FINAL EXAM: PROVIDER PAYMENT AND MANAGING CARE /PERFORMANCE INDICATORS

332 PART Ill Management of Utilization and Quality

NCQA Member Connections standards are designed to measure how well health plans connect their members with important information such as their health status, the re­sources provided by their health plan, their care options, and the costs of different services and prescription drugs. Member Connections standards have been included in the NCQA HMO and PPO Accreditation standards since 2007 and Health Plan Accreditation since 2008. Some plans vol­untarily achieved distinction in this area prior to its inclu­sion in accreditation.

HEDIS

As noted earlier, HEDIS is a performance measurement tool used by more than 90% of the nation's MCOs. It is a ro­bust set of standardized measures that specifies how health plans collect, audit, and report on their performance in im­portant areas such as delivery of preventive health services, member satisfaction with care, utilization of services, and treatment efficacy for various illnesses. Measures are re­viewed annually, updated, revised, and even retired through a broad-based process that includes public comment on each proposed new measure or change.

By specifying not only what to measure but also how to measure it, HEDIS allows true "apples-to-apples" comparisons between health plans. HEDIS allows health plans to manage and improve quality and purchasers of health care to make informed choices. Every year, dozens of national news maga­zines, newspapers, employers, and others use HEDIS data to generate health plan "report cards" during open enrollment. All H�DIS data are independently audited and verified.

HEDIS consists of more than 70 measures (not including the CAHPS survey, which includes dozens of individual questions) that fall into eight broad categories or domains:

• Effectiveness of Care, • Access/ Availability of Care, • Satisfaction with the Experience, • Use of Services, • Cost of Care, • Health Plan Descriptive Information, • Health l?lan Stability, and • Informed Health Care Choices.

The full 2011 HEDIS measure set is liste<;l in Table 15-1.

Effectiveness of Care: Measures in this domain provide information about clinical care quality provided by the organization. The measures consider how well the organization incorporates widely accepted preventive practices and recom­ mended screening for common diseases. This do­ main has been expanded to include some overuse and patient safety measures listed.

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