HEDIS is the Healthcare Effectiveness Data and Information Set, a collection of information about the effectiveness of how well doctors and hospital do at providing preventive screening, superior clinical processes, and the best outcomes for patients. It’s created by the National Committee for Quality Assurance (NCQA), a non-profit organization focused on quality measurements of doctors, hospitals, and other medical providers that is used by the government for health plan ratings. HEDIS uses 90 different measures to compile a score for each health plan. But it doesn’t actually measure the providers. Rather, it measures the effectiveness of health plans who use certain providers. The actual HEDIS score is placed on the health plan, not the doctor or hospital.
You may or may not have heard about HEDIS based on a few reasons. Your broker/advisor may not be familiar with the process, or the health plan he/she placed you with doesn’t have a very good score. Similarly, the health insurance plan you’re with doesn’t promote their HEDIS score for the same reason. If you are familiar with HEDIS it’s probably because your health plan scored higher than their competitors in your area and promote it as a competitive advantage. In either case you shouldn’t put too much weight on your health plan’s HEDIS score. Here’s why.
If your health plan is with one of the big national health carriers using a national PPO network – you know, like the one that boasts 97% of all claims paid in-network – the HEDIS score is aggregated across the thousands of doctors and hospitals within the network. Remember, the HEDIS score is created for the health plan, not the doctors and hospitals that are in the health plan’s network -even though the measurement comes from the providers’ performance. The score provides no insight into the quality of individual providers that may be used by your plan members. You’re probably thinking “well, if the health plan wants to improve its HEDIS score in order to demonstrate better quality why don’t they just eliminate the worst performing doctors and hospitals from their network?” And therein lies the problem. When the mega insurance companies negotiate with a health system made up of inter-connected hospitals and doctors, they are required to include all of the providers within the health system. They are prohibited in excluding the worst performers. This is done to give the health system a competitive advantage, because bigger is always better, right? There are other reasons health systems require the “all or none” approach, but that’s for a different blog. Suffice to say, none of the reasons include efforts to lower your health care costs or improve quality outcomes for your employees. Some will try to argue that the giant carriers also offer Narrow Networks that are “high performing networks” but in my three-plus decades of carrier experience narrow networks were more about getting the providers to take less reimbursement than it was about only including the best performing doctors and hospitals.
But there are ways you can improve the quality of the care you pay for as a health plan sponsor. You can work with an advisor that has access and support to provider performance data specific to your employees and their families. But why should you worry about improving health care quality for your employees? If your health plan can provide guidance to the best hospitals and doctors based on verifiable outcomes your employees will have better health results, miss less work, and save you money by avoiding preventable hospital readmissions and extra surgeries and treatments. And it’s just the right thing to do. You owe it your health plan members to have the right information to make the best health care choices. It’s a complete game changer when you can choose a health provider based on measurable performance instead of a Yelp review or a Twitter post.
Not every broker or advisor has the ability to offer this kind of service. But if you have the right advisor, like Primum Risk Strategies, Inc. you can access these types of strategies whether you’re self-funded or fully insured. And the best part is it will reduce your benefit plan costs. Call us at (815) 742-2066 to have a no obligation discussion to find out more.
If you want to find out more about HEDIS I highly recommend this short video https://www.youtube.com/watch?v=N2DtdO2hJHc by industry-renown health care economics expert Dr. Eric Bricker.