In 1991, the average premium for a family with employer-sponsored health care was less than $1,300, and two thirds of all workers were in traditional fee-for-service insurance plans. One year later, a relatively unknown governor of Arkansas was elected president, and two years after that he introduced his ill-fated health care reform plan.
At the time, managed care plans were going like gangbusters—their 5% share of all workers in 1984 had risen to 26% in 1989 and 50% in 1993. Concerned that capitated payment might lead to poor care for American workers and their families, employers and consultants called for a system to evaluate the quality of care health plans delivered. The result was the HMO Employer Data and Information Set, since rechristened the Healthcare Effectiveness Data and Information Set, a health plan performance measurement tool. American health care has never met an acronym it didn’t like, so that long name gets shortened to HEDIS, which is pronounced HEE-dis. To some ears that sounds more like an infectious disease than a quality improvement tool.
Two and half decades later, HEDIS plays as large a role as it ever has in the evaluation of health plans. More than 90% of managed care plans use HEDIS to collect information on the performance of their physicians in 81 areas of care delivery and service. In 2016, NCQA collected HEDIS data on health plans covering 81% of all insured lives.
Because of HEDIS, health plans collect data on everything from how many times a physician has eligible patients screened for colorectal cancer to what percentage of patients have their hypertension managed to how well patients adhere to immunization schedules.
Assessing care delivery in these 81 areas is important. But what do these assessments tell us? Are patients more or less likely to die as a result of being enrolled in one of the nation’s best health plans? When doctors can check all the appropriate boxes on the HEDIS survey, are their patients healthier than those of a doctor who has no idea if HEDIS data are being collected on his or her patients?
And now there is another important question to ask. Because of MACRA, CMS is introducing new quality measurement requirements this year. Are doctors, already drowning in paperwork, being asked to fill out too many forms when they could be using that time caring for and listening to patients? The fact is that much of the data collection and reporting goes on behind the scenes. Many physicians aren’t even aware that somewhere in their office, someone or some system is busy scooping up data and plugging in 81 HEDIS measures. But those 81 represent less than 10% of the 900 or so quality measures in use today. It may happen in the background, but all this effort to measure quality is getting burdensome and adds to the cost of American health care.
Even though some physicians consider HEDIS data collection to be a burden, many others have developed sophisticated data systems to collect the numbers they need for quality reporting in the background. What’s more, physicians who embrace HEDIS have come to view it for what it has become, a way to measure their ability to improve patient care and a key to collecting financial rewards for meeting health plans’ quality goals.
While some physicians today see value in their HEDIS scores, others still echo the complaints heard about HEDIS from its earliest days, when critics noted that most of the measures were limited to the processes of care. Payers—chiefly employers—had no way to know if people were actually healthier than before they enrolled in an HMO—and part of the promise of the HMO was that preventive care would keep people healthier and their health care less expensive. That inability to evaluate patient outcomes is a flaw in HEDIS that remains today. But instead of addressing that flaw, quality measurement organizations have added many more quality measurement data collection requirements and are planning still more. So while HEDIS may be the most important and longest-tenured quality measurement system, many physicians and other providers tend to view it as, at best, a bother.
Here’s a telling comment from a physician interviewed for Managed Care in 2012, the year NCQA added the HPV vaccine as a HEDIS measure. Chuck McKinzie, MD, an ob-gyn in rural Minnesota, said HEDIS was not widely known among physicians in remote parts of the state. “Making it a HEDIS measure will help,” he said of the HPV vaccine. “But out here HEDIS is hardly on anyone’s radar. The doctors in these small rural towns think, ‘HEDIS schmedis!’”
“We have a lot of work to do to clean up the way that measurement intersects with practitioners at the delivery system level,” says NCQA President Peggy O’Kane.
While McKinzie represents a sample of one, his comment is telling, says NCQA President Peggy O’Kane: “I don’t blame doctors for thinking that way. To them, quality measures probably seem like an unnecessary nuisance defined by someone somewhere on behalf of employers or CMS or somebody else.” Meeting such standards may seem removed from what physicians were trained to do.
“It’s understandable that doctors are feeling frustrated,” O’Kane says. They are asked to spend a good part of every day collecting and reporting data on their own performance, pay for sophisticated systems to collect and report the data, or hire someone to do it for them. It doesn’t end with HEDIS. Now there are new requirements from MACRA that will affect any physician with Medicare patients as well as the data-collection rules that most health plans impose in addition to HEDIS, which physicians can’t blow off because they are often used to determine sizable bonus payments.
