HEDIS: Is Yours a Five-Star Health Plan?

To most patients, quality is amorphous; we know it when we see it. To a healthcare administrator, however, quality has a whole other meaning. It’s measurable, measured and a measure of the congruence of several factors.  In managed care, quality is spelled H-E-D-I-S, which is a measurement of performance on criteria that support clinical excellence.  Using the Healthcare Effectiveness Data and Information Set, employers and patients can then compare plans on a level playing field and assess the value of their premium dollar.

HEDIS measures are refined every year, and include assessing successful diabetes and cholesterol management, in addition to several preventive measures, such as screenings for breast cancer, colo-rectal cancer, osteoporosis and glaucoma. HEDIS scores are reported as the percentage of patients who meet specific criteria.  For example, colorectal cancer screening includes services like fecal occult blood tests, flexible sigmoidoscopy and/or colonoscopy at certain intervals. Mammogram rates evaluate the percentage of females under the age of 70 who received the screening during the study period.

Health plans conduct HEDIS reviews primarily by assessing the presence of specific CPT codes reported on claims and encounters.  Chart reviews are also performed to glean additional information, and nurses have historically been integral to this effort.

CMS rates Medicare Advantage plans by assigning a ‘star-rating’ which adds HEDIS measures, member satisfaction scores and the results of a health outcomes survey to its own data.   The stars, which range from one (poor performance) to five (excellent performance), correspond to bonus payments added to the funding that plans receive from CMS. The Henry J Kaiser Family Foundation reports that 91% of MA plans will receive a bonus payment in 2012; the value of these bonuses is estimated at $3.1 billion. One-third of the plans rated four or more stars.  Nine percent of the plans received a score of two or less stars and consequently, have an incentive to work harder for the 2013 bonuses.

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