Health Plan Employer Data and Information Set

The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance. HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks. Although not originally intended for trending, HEDIS results are increasingly used to track year-to-year performance. HEDIS is one component of NCQA's accreditation process, although some plans submit HEDIS data without seeking accreditation. An incentive for many health plans to collect HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement that Health maintenance organizations (HMOs) submit Medicare HEDIS data in order to provide HMO services for Medicare enrollees under a program called Medicare Advantage. HEDIS was first released in 1993 as HEDIS 2.0. The latest version, HEDIS 2007, reports on data through 2006 and comprises more than 60 measures.

Structure
HEDIS measures are divided into eight categories:
 * 1) Effectiveness of Care
 * 2) Access/Availability of Care
 * 3) Satisfaction With the Experience of Care
 * 4) Health Plan Stability
 * 5) Use of Services
 * 6) Cost of Care
 * 7) Informed Choices
 * 8) Health Plan Descriptive Information.

Measures are added, deleted, and revised annually. For example, a measure for the length of stay after giving birth was deleted after legislation mandating minimum length of stay rendered this measure nearly useless. Increased attention to medical care for seniors prompted the addition of measures related to glaucoma screening and osteoporosis treatment for older adults. Other health care concerns covered by HEDIS are immunizations, cancer screenings, treatment after heart attacks, diabetes, asthma, flu shots, access to services, dental care, alcohol and drug dependence treatment, timeliness of handling claims and phone calls, prenatal and postpartum care, mental health care, well-care or preventive visits, inpatient utilization, drug utilization, and distribution of members by age, sex, and product lines. New measures in 2007 address potentially harmful drug-disease interactions in the elderly and relative resource use for diabetes, asthma and acute low back pain.

Data collection
HEDIS data are collected through surveys, medical charts and insurance claims for hospitalizations, medical office visits and procedures. Survey measures must be conducted by an NCQA-approved external survey organization. Clinical measures use the administrative or hybrid data collection methodology, as specified by NCQA. Administrative data are electronic records of services, including insurance claims and registration systems from hospitals, clinics, medical offices, pharmacies and labs. For example, a measure titled Childhood Immunization Status requires health plans to identify 2 year old children who have been enrolled for at least a year. The plans report the percentage of children who received specified immunizations. Plans may collect data for this measure by reviewing insurance claims or automated immunization records, but this method will not include immunizations received at community clinics that do not submit insurance claims. For this measure, plans are allowed to select a random sample of the population and supplement claims data with data from medical records. By doing so, plans may identify additional immunizations and report more favorable and accurate rates. However, the hybrid method is more costly, time-consuming and requires nurses or medical record reviewers who are authorized to review confidential medical records.

Reporting
HEDIS results must be audited by an NCQA-approved auditing firm for public reporting. NCQA has an on-line reporting tool called Quality Compass that is available for a fee of several thousand dollars. It provides detailed data on all measures and is intended for employers, consultants and insurance brokers who purchase health insurance for groups. NCQA's web site includes a summary of HEDIS results by health plan. NCQA also collaborates annually with US News and World Report to rank HMOs using an index that combines many HEDIS measures and accreditation status. The "Best Health Plans" list is published in the magazine in October and is available on the magazine's web site. Other local business organizations, governmental agencies and media report HEDIS results, usually when they are released in the fall.