Certainly some of the data required to comply with MACRA will overlap with what’s in HEDIS, and some health plans are just beginning to align the goals of disparate data-collection programs.
“That’s a problem that we’re collectively responsible for,” O’Kane adds. “We have a lot of work to do to clean up the way that measurement intersects with practitioners at the delivery system level.” Even something as straightforward as a blood-pressure check can get needlessly complicated because of the proliferation of quality measurements and the differences among them.
“I am sympathetic to doctors’ complaints because each health plan seems to be doing something different from the standpoint of collecting data on quality,” says Humana’s chief medical officer, Roy Beveridge, MD.
Humana’s chief medical officer, Roy Beveridge, MD, agrees that quality measurement takes up an extraordinary amount of physicians’ time. “Having practiced for 20 years, I am sympathetic to doctors’ complaints because each health plan seems to be doing something different from the standpoint of collecting data on quality,” he says. “We’re taking time from providers that they should be spending with their patients.”
Early last year, Humana, other insurers, AHIP (the health insurance trade association), and 18 specialty societies began grappling with how to reduce the overload. AHIP and CMS released seven sets of clinical quality measures that support what CMS calls “multi-payer alignment.” The core measure sets are designed to align quality measures for physicians and group practices serving patients in ACOs and patient-centered medical homes. The measures apply to physicians in primary care, cardiology, gastroenterology, oncology, ob-gyn, and orthopedics, among other specialties.
Still, HEDIS isn’t going away. “HEDIS scores work well, particularly for primary care,” says Beveridge. “They’re universally accepted in the United States.” Physicians may not like quality measures in general, says Beveridge, but by now most have gotten used to HEDIS and are comfortable with meeting its requirements. But reaching that comfort level has been expensive. Doctors and medical groups have invested considerable time and money to develop systems that collect and report the required data. Some use their electronic health record (EHR) systems to collect the data, others hire assistants to comb through claims, and many use a combination of the EHR and human handwork.
In October, the Government Accountability Office (GAO) reported that the wide variety of quality measurement systems in use today and the lack of alignment among them can have adverse effects on physicians and other providers and on efforts to improve quality of care. “Misalignment occurs when health care payers require providers to report on measures that focus on different quality issues or define the measures using different specifications,” said the report. Bruce Muma, MD, the chief medical officer of Henry Ford Health System ACO in Detroit, says that different organizations use the 900 quality measures differently.
Health plans should eliminate all but about 30 to 50 of the best quality measures, suggests Bruce Muma, MD, the chief medical officer of Henry Ford Health System ACO in Detroit.
“Every insurer has its own subset of those 900 measures,” he says. “Then, it builds its own pay-for-performance contracts and value-based payments around those measures. Then it imposes those measures on the doctors in multiple ways by sending us reports, requiring us to submit data, sending people out to our practices to extract data from our charts, and forcing us to have educational programs about their particular metrics that they think are important.”
Health plans should eliminate all but about 30 to 50 of the best quality measures, he suggests. “If all of the payers agreed on 30 metrics that would define value and quality and all doctors were measured on those 30 metrics, we would not have the problems we have today with such an abundance of measures,” Muma says. “Of course, all the EMRs would need to be programmed to collect and report data on those 30 measures, and then automation would handle everything behind the scenes.”
Oak Street Health is a group practice that uses several electronic tools to collect HEDIS data, says Griffin Myers, MD, co-founder and chief medical officer. Its 75 physicians serve 25,000 low-income Medicaid and Medicare Advantage patients in some of Chicago’s underserved neighborhoods. “Collecting HEDIS data is not all done at the point of care,” says Myers. The data also come from claims, reviews of lab reports, and a variety of other sources.
The data systems at Oak Street Health are sophisticated enough so that Myers and his staff often recognize problems with their HEDIS data before their health plans do, he says. The group contracts with Blue Cross Blue Shield of Illinois, Cigna, Community Care Alliance of Illinois, HealthSpring, Humana, and WellCare, among other plans. “The reason we know about gaps in HEDIS before they do is that we keep all those data in our enterprise data warehouse so that we can submit them directly to the plans,” he says. “That way, they don’t have to audit our charts as they did in the past.”
Myers is not among those who view HEDIS as so heinous. Quality metrics, including HEDIS, are a way to measure the group’s progress toward improving the health of all patients, he says. While he concedes that HEDIS does not capture outcomes, adhering to processes can be an adequate proxy.
