HEDIS Quality Scores Explained

Summary

Dr. Eric Bricker's video explains HEDIS, a set of standardized measures for assessing healthcare quality, created by NCQA. HEDIS evaluates over 400 Medicare, Medicaid, and commercial health plans, focusing on process and outcome measures like mammogram screening rates and hemoglobin A1c control for diabetes. The video clarifies misconceptions about HEDIS's relevance to individual provider quality and its impact on Medicare Advantage plans, emphasizing the importance of understanding HEDIS in the broader context of healthcare quality assessment.

Takeaways

• 📚 HEDIS stands for Healthcare Effectiveness Data and Information Set, a tool used to measure performance in health plans.
• 🏥 Created by NCQA (National Committee for Quality Assurance), a non-profit organization that is not part of the government.
• 🔢 HEDIS evaluates a large number of health plans: 412 Medicare Advantage, 171 Medicaid, and 438 commercial plans.
• 🏬 The high number of commercial plans is due to the inclusion of various HMO, POS, and PPO plans offered by different providers and states.
• 👩‍⚕️ HEDIS measures include process measures like the use of beta blockers in heart attacks and outcome measures like hemoglobin A1c control for diabetics.
• 📉 HEDIS focuses on the quality of health plans rather than individual providers, which can make it difficult to assess the quality of specific doctors or hospitals.
• 💊 HEDIS measures can influence Medicare Advantage payments and enrollment periods, with higher scores leading to better ratings and year-round enrollment opportunities.
• 🌟 Medicare Advantage plans have a vested interest in achieving high HEDIS scores, which can impact their operations and patient care strategies.
• 🛑 For commercial PPO plans, HEDIS scores may not be as relevant due to the aggregated nature of the data, making it hard to assess individual provider quality.
• 📈 HEDIS scores are used by consumers to evaluate health plans, particularly when choosing Medicare Advantage plans based on star ratings.
• 🔑 Understanding HEDIS and NCQA provides context for evaluating health plan performance and the broader healthcare system's effectiveness.

Q & A

What is HEDIS?

HEDIS stands for Healthcare Effectiveness Data and Information Set. It is a tool used to measure performance in health plans.

Which organization created HEDIS?

HEDIS was created by the NCQA, which stands for the National Committee for Quality Assurance.

What does NCQA stand for and what type of organization is it?

NCQA stands for the National Committee for Quality Assurance. It is a non-profit organization near Washington DC and is not part of the government.

How many health insurance plans does HEDIS measure?

HEDIS measures 412 Medicare Advantage plans, 171 Medicaid plans, and 438 commercial plans.

Why are there so many commercial health insurance plans in America according to HEDIS?

The high number of commercial plans is due to the individual listing of HMO, POS, and PPO plans for various Blue Cross, United, Cigna, and other providers, differentiated by state.

What types of measures does HEDIS include?

HEDIS includes measures such as mammogram screening rates, the use of beta blockers in myocardial infarctions, and control of hemoglobin A1c and hypertension for people with diabetes and high blood pressure.

What is the difference between process measures and outcome measures in HEDIS?

Process measures in HEDIS are actions taken during healthcare (e.g., giving beta blockers after a heart attack), while outcome measures are the results of healthcare (e.g., control of hemoglobin A1c levels).

How many total measures does HEDIS have?

HEDIS has a total of 90 measures.

How does HEDIS relate to the quality of healthcare providers?

HEDIS measures the quality of health plans, which then contract with healthcare providers. It is an indirect measure of provider quality, as plans may use strategies like narrow networks to control quality.

Why are high HEDIS scores important for Medicare Advantage plans?

High HEDIS scores are important for Medicare Advantage plans because they can affect star ratings, which in turn can influence year-round enrollment opportunities and government payments.

Are HEDIS scores relevant for all types of health insurance plans?

HEDIS scores are particularly relevant for Medicare Advantage plans due to their impact on payments and enrollment. However, for commercial PPO plans, the aggregated nature of HEDIS scores makes them less relevant for assessing specific provider quality.