The agency that brought standardization to commercial managed-care performance measurement has unveiled a draft of measures for Medicaid plans.
In the proposed standards, children's needs and access to care take on heightened importance.
The 250-page draft is an adaptation of the Health Plan Employer Data and Information Set of the National Committee for Quality Assurance. HEDIS is a roster of about 60 measures of quality, efficiency, access and membership policies used by more than 300 of the nation's health plans to report performance information to employers and other large healthcare purchasers.
Mindful that managed-care plans would be operating both commercial and Medicaid programs, the NCQA worked to maintain a "substantial overlap" between its two HEDIS development efforts, said Cary Sennett, M.D., the committee's vice president for performance measurement.
For example, the entire set of finan-cial measures-such as net worth, cash reserves, percentage of revenues used for administration and other indicators of stability-was preserved in the Medi-caid draft. The 25-person work group that developed the measures took the position that plans serving Medicaid populations should be equally protected against insolvency.
But the Medicaid version added seven indicators that measure access to preventive and clinic-oriented services (See chart). It also called for arrangements with public health and social services agencies, to give tax-funded state programs a measure of how well a plan is leveraging the other available resources in a community.
Reflecting the fact that 75% of enrollees in Medicaid managed-care plans are under age 20, the HEDIS draft emphasized measures of pediatric, obstetric and adolescent care. At the same time, it removed measures such as cholesterol screening rates and frequency of spinal disc surgery, which apply more to the demographics of a commercial plan.
Those changes and additions were needed to make HEDIS a better fit for state Medicaid programs, given an increasing shift of beneficiaries into managed-care plans and the need to measure how the plans are serving a very different population, Sennett said.
The NCQA has always acknowledged that the original HEDIS roster "was a fairly large set but still incomplete," Sennett said. A new push began last month to improve and add to HEDIS (June 26, p. 16), and adjunct programs such as Medicaid HEDIS ultimately work to expand the measurement effort into new domains, he said.
Medicaid was targeted for accelerated treatment because of "enormous interest" in adapting the commercial version of HEDIS for that population, said Sennett. "We were anxious that commercial measures might be used without regard to their appropriateness or utility" in the absence of something more fitting, he said.
With a $400,000 grant from the David and Lucile Packard Foundation, the Medicaid effort was developed during the past year in conjunction with HCFA, the American Public Welfare Association and a coalition of interests including state Medicaid agencies and advocates for beneficiaries.
The commercial and Medicaid implementation efforts will operate side by side for the next few years, but over time the NCQA aims to integrate them into a single set for private and public sector alike.
Last week, the NCQA distributed copies of the Medicaid draft to 1,000 organizations for their comments, which will help refine the measurement set before being completed in December.
HCFA said it will distribute the final version to states and promote its use along with other measures to evaluate plan performance.
======================================================================= Measures of pediatric, obstetric and adolescent care are emphasized.
Retooling HEDIS for a Medicaid population
Here are some ways the Health Plan Employer Data and Information Set was modified for a younger, more disadvantaged and less-consistent Medicaid base of enrollment in managed-care plans:
Medicaid members by age, sex and type of Medicaid eligibility.
Cultural diversity of Medicaid membership.
Stage of pregnancy at time of enrollment in the plan.
Disenrollment-an indicator of satisfaction with commercial plans, but not as relevant for a population in which half of all enrollees are continuously enrolled in the same plan for only a year or less.
Utilization-frequency of procedures
Procedures for younger enrollees, such as dilation and curettage for women, and ear-tube insertions for young children.
Heart-disease procedures such as angioplasty, cardiac catheterization and coronary artery bypass surgery.
Quality of care
Utilization of prenatal care; wellness and prevention visits through age 1, for ages 4 through 6, and for adolescents; screening for alcohol, illegal substances and tobacco in adolescents, and counseling for those it identifies.
Access to care
Children's access to primary-care providers.
Obstetric and prenatal-care providers.
Mental health providers.
Linguistically appropriate services.
Low-birthweight deliveries at facilities for high-risk deliveries and infants.
General plan management
Arrangements with public health, education and social entities.
New-member orientation and education.
Mental-health providers with pediatric expertise.
Chemical dependency services.
Source: National Committee for Quality Assurance