“My personal commentary on quality measurement systems, including HEDIS, is that they do not reflect whether we deliver good care or not,” says Myers. Instead, HEDIS reflects whether a physician or group practice is meeting certain minimum standards of care. “Doing these things on the HEDIS scorecard is better than not doing them, and so in that way HEDIS demonstrates our commitment to value-based care and to quality reporting,” he explains. “And to do all these things well, including reporting our HEDIS scores, we need to have a sound infrastructure, which we have.”
Subset of many different things
“In a fee-for-service environment, your price is whatever is listed on the fee schedule,” Myers says. In a value-based model, price is based on how sick somebody is today and how well I can make him or her tomorrow, he adds. “So we’ve invested in the systems needed to demonstrate clearly what our HEDIS results are, and HEDIS is a subset of the many different things that we report on because there are many different things that we think are important to care.”
Collecting the number of flu shots dispensed is not a HEDIS metric, Myers says. But Oak Street tracks and reports those data because that is meaningful in terms of the health of the group’s patients. The data collection system even collects data when patients get a flu shot at another facility, such as a Walgreens pharmacy, when a patient is on vacation. “Otherwise, we would never know that and so that would be a gap that we would need to address,” he says.
The data warehouse contains all the patient data that Oak Street Health collects and data on any in-network care. “Because we’re value-based, we’re paying all those claims for all of the care that patients get, whether it’s in our building or not. So we need that data on every patient encounter,” he says.
When physicians begin collecting data to comply with MACRA, 60% or more of the data they collect will be based on HEDIS scores, says Anas Daghestani, MD, CEO of the Austin Regional Clinic.
Data-collection systems like the one Oak Street Health uses are necessary because most physicians are to this day unaware that HEDIS scores need to be collected on every patient encounter, says Anas Daghestani, MD, CEO of the Austin Regional Clinic, one of the largest group practices in Texas.
“As a physician seeing patients, you don’t think in HEDIS terms,” he says. “You are just doing whatever you think is the right thing and hoping that will translate into a better HEDIS score.”
Like Oak Street Health, Austin Regional has a data warehouse system that collects HEDIS data from the group’s electronic health record system and other sources. Daghestani notes that HEDIS is the source of many—if not most—of the quality measurement systems in use today. The 33 metrics CMS uses in its ACO program are based on HEDIS. Even when physicians begin collecting data to comply with MACRA, 60% or more of the data they collect will be based on HEDIS scores, he says.
To ensure that it collects all the HEDIS numbers needed from every patient encounter, Austin Regional has a group of programmers who build data collection programs into the group’s electronic record system. “That way, the system can alert them to any gaps in care and they can address that gap right then and there,” Daghestani says. All of this HEDIS-related work doesn’t come cheaply, however. Austin Regional spent about $1 million to build the necessary infrastructure, and the annual operating budget is about $2 million.
“We’re also looking at what data we can get the system to collect so that we can avoid pushing all of that data collection work onto our physicians,” Daghestani says. “If it’s something that can be done behind the scenes, we’ll do that. If it’s something that our nursing staff can do, we’ll do that.”
Two months ago, Humana released the results of a study that compared 1.2 million members under value-based Medicare Advantage (MA) contracts to 170,000 members under standard MA contracts. The HEDIS scores for the providers associated with the value-based contracts were 19% higher than those associated with the standard contracts. Members served by value-based MA providers had 6% fewer ER visits than members in standard MA arrangements and also had higher breast cancer screening rates (6% higher), colon cancer screening rates (8% higher), and management of osteoporosis (13% higher).
Cost is not part of HEDIS, but, of course, it is an issue that insurers are concerned about. Humana reported that costs for the valued-based MA members were 20% lower than for the standard-issue MA members.
“If you want to drive cost out of the system, you start by making sure that all of your patients get colon cancer screening at the right time, because screening for colon cancer is a lot cheaper than treating someone who develops metastatic colon cancer,” Beveridge says. “Same thing with mammograms, and screenings for prostate cancer and flu shots.”
He waves off the old objection that prevention doesn’t pay because some other insurers may reap the benefit of people staying healthy long after they leave the health plan that paid for the preventive efforts. Humana members stay with the company an average of seven years, according to Beveridge, which may not be long enough to get all of the return on the investment in prevention but it’s enough to get some. Besides, sometimes the return can show up quickly. Flu shots for a plan’s members are a good deal compared with a hospital stay for a complicated case of flu, which could cost up to $80,000, Beveridge explains. And many patients with diabetes will avoid hospitalizations and emergency room visits if their HbA1c levels are kept under control.