

Medicare Part D Enrollees' Use of Out‐of‐Plan Discounted Generic Drugs, Revisited

Interpreting Market Share Changes as Evidence for Effectiveness of Quality Report Cards

report cards have become an integral part of the American health care system. Quality From the early, now abandoned, efforts by the then Health Care Financing Administration (HCFA), which began publishing reports with risk-adjusted mortality rates for all hospitals in the country in the mid 1980s, we have moved into an era in which report cards abound. The federal government, through the Centers for Medicare & Medicaid Services (CMS), formerly HCFA, is now publishing Web-based report cards on hospitals, nursing homes, home care agencies, and managed care organizations (see http://www.medicare.gov). Many state governments, health plans, employers, and employer coalitions publish report cards as well. These reports typically focus on the quality of the clinical services of medical providers, although some may include information about other aspects of care, such as office staff courtesy, helpfulness, and respect.1 Although the market seems to have forged enthusiastically ahead with report cards, the scientific evidence about their effectiveness, and in particular, their impact on patient referrals, is mixed. Four review articles have examined studies of various report cards and concluded that, for the most part, there is only minimal evidence that report cards influence referral choices made by patients and their physicians. Mukamel and Mushlin2 reviewed 8 studies, including the HCFA Hospital Mortality reports, the New York State (NYS) and the Pennsylvania Coronary Artery Bypass Graft (CABG) reports, and the Health Plan Employer Data Information Set (HEDIS) managed care report (studies that were published between 1988 and 2000) and concluded that there is only a minimal effect on choice of provider. Marshall et al3 reviewed 9 studies including the HCFA Hospital Mortality reports, the NYS and the Pennsylvania CABG reports, and physician fee data (studies published between 1988 and 1998). They also found that, if an effect on provider choice and market shares is detected, it tends to be small. Schauffler and Mordavsky4 reviewed 16 studies of report cards on hospitals, cardiac surgeons, and managed care organizations (published between 1996 and 2000) that examined choice of providers made by patients, managed care organization, and employers. They also found that the impact of report cards is small and concluded that they do not make a difference in decisionmaking. A more recent review by Werner and Asch5 reached similar conclusions. This body of evidence, which has led some scholars to conclude that report cards do not influence choice of providers, flies in the face of the market's belief in the importance of report cards, as evidenced by the proliferation of these reports in recent years. This apparent paradox warrants examination of the question of whether the conclusions drawn from the empirical evidence indeed imply that the reports have no impact and have failed to play an important role in the health care system. In the remainder of this essay we examine the rationale and theoretical expectations for report cards and then discuss several reasons for the empirical findings of minimal effect on referrals, including the credibility and usefulness of the information in different report cards, their news content, and the impact of providers' capacity limitations. We then argue that a

The Impact of a Change in Medicare Reimbursement Policy and HEDIS Measures on Stage at Diagnosis Among Medicare HMO and Fee-For-Service Female Breast Cancer Patients

To examine the effects of health plan enrollment [health maintenance organizations (HMO) or fee-for-service (FFS)], a change in Medicare reimbursement policy which allowed for annual rather than biennial mammograms, and Health Plan Employer Data Information Set (HEDIS) measures on stage at diagnosis among older women with breast cancer. We used the population-based Surveillance Epidemiology and End Results (SEER)-Medicare database to identify all elderly women age 65-74 who were diagnosed with breast cancer from 1994 to 2002. We compared stage at diagnosis, demographic characteristics, and tumor characteristics for FFS or HMO enrollment in the periods before and after the 1998 policy change. We compared the effect of women age 65-69 whose mammography use in the HMO system is measured by HEDIS and those who are older (age 70-74). We identified 20,106 women enrolled in FFS Medicare, and 10,751 women enrolled in an HMO. Women ages 65-74 who were enrolled in a Medicare HMO were more likely to be diagnosed at an early stage both before and after the policy change, but the disparity decreased from 4.7% to 2.3%, a relative change of 51.1%. The disparity was not specific to the ages included in the HEDIS measure. A decrease of 51.1% in the HMO-FFS disparity in breast cancer stage at diagnosis coincided with the 1998 change in Medicare mammography reimbursement policy. The existence of HEDIS measures for HMOs does not create a disparity in stage at diagnosis between those whose mammograms are measured by HEDIS (younger women) and those whose are not (older women).

