The Georgia Scroll
April 1998
HEDIS®: What
it Means to Health Plans and Providers
By: Marci Thomas
Director, Healthcare Enterprise Risk Services
The Health Plan Employer Data and Information Set (HEDIS®) is a set of health plan performance indicators which were created by the National Committee on Quality Assurance (NCQA) to provide a uniform quality measurement system to employers, consumers, payers and other interested parties. HEDIS® is a compliment to, not a substitute for, NCQA accreditation.
HEDIS® reports are prepared annually by many health plans and are used as a marketing tool by those with large employer groups. State and Federal agencies as well as many large employer groups require the submission of HEDIS® reports.
HEDIS® consists of 71 quality measures in eight domains:
Basically, membership, provider and medical event information is gathered in a repository. Measurements are established by ratio of eligible population based on criteria over total eligible population.
If this sounds fairly simple, be assured that it is not. The health plan involved in calculating the HEDIS® performance measures faces a myriad of concerns in obtaining data, abstracting medical records, ensuring the correct coding of the data and entering and integrating the data. In addition, the health plan has to develop measurement numerators and denominators according to a complicated set of instructions set forth by NCQA.
The health plan must be concerned with data completeness, data security and data integrity. It also has to deal with obtaining data from providers, many of whom may not produce data in electronic form and many of whom are not accustomed to providing detailed information at all.
Reliable and accurate translation of medical record information into acceptable computerized documentation (abstraction) is another concern for the healthplan.
The health plan will be reporting HEDIS® data for specific periods of time, generally one year. The data to be used in HEDIS® reporting will come from many sources and must be integrated into a central repository or data warehouse so that the performance measures can be calculated. Appropriate internal controls surrounding this function are critical to ensure the integrity of the data and therefore the accuracy of the measure.
NCQA HEDIS Compliance Audit™
Health plans have been computing HEDIS® performance measures for a number of years. However, to ensure comparability among the performance measures of health plans the NCQA has recently devised the NCQA HEDIS Compliance Audit™. The NCQA HEDIS Compliance Audit™ is a precise, standardized methodology that verifies a health plans ability to appropriately capture and report HEDIS® performance measures. The NCQA is licensing firms who meet specified requirements to perform these audits. Individuals within the licensed firms are required to sit for a comprehensive examination in order to become certified to perform the audits.
The auditor develops an audit plan based on a review of the healthplan’s baseline assessment. The baseline assessment documents the healthplan’s internal structure, information systems, provider structure, internal control and other information. From this review the auditor will select 15 specific performance measures to audit. In addition to performing detailed procedures on those measures, the audit also focuses on:
Additional measures could be selected for testing based on the results of the initial procedures. As time permits, healthplans are able to take actions necessary to correct measures where the auditor has issues. The auditor will then look at the corrective action and determine if the measure can be reported. Failure to report measures may reflect poorly on the health plan.
Based on results of the pilot projects and readiness review performed to date these are some of the issues that have caused healthplans the most difficulties in reporting HEDIS® measures.
Due to the difficulties health plans are encountering under audit and the time pressures involved in reporting HEDIS® statistics, a healthplan should take steps to perform a readiness assessment of its HEDIS® system. The buy in of senior management is essential for any readiness review to be effective since the resources required to undertake such an effort are considerable. The assessment could be performed by an internal HEDIS® team comprised of personnel from quality improvement, medical records, information services including HEDIS® programmers and statistician used to develop the sampling strategy. Alternatively, the healthplan could engage a consulting firm to perform the readiness assessment. Addressing these issues now will help to prevent surprises when the healthplan is under pressure to produce its HEDIS® results.
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Last modified: June 22, 2001