By Jonathan Jantz, MD, FAAP
What is HEDIS and why does it matter? The acronym stands for Healthcare Effectiveness Data and Information Set and consists of 81 measures across 5 domains of care.
HEDIS is a tool that evolved in the late 1980s from a need to evaluate quality of health care delivery by various systems that includes providers, hospitals and insurance companies. It is currently used by more than 90% of health plans in the United States including Medicare and Medicaid. Since the measures are specifically defined, HEDIS data creates a level playing field for comparing the performance of various health plans directly. Health plans review the results to see where they excel and where they need to improve. At that point, if the area in question is clinical, they put pressure on the providers in their network to improve various measures.
HEDIS measures include a wide range of important health issues that most of us agree are important. Some of the ones pertinent to pediatricians include:
- Asthma medication use. (This might be whether your patients are refilling their preventative medications appropriately or whether they are over using rescue medications.)
- Controlling high blood pressure.
- Antidepressant medication management.
- Childhood and adolescent immunization status.
- Lead screening in children.
- Well child visits in the first 15 months of life.
- Well child visits in the third, fourth, fifth and sixth years of life.
- Children and adolescents’ access to primary care defined as the percentage of members from 12 months to 19 years who have had a visit with their PCP, usually defined as a well visit.
- Follow up care for patients prescribed ADHD medication.
The primary stated goal is to use the data to make improvements in their quality of care and service. Purchasers of health care frequently use the data to help them select the best health plan for their needs. NCQA (National Committee for Quality Assurance) is the body responsible for monitoring and auditing the data for quality and to oversee the program since the early 1990s. The results are then published in various “report cards” that may appear in magazines and even local newspapers.
The current issues focused on by HEDIS varies from year to year depending on feedback from employers, consumers, health plans and public debates. Also included is the CAHPS 5.0 survey Consumer Assessment of Provider Healthcare and Systems) which measures member satisfaction in multiple areas including claims processing, customer service and getting needed care quickly.
NCQA offers six accreditation programs, five certification programs and five physician recognition programs of which the one most pertinent to pediatricians is the Patient-Centered Medical Home (PCMH). Currently this is relevant in the greater Kansas City area, but not the rest of Kansas.
What is relevant to all of us is that many insurance companies are now frequently focusing on all or some part of the HEDIS reports to decide whether to give/pay a bonus of 1-3% to your practice depending on how your data compares. Insurance companies will also add their own spin to these measures, such as electronic prescriptions or whether antibiotics are prescribed ONLY after a positive strep test. They have various ways to track these things, all supposed to be “on the back end,” which usually means claims and keeps a provider unable to either track or challenge a measure.
It should be apparent that some of the issues that go into deciding whether we each receive that bonus are mostly out of our control. For instance, insurance companies have not come up with consistent ways to motivate patients to come in for well checks as scheduled, so they have passed the responsibility to the PCP in the hope that we will figure out how to do it. At our office, we have tried 1. nagging, 2. holding flu shots up until a well check is scheduled, and 3.sending out postcards. Number one was a wash, number two was 50 percent or less effective with the resulting problems of no-shows and cancellations, and number three was a wash.
The measures used for pediatricians are not poor choices – we all strive for them daily. It’s just that holding providers accountable for patient behavior (or more accurately, parent behavior) is a dead end when it comes to quality measures.
In the meantime, if anyone has specific successful methods of achieving these goals, please share them with the rest of us.