Measures for 2004 target timeliness, clinical care
The National Committee for Quality Assurance (NCQA), which accredits managed care plans, has released 10 new measures for health plans to use in evaluating and improving the quality of their clinical care and customer service.
Three of the 10 new 2004 Health Plan Employer Data and Information Set (HEDIS) measures address customer service, including the timeliness of claims processing and the responsiveness of plan call centers. The remaining seven measures address aspects of clinical care that pertain primarily to ambulatory care:
- treatment of urinary incontinence;
- management of osteoporosis;
- colon cancer screening;
- prescription and use of antibiotic drugs;
- treatment of drug and alcohol dependence (which includes several different categories).
The HEDIS measures affect quality well beyond managed care organizations, explains Greg Pawlson, MD, MPH, executive vice president of NCQA.
"HEDIS measures are used by not only a lot of health plans but by physician group practices," he observes. "What they provide is a practical, reliable, and valid way of tracking adherence to very widely accepted and scientifically valid clinical guidelines. This gives you a way of knowing whether you are adhering to best practices."
The link to quality
The NCQA’s thought process in including service among its quality measures is instructive.
"We consider that there are technical domains of quality as well as domains that are really defined by the users," Pawlson explains. "There are important parts of care that only the users can tell us about."
They also can have a direct impact on clinical outcomes, he adds. "For example, a physician being seen as more trustworthy seems to influence the outcomes of care, adherence to meds, and so on," he notes. "As with any service industry, customer satisfaction is very important. For us to try to inculcate provider services that are efficient, convenient, and friendly is part of performance measurement."
The three service measures are:
• Claims Timeliness. This refers to the rate of claims paid or denied within 30 calendar days of receipt by the health plan or its claims processing center.
• Call Answer Timeliness. This also addresses the performance of plan call centers, calculating the percentage of calls answered by a live voice within 30 seconds.
• Call Abandonment. This determines the rate of calls to the health plan call center (during operating hours) that were abandoned (i.e., the caller decided to hang up) before being answered by a live voice.
"We have always attempted to come up with the most valid and reliable measure of whatever quality characteristic we go after," Pawlson explains.
"Sometimes, it’s a standard in our accreditation process, such as, Have a process in place for timely completion of claims.’ Second, it could be asking the patient if the claim was completed in a timely way. The third level is to have an administrative performance measure," he adds. "Sometimes, if a claim is processed in a month, it would be OK to the patient, but it may not be the best [performance]. These three measures were attempts to move beyond what the patients tell us to an actual measure. They can be monitored periodically, as well as on an ongoing basis."
Of the 10 new measures, seven deal with what is commonly referred to as public health. Pawlson, however, prefers the term "population health."
"This involves the interface between what a clinician does with individual patients and what outcomes occur among groups of patients," he explains. "For example, it is the difference between looking at one patient with diabetes and all the diabetic patients in a given population."
The recent work of the Institute of Medicine (IOM) helped inform NCQA’s choices, Pawlson says. "In the last two or three years, the IOM has come out with reports that really lay out a framework for thinking about quality of care and delivery of services. One particular report this year dealt with laying out priority areas. We looked at where there were gaps in measures and worked with our committee on performance measurement, which is external to the NCQA, to make the final decisions."
The committee is composed of purchasers, consumers, physician practice leaders, health plan medical directors, and measurement experts. It is the committee members, not the NCQA staff, who have the final decision-making authority, he says.
"We have noted for some time that we did not have a lot of measures related to the health of the more vulnerable, or older Medicare patients," Pawlson continues. "These two measures [urinary incontinence and osteoporosis] are major issues."
Urinary incontinence will be handled as a survey measure. "We will ask in our Medicare surveys whether or not the person has a problem, whether it has been recognized by a health care provider, and whether anything has been suggested in terms of treatment," he says.
For osteoporosis, however, a clinical measure will be used, relying on administrative data on women 67 or older, Pawlson states. "We will look back at whether they had a fracture and, if yes, whether they got a bone density test or treatment within six months."
Colorectal screening will be handled by a hybrid methodology — a combination of administrative data (claims, lab, and pharmacy records) and medical record reviews.
"This is a huge problem, and there is good evidence of a relatively low adherence to screening guidelines," notes Pawlson, who adds that the NCQA worked closely with the Centers for Disease Control and Prevention (CDC), Harvard School of Public Health, and Rand Corp. on this measure, and with the Centers for Medicare & Medicaid Services on the measures dealing with older patients.
The CDC also was a partner in the area of antibiotics. "They are increasingly concerned about the emergence of resistant bacteria," Pawlson declares. "One contributing factor is the overuse of antibiotics in children."
For this measure, the NCQA will rely on administrative data, including pharmacy statistics, in terms of children with upper respiratory infections. "The overwhelming majority of these cases are viral, and antibiotics do not do any good," he explains. The second area will be children with sore throats who have not tested positive for strep, yet still receive antibiotics. "Again, the overwhelming number of these are viral," Pawlson asserts.
Finally, the chemical dependency measures a re part of an ongoing effort to create additional measures of care in behavioral health. "This is another IOM priority area," he says. "We don’t have enough good measures [in this area]. We developed these in conjunction with a number of behavioral health groups to try to look at adults who have either chemical- or alcohol-dependency problems, and what proportion are receiving treatment."
The new HEDIS measures will be phased in over a period of several years to allow health plans sufficient time to prepare to capture required data and report the results.
Need More Information?
For more information, contact:
• National Committee for Quality Assurance, 2000 L St. N.W., Suite 500, Washington, DC 20036. Telephone: (202) 955-3500. Web site: www.ncqa.org.
The National Committee for Quality Assurance (NCQA), which accredits managed care plans, has released 10 new measures for health plans to use in evaluating and improving the quality of their clinical care and customer service.
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