Medical Director’s Letter

In previous articles we have included information about the National Committee for Quality Assurance (NCQA) and the Health Plan Employer Data and Information Set (HEDIS®). NCQA is the accrediting body for managed care organizations and is the organization responsible for managing further development and applications for HEDIS® (a registered trademark of NCQA). HEDIS® measurements reflect how managed care organizations organize and influence care delivery against objective standards. NCQA also produces Quality Compass®, a comparative database that reports HEDIS® measurements for managed care organizations that have consented to have results publicly released. More information about NCQA, HEDIS® and Quality Compass® can be obtained from the NCQA Web site at www.ncqa.org.

HNE produces HEDIS® measurements on an annual basis. Among the HEDIS® Effectiveness of Care measures are rates for the provision of preventive health services such as mammography screenings, cervical cancer screenings, and immunizations. Other measures include follow-up after hospitalization for mental illness, percentage of members treated with Beta-blockers after a myocardial infarction, timely provision of prenatal and postpartum care as well as other aspects of clinical care delivery. Many of the HEDIS® measurements are process measures that reflect how clinical care is delivered to a given population of patients. One of the things that is clear from a review of comparative HEDIS® results is that there is wide variations in performance between different parts of the country. It would appear that parts of the country with a high managed care penetration among the insured population have the highest HEDIS® results.

Managed care organizations do improve physician performance and compliance with accepted medical standards for preventive health screenings, immunizations, secondary disease prevention and chronic disease management. MCO disease management programs for conditions such as asthma and diabetes identify members who are not receiving care consistent with recognized guidelines. Physicians who want to provide the very best care to their patients can not do it alone. The combination of excellent clinical care provided by individual physicians and value added HMO programs such as disease management and preventive health reminders can improve the processes of care and, we believe, improve clinical outcomes.

Periodically you receive requests from us asking you to review your medical records to gather information for HNE’s yearly HEDIS® measures. Occasionally you also receive notification from us identifying our members in your panel who have missed a preventive service or who require a clinical intervention for a chronic disease. We at HNE can only measure our combined effectiveness using claims data and medical record review. We realize that some of our requests may become an imposition to your busy office. Please realize that together we can improve the care we give to your patients.

Thomas H. Ebert, M.D. Vice President, Medical Director