Healthcare Research and Quality (AHRQ), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and CMS. In recent years, recognition of the need to coordinate and harmonize quality measurement has led to increased collaboration. Widespread participation in standardized measurement and reporting activities has occurred among private purchasers (such as those in the Pacific Business Group on Health, the Leapfrog Group, and Bridges to Excellence), public purchasers (especially CMS, the largest purchaser), private-sector organizations (such as the National Quality Forum [NQF]), and health plans (such as PacifiCare and Aetna).
One of the oldest and perhaps most successful quality measurement efforts is the Health Plan Employer Data and Information Set (HEDIS), first released in 1989 by a coalition of health plans (members of The HMO Group) and large employers. The initial set of measures was subsequently adapted and refined by NCQA (NCQA, 2005b). Health plans seeking accreditation by NCQA are required to report on HEDIS measures, and their performance scores on these measures are factored into the accreditation process.
Originally spearheaded by private purchasers, HEDIS was adapted in the mid-1990s for use by public purchasers (NCQA, 2005b). CMS now requires health plans participating in the Medicare program to submit data on HEDIS-developed measures of health care quality, many of which are incorporated in comparative quality reports available on the CMS Web site (CMS, 2005d). Many state governments also require plans participating in Medicaid to report HEDIS data (New York State Department of Health, 2002; Texas Health and Human Services Commission, 2004; Washington State Department of Health and Human Services, 2005). Additionally, HEDIS measures are frequently used in the nearly 90 pay for performance programs sponsored by private purchasers (Rosenthal et al., 2004).
Most though not all health plans produce HEDIS reports for their privately insured populations. Those plans that choose not to participate in HEDIS reporting are likely to be the very lowest performers (McCormick et al., 2002). NCQA’s Quality COMPASS data repository includes comparative HEDIS reports for more than 300 commercial managed care products (NCQA, 2005c). However, as only health maintenance organizations (HMOs) report on HEDIS measures, recent declines in HMO relative to preferred provider organization enrollment have resulted in a decrease in the total population included in the reporting pool. CMS is attempting to address this problem, at least within the Medicare program, and a few employers are beginning to look at HEDIS measures for the commercial sector.