Pediatric Asthma Surveillance Using Medicaid Claims

The purpose of this study was to describe the prevalence of asthma among children using alternative case definitions applied to administrative claims data, and to assess year-to-year classification concordance. This study was a retrospective cohort analysis of 357,729 children 0-18 years using 2001-2002 Michigan Medicaid claims. Asthma cases were classified using six alternative definitions based on outpatient, emergency department, inpatient, and pharmacy claims for asthma, including the Health Plan Employer Data Information Set (HEDIS) persistent asthma criteria commonly used for assessments of asthma health care quality: at least one asthma inpatient admission or emergency department visit, four or more asthma medications events, or four asthma outpatient visits and two asthma medication events. Overall, asthma prevalence varied widely between alternative case definitions, ranging from 14.9% based on claims evidence of any type of asthma utilization to 3.7% when restricted to those with four or more asthma medication dispensing events. Among cases meeting HEDIS persistent asthma criteria in 2001, 55.5% met these criteria in 2002. Those with four or more asthma medication dispensing events had the best overall classification concordance between 2001 and 2002. Utilization of asthma services and prevalence estimates were highest among children younger than 5 years old, but year-to-year classification concordance was poorest among these cases (p < 0.0001), irrespective of case definition. While overall asthma prevalence may remain relatively stable from year to year, individuals may not be classified consistently as cases over time, regardless of case definition. Studies that identify asthma cases in one year and assess asthma outcomes in a subsequent year may introduce substantial bias as a result of case misclassification. Among the case definitions considered in this study, our findings suggest that this bias is minimized among cases classified using the four or more asthma medication dispensing events criterion.

Limits of the Health Plan Employer Data Information Set (HEDIS) Criteria in Determining Asthma Severity for Children, Applied to an Impoverished, Urban Population

To the Editor .— The Cabana et al1 article in the October 2004 issue of Pediatrics , which compares the National Heart, Lung, and Blood Institute recommendations for treatment of pediatric asthma with the quality-of-asthma-care measure developed by the Health Plan Employer Data Set (HEDIS), effectively addresses the limitations of standardized guidelines. The HEDIS asthma measure identifies health plan members with “persistent” asthma if there was 1 emergency-department (ED) visit or inpatient discharge listing asthma as the primary diagnosis, ≥4 outpatient asthma visits with 2 medication-dispensing events, or 4 medication-dispensing events in the year before evaluation. To pass the measure, members with “persistent” asthma must fill a prescription for a qualifying medication (inhaled steroid, leukotriene modifier, etc) in the year of …

HEDIS administrative data to track chlamydial screening for teens: Are we measuring what we think we are?

Chlamydia trachomatis (CT) screening of sexually active girls (15–25) is a performance standard in the Health Plan Employer Data Information Set (HEDIS) as part of the National Committee for Quality Assurance (NCQA) to monitor the quality of care in managed care organizations. There has only been one published study to date examining the validity of the HEDIS measure to identify sexually active females. However, this study did not specifically report on the teen data. Because of the lack of data and concern about the HEDIS measure for teens (e.g., oral contraceptive prescription use for acne & reproductive counseling as a preventive service), we compared two different methods for calculating CT Screening rates among sexually active adolescent females: HEDIS specifications vs. teens’ self-report survey data.

