HEDIS at Work

HEDIS® reports are generated based on standard performance measures published by NCQA and can be used to evaluate the effectiveness of health plans. In addition to standard HEDIS® reports, GWI-HEDIS includes quality reports for PCPs. PCP’s quality performance is measured and compared to the average in the health plan and expressed as an index of quality.

There are two parts to HEDIS reporting:

Administrative – Claim, membership, provider and other ancillary information is downloaded from the computer to the GWI-HEDIS system. Chart review ­ Manual analysis of treatment performed outside of the provider network. This information is generally left out of the HEDIS report. HEDIS provides extra data files to support medical chart review.


Standard Reports
Client data such as medical claim, membership and provider information are collected from the health plan and run against the GWI-HEDIS reporting system to generate reports on these topics:

• Effectiveness of Care
• Access/Availability Care
• Health Plan Stability
• Use of Services
• Cost of Care
• Health Plan Description

Consumer experience information, such as customer service and claims processing is also included in the report.

HEDIS is a registered trademark of the National Committee of Quality Assurance (NCQA) standards.

HEDISReporting

The Health Plan Employer Data and Information Set (HEDIS®) evaluation has become a requirement for health plans that must be approved by the National Committee of Quality Assurance (NCQA) to maintain viable candidacy for employer groups. Employer groups rely on HEDIS reports during health plan evaluation and are vitally concerned with the quality of care that physicians provide within their plan.

The Key to Informed Choice

In addition to the standard HEDIS reports that measure the quality of health plans, GWI-HEDIS incorporates rigorous HEDIS standards to provide expert evaluation of PCPs and health plans.

GWI-HEDIS may be one of the only quality measures for PCPs available to plans, and thus, the key to informed choices when selecting PCPs as network providers. “In the past, plans were unable to assess the quality of care each PCP provided,” says Solomon J. Zak, Medical Director for Government Works and developer of the GWI-HEDIS system. With GWI-HEDIS , the technology is in place to provide plans with a “report card” on quality performance of PCPs, adds Zak.

Spotlight on Quality

GWI-HEDIS PCP evaluation reflects the PCP’s quality performance on all levels and provides a report card for quality of care. For example, compare two PCPs who each have 300 females at risk of breast cancer between the ages of 52 – 59 years. Physician A has a mammography success rate of 50%; physician B has a success rate of 88%.

The relative rates within the plan are as follows:
Physician A: .76/.50 = 1.55
Physician B: .76/.88 = .86
Physician A’s performance level for mammography is 55% worse than the average, whereas physician B is 14% more effective. This data, together with other HEDIS measures, are averaged against peer ratings to provide a measure of success. This composite average is called the ZQI, or the Zak Quality Index.