NCQA implements new outcomes audit standards
Comparability of HEDIS data is questionable
The National Committee for Quality Assurance (NCQA) released new compliance audit standards in April that will verify health plans’ compliance with Health Plan Employer Data and Information Set (HEDIS 3.0) technical specifications and, NCQA representatives hope, give employers and consumers more confidence in HEDIS results.
NCQA’s HEDIS a standardized set of 71 performance indicators that includes measures related to cancer, heart disease, asthma, and other conditions is used to generate "report cards" on about 100 health plans nationally. Variability in the way health plans collect and calculate HEDIS data, as well as in auditors’ methods of verifying such data, has raised issues related to the comparability of HEDIS results.
Building confidence
"Employers and consumers need to have confidence that health plan quality information is accurate and comparable," says NCQA President Margaret E. O’Kane. "NCQA’s HEDIS Compliance Audit Program will ensure that it is, thus encouraging even broader use of HEDIS data in health care purchasing decisions."
NCQA’s effort to standardize HEDIS auditing procedures is supported by the Health Care Financing Administration (HCFA), the Pacific Business Group on Health, the New England HEDIS Coalition, and the Gateway Purchasing Coalition. The Audit Committee, the group that developed the standards over the past year, included representatives from each of these groups. In February, NCQA released a draft of the standards to about 150 experts for review and comment.
"With the implementation of formal, standardized audit procedures, the purchaser community can move beyond worrying about issues surrounding self-reported data from health plans," says Fran Bastien, U.S. Health & Welfare Benefit Manager for Digital Equipment Corporation and a member of the New England HEDIS Coalition. "This program will allow us to make progress on performance measurement and accountability with a higher degree of confidence in the information."
Independent audits for Medicare
HCFA is requiring Medicare managed care plans to report selected HEDIS 3.0 data in 1997. The agency considers standardized audit procedures a critical part of its work to hold Medicare plans accountable for the care they deliver. "Until certified auditors are available, HCFA will require and pay for Medicare managed care plans to undergo an independent audit and validation procedure," says Jeffrey Kang, MD, MPH, chief medical officer of HCFA’s Office of Managed Care.
NCQA’s HEDIS Audit Standards call for a two-part review of a health plan’s HEDIS collecting and reporting processes, including an overall information systems capabilities assessment and an evaluation of the health plan’s compliance with HEDIS specifications. The audits will focus on health plans’ data management processes and the mechanisms used to translate captured data into HEDIS statistics.
Audit means report’ or not report’
Specifically, audits will examine the following areas:
• information practices and control procedures;
• sampling methods and procedures;
• data integrity;
• compliance with HEDIS specifications;
• analytic file production;
• reporting and documentation.
The audits will result in a "Report" or a "Not Report" designation for each HEDIS measure audited. NCQA’s HEDIS Compliance Audit Advertising and Marketing Guidelines bar health plans from using measures receiving a "Not Report" designation in their advertising and marketing materials.
All plans undergoing an audit will receive feedback from their NCQA-certified auditors on how to design information control practices, methods to better comply with HEDIS specifications, and advice on streamlining data gathering efforts. The length of an audit and the size of the audit team will vary from plan to plan, depending on the number of measures audited. Health plans will learn the result of their audit four to six weeks after the site visit.
New audit is being tested
Pilot testing based on the new standards began in April at several sites across the country. "We support NCQA’s efforts in this and other areas, and we are open to feedback and possible enhancement of our HEDIS collection and reporting efforts," says Kathy Hiltunen, director of utilization and case management for Finger Lakes (NY) Blue Cross/Blue Shield, which is a test site.
"Our members and potential members deserve to know that they can compare our HEDIS data with that of other health plans on an apples-to-apples basis," Hiltunen says.
When the pilot testing ends in August 1997, CQA will begin licensing organizations and certifying members of their staffs to conduct HEDIS Compliance Audits. To become NCQA-certified auditors, individuals will be required to pass a biannual examination administered by NCQA.
The Chauncy Group, a subsidiary of the Educational Testing Service, is developing the exam, which will include an audit of a hypo-thetical health plan’s HEDIS processes against NCQA standards.
[Editor’s note: NCQA’s HEDIS Compliance Audit Standards can be purchased for $150 from NCQA’s Publications Center at (800) 839-6487.
For more information or to discuss licensure (for organizations) or certification (for individuals employed by licensed organizations), call Wendy Van Ginhoven at (202) 955-5186.]
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