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Free «HEDIS» Essay Sample

The Health Plan Employer Data and Information Set (HEDIS) is a means employed by more than 90% of the health plans in America to evaluate performance on main service as well as care dimensions. HEDIS has seventy five measures, which are spread across eight domains of care. It is usually overseen by the National Committee for Quality Assurance (NCQA) and its aim is to offer consumers and purchases information, so that they can make educated choices, when choosing health plans. Health plans also use the HEDIS data report to improve their quality of service and care (NCQA, 2011).

The five new HEDIS measures, which recently have been added to the HEDIS data set, are ‘Medical Health Outcomes Survey (HOS)’, ‘standards and guidelines for assessing a health plan’s information’, audit standards, HEDIS roadmap, the survey instrument and information that health plans and vendors require to report results. The HOS measure was developed so as to check and assess the quality of service and care offered by medical beneficiaries. It offers the beneficiaries information that supports plan to plan contrast. The standards and guidelines for assessing a health plan are used for evaluating a health plan capacity to meet the terms set by HEDIs. The audit standards ensure reliable, accurate, and publicly reportable data, which can be used by consumers and purchasers to contrast managed care organizations. The standards also ensure a comprehensive evaluation of a managed care organization information system capabilities and observance with every HEDIS specification.



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HEDIS roadmap sets performance goals around specific care processes that will lead to improved health outcomes. The care processes performance is measured and fed back to practice teams to focus and direct their improvement endeavors. The survey instrument assesses health plan performance. Survey instruments vary from plan to plan. The information that health plans and vendors require to report results is also a new measure. Health plans report normally survey reports and this is viewed as part of data collection in HEDIS. The survey results are then used by NCQA to inform accreditation decision and to set national benchmarks for care (NCQA, 2011).

The five categories for Star Ratings (quality of plan measurement) of NCQA (National Committee for Quality Assurance) accreditation are access and service, qualified producers, staying healthy, getting better, and living with the illness. When it comes to ‘access and service’, NCQA assesses how well the health plan offers it members access to much required care as well as with good customer service. In evaluating these activities, NCQA assesses appeals and health plan denial records, interview the staff in the health plan and also grade results received from consumer survey.

When it comes to’ quality providers’, NCQA assesses the health care activities, which make sure that every doctor is licensed and trained to practice medicine and that the members in the plan are contented with their doctors. NCQA uses doctors’ credentials records, interviews health plan staff, and grade the results from consumer surveys. Health plans with health plan accreditation and MCO attain about four stars, whereas plan with PPO accreditation receives about three stars. In using ‘staying healthy’ while rating, NCQA examines the health plan activities that assist people to maintain good health and steer clear of illness. In evaluating these activities, NCQA reviews health plan records, it also grades confirmed clinical data independently and finally reviews that is sent to health care members (NCQA, 2011).

When it comes to ‘getting better’, NCQA assesses health plan activities that assist people to get better after an illness. In reviewing these activities, NCQA evaluates health plan records and also interview the staff in the health plan. When it comes to “Living with Illness” NCQA assesses the health care actions, which assist people handle serious illnesses. Verified clinical data and the interviews held with the health plan staff are graded differently (NCQA, 2011).

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Performance guidelines actually measure the functional effectiveness of health plans. The guidelines are useful in tracking performance over time. The guidelines enable managed care organizations to determine their current positions at a particular point in time and to repeat the measure in the future to assess if any changes have taken place. For instance, an MCO can use the immunization rates guidelines and apply them over time to evaluate whether the interventions it has employed are effective.

The guidelines also offer information for external sources. For instance, in the issue of value, an MCO can employ a specific ratio, such as the medical cost ratio to market its products’ to the employers and then employ that particular measure to demonstrate its value to the buyers.

The performance guidelines also identify areas that need to be improved. The results attained from the data collection process on standard performance measures allow the medical care organizations to effectively target their improvement efforts. This information assists MCOs to objectively determine the services or area that require to be improved. For instance, a service or area that is less desirable can be improved by MCO establishing planning interventions to improve the rate. The guidelines also enable comparison of health plans.

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The activities that NCQA undertakes in its HEDIS efforts are devoted to letting comparisons across health plans. Purchasers and consumers make well informed choices, when selecting health plans, because they use standardized performance measures. An MCO also can easily compare itself to the others and market it services and products accordingly. The guidelines also establish the priorities for health plans. When an MCO employs various performance measures, it can direct its resources into areas that can bring about a difference. Lack of these relevant performance measures promotes the use of “hit or miss” strategy in allocating valuable resources. The guidelines enable the MCOS to male sound programs and resource decisions depending on objective data.

In determining whether the Open MRI is complying with the standards, the information that would be relevant would be the effectiveness of care, cost of care, stability of the plan, access, and availability of care, satisfactory with the experience of care, health plan descriptive information, informed health care choices, and the use of services.

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The effectiveness of care of an open MRI clinic can be evaluated by focusing on the clinical care offered and the results obtained. Example of measures includes low back pain: use of imaging studies, initial visits, mental health assessment, proper imaging for acute back pain. These measures should be used by medical management departments to assess and prove the effectiveness of treatment procedures.

The access and availability of care in the open MRI clinic also can be evaluated by focusing on the accessibility and availability for the health plan members. For instance, measure such as children’s access to primary care providers, yearly dental visits as well as the availability of language interpretation services would be very useful in this case. The satisfaction with the experience of care in the health clinic also can be measured using measures that focus on the way the health plan meets the population diverse needs. A standard member satisfaction survey that has many measures and questions can be employed.

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The cost of care of an MRI clinic can be evaluated by focusing on measures that evaluate the value of services offered by the health plan. The information that is gathered should focus on high incidence and high cost diagnosis allied groups and the rate trends. Most medical management activities are often directed towards managing the health interventions and as a result the medical managers are especially interested in the way their plans costs compare with others. In evaluating the cost of care in the MRI clinic, the clinic health plan cost should be compared with others to determine whether it is cost effective for the health plan members.

The stability of the health plan of the MRI clinic can be evaluated by focusing on measures that focus on the possibility of the health plan to go through stability issues. Measures such as provider turnover and disenrollment figures, total membership, and information on years in business are important in establishing the stability of the clinic health plan. Informed health care choices are also relevant in determining whether the open MRI is complying with standards set by HEDI. Informed health care choices measures should focus on the usefulness of the open MRI plan in assisting members to become active partners in the health care choices. Two methods can be used for evaluating informed health care choices; addressing the language translation services in the clinic, and addressing new members’ education and orientation.

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The use of services in the clinic can be evaluated by focusing on measures that focus on the way health plan, use its resources to evaluate whether the required services are being offered to the members. Such measures include inpatient as well as outpatient drugs, utilization of mental health, chemical dependency, and the frequency of prenatal care as well as cesarean section, and virginal birth after cesarean rate among others.

Health plan descriptive information refers to the information that time after time interests the consumers and purchasers. The clinic health care information should include provider compensation, risk management, case management, and certification by the board, and payer enrollment among other elements. The eight dimensions of performance measurement by HEIDIS are important for the clinic and would assist it to avoid losing business to the organizations that measure and report their performance.


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