HEDIS: LOOKING AT THE NUMBERS

A Managed Care magazine analysis of Quality Compass 98 — the National Committee for Quality Assurance's annual compilation of HEDIS data — has blown the dust off of some controversial generalizations about the health plan industry. Our study of Quality Compass data indicates that on the whole, not-for-profit health plans tend to outperform for-profit plans on Health Plan Employer Data and Information Set measures. We also found that large national health plans can have large regional differences in quality of care and that pure HMOs appear to score higher than point-of-service plans.

This year, 447 plans reported HEDIS data to NCQA; 292 agreed to allow NCQA to make their scores public. NCQA offers that plans that publicly report data tend to score higher on HEDIS measures than plans that choose to keep their scores confidential. Similarly, NCQA-accredited plans outperform health plans that do not seek the NCQA seal.

In all charts, the numbers represent the percentage of enrollees eligible for the service who actually received it.

This article is also available in PDF

For-profit vs. not-for-profit

Regional variances

HMO vs. POS plans

To report or not to report?

The accreditation correlation












HEDIS: LOOKING AT THE NUMBERS

For-profit vs. not-for-profit

Some not-for-profit health plans have long looked down their noses at their for-profit cousins, claiming superiority of priorities. Quality Compass could give the not-for-profits fuel for their arguments. While generalizations about quality of care are difficult to state definitively, for each of six key HEDIS measures that we checked out, the average score of all not-for-profit plans is higher than that of for-profit plans. (Averages for each measure are calculated for publicly reporting plans that furnished data to NCQA for the specified measure.)

Regional variances

NCQA found significant regional variance within plans and differences from plan to plan. For instance, the average health plan in New England administered beta blockers to heart attack patients 90 percent of the time, while plans in the south central U.S. did so only 60 percent of the time. In general, New England outperforms the nation on HEDIS measures.

Given regions' varying resources and demographics, can these differences be overcome? At an NCQA news conference, Jeffrey Harris, M.D., M.P.H., director of prevention research and analytic measures for the U.S. Centers for Disease Control, related a discussion he had recently with quality-improvement managers from the nation's largest health plans. When some managers told him their plans were "pushing the limit on improvement," Harris replied, "Oh yeah? What about New England? How come they can do so well?" The managers talked about New England "all night long," Harris recalled, "and tried to figure out how they could get to that standard."

It would be little surprise to compare, say, a small health plan in New England to a small plan in another region and find different levels of HEDIS performance. But regional differences appear to extend to large national plans, which generally attempt to standardize care. For the three largest national plans' HMO products, a comparison of six important HEDIS measures by location reveals some profound differences.

HMO vs. POS plans

While point-of-service offerings are rapidly gaining popularity, they tend to lag HMOs on HEDIS performance. Quality Compass reports separate scores for HMOs, point-of-service plans and preferred-provider organizations (though insufficient information exists to make valid comparisons about PPOs).

To report or not to report?

There are reasons, often valid, why some plans participate in HEDIS but do not make their scores public. But in an effort to turn up the heat on nonreporting plans — and as a message to employers to support plans that are gutsy enough to lay their cards on the table — NCQA released data showing that, overall, plans that report publicly outscore plans that do not.

The accreditation correlation

NCQA-accredited plans tend to outscore those that do not seek accreditation. This takes on new significance next year, when HEDIS performance will count toward accreditation scores. "Accountability will drive better performance," says NCQA President Margaret O'Kane, noting that plans that participated in HEDIS two years in a row outperformed the industry as a whole.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.