Quality and employers’ choice of health plans

We seek to understand the relationship between employer decisions regarding which health plans firms choose to offer to their employees and the performance of those plans. We measure performance using data from the Health Plan Employer Data Information Set (HEDIS) and the Consumer Assessment of Health Plan Survey (CAHPS). We use a unique data set that lists the Health Maintenance Organizations (HMOs) available to, and offered by, large employers across markets in the year 2000, and examine the relationship between plan offerings, performance measures and other plan characteristics. We estimate two sets of specifications that differ in whether they model plan choice as a function of absolute plan performance or plan performance relative to competitors. We find that employers are more likely to offer plans with strong absolute and relative HEDIS and CAHPS performance measures. Our results are consistent with the view that large employers are responsive to the interests of their employees.

Assessment of factors influencing blood pressure control in a managed care population.

We attempted to determine the percentage of patients meeting Health Plan Employer Data Information Set (HEDIS) criteria for blood pressure control (< or = 140/90 mm Hg), to identify factors contributing to differences in blood pressure control among those who met HEDIS criteria and those who did not, and to assess compliance with blood pressure management recommendations established by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) for diabetes mellitus and myocardial infarction. In this retrospective analysis, we randomly selected 502 patient records from three primary care clinics in southeast Michigan. All patients were commercial members of one health maintenance organization, 74% of whom met HEDIS criteria for blood pressure control. These patients took fewer blood pressure drugs throughout the year (p=0.023) and had lower antihypertensive drug costs than those who did not achieve HEDIS blood pressure goals (p=0.016). According to JNC-VI criteria, 46% of diabetic patients were at their blood pressure goal of below 130/85 mm Hg and 71.6% were managed with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Eighty-five percent of patients were taking beta-blockers after myocardial infarction. The percentage of patients achieving target blood pressure exceeded the national average and was associated with few antihypertensive drugs and low drug cost. Effective and appropriate management of blood pressure in people with diabetes remains a challenge.

HCFA Focuses on New Plans for Quality Care

AFTER DECADES of serving as the checkbook for millions of Americans' health the federal Health Care Financing Administration (HCFA) wants to ensure that its beneficiaries get the most bang for the buck. Toward that end, Congress recently approved a budget act with a mandate that HCFA establish quality requirements for managed care organizations that provide health care for people enrolled in Medicare and Medicaid. Both programs already use the Health Plan Employer Data Information Set (HEDIS)—created by the National Committee for Quality Assurance—as a means to measure the performance of managed care plans that serve their beneficiaries. But HCFA's new mandate, known as the Quality Improvement System in Managed Care (QISMC), will require that participating health plans show evidence of improvement in the health care they provide. The initiative moves from a structural process to the next generation of standards requiring managed care organizations to improve health care, said

Ensuring health care quality: perspective from a member of NCQA's committee on performance measurement

Using the California Public Employees' Retirement System (CalPERS) as an example, this paper illustrates how an employer can abandon the more traditional role of passive purchaser of health care benefits and become an active participant in cost containment and quality improvement in the health care industry. Through the use of the Health Plan Employer Data Information Set (HEDIS) 3.0 and other data collection and reporting methods, the communication gap between consumers, purchasers, health plans, and providers is narrowing. Increasingly, purchasers like CalPERS are becoming involved in quality improvement; they are recognizing the need to serve as intermediaries between consumers and health plans, to understand available data, and to disseminate that information to the consumer. The purchaser's impact on the health care community's business practices is growing. As a result, the collection and reporting of HEDIS data are now emerging as substantial fiduciary reporting responsibilities for health plans. This paper outlines a plan implemented in California for improving HEDIS data gathering and examines surveys, results, and problems encountered in improving and integrating health care information.

HEDIS: implementation issues.

Historically, employers have asked health plans to measure performance in terms of quality, utilization, satisfaction, and cost. As organizations collected these data, employers realized that rarely were all the data comparable. Several employers, such as Xerox Corporation, Digital Equipment Corporation, and Bull HN Information Systems, Inc., agreed to work together to create reporting criteria that would standardize measurement. This collaboration resulted in the Health Plan Employer Data Information Set (HEDIS) criteria. This article reviews some of the implementation issues and decisions that a plan must resolve to gather accurate HEDIS data.