Continuous Improvement and the Expansion of Quality ... - NCQA

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HEdIs Measure definition T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 • H E D I S M E A S U R E S o f C A R E The percentage of adults with a primary diagnosis of low back pain who did not have an imaging study (plain x-ray, MRI or CT scan) within 28 days of the diagnosis. results With the use of costly imaging studies failing to produce positive health outcomes for patients with low back pain, x-ray, MRI and CT scans should primarily be used for patients with neurologic deficits or other serious underlying conditions. yEAR IMagIng studIEs for loW baCk PaIn 29 CoMMERCIAl MEDICARE MEDICAID HMo PPo HMo PPo HMo 2010 74.2 73.3 NA NA 75.5 2009 73.9 72.7 NA NA 76.1 2008 73.1 72.3 NA NA 75.7 2007 74.6 73.3 NA NA 77.3 2006 73.9 72.1 NA NA 78.3 2005 75.4 72.6 NA NA 79.0 S A f E T y A N D P o T E N T I A l W A S T E
S A f E T y A N D P o T E N T I A l W A S T E 30 RElATIVE RESoURCE USE NCQa’s Relative Resource Use (RRU) measures indicate how intensively health plans use heath care resources (e.g., doctor visits, hospital stays, surgery, drugs) compared with other plans in the same region, adjusted for the population of members they serve. When combined with NCQa heDiS quality measures, rru measures reveal value. RRU measures help health care purchasers identify health plans that deliver high-quality care while managing associated costs. The table below is a hypothetical example of RRU results for plans in one region for patients with diabetes. Scores above 1.0 indicate higher-than-average use, while scores below 1.0 indicate lower-than-average use. In this example, Plan D is highlighted because it offers an appealing combination of above-average quality and below-average resource use. Plan N AT I o N A l C o M M I T T E E f o R Q U A l I T y A S S U R A N C E HyPotHEtICal dIabEtEs rru In a sInglE rEgIon Quality score Combined Medical diabetes Medical resource use Inpatient Hospital Evaluation & Management surgery & Procedures rx drugs Plan A 1.06 1.14 1.32 1.00 0.89 1.14 Plan b 1.10 0.85 0.96 0.74 0.73 1.12 Plan C 1.10 0.80 0.84 0.79 0.71 1.16 Plan D 1.14 0.74 0.77 0.85 0.56 1.13 Plan E 0.97 0.73 0.79 0.76 0.54 1.19 NCQA collects RRU data for five conditions that account for more than 60 percent of all health spending: asthma, cardiovascular disease, CoPD, diabetes and hypertension. overall, RRU measures reveal that the amount of services used to treat people often has little correlation to the quality of care. To allow fair comparison of plans, RRU measures feature risk adjustment and price standardization of services. The goal of risk adjustment is to eliminate sources of variation that neither health plans nor providers can control. factors used in risk adjustment include age, gender and presence of other serious health conditions. Standardized prices are assigned to each unit of service delivered to health plan members and reported by service category (e.g., inpatient hospital care, evaluation and management, surgery and other procedures, diagnostic lab and imaging, prescription drugs) for each of the five conditions.
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128 N AT I o N A l C o M M I T T E
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130 APPENDIx 1: HEDIS EffECTIVENESS
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134 APPENDIx 2: HEDIS EffECTIVENESS
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158 APPENDIx 8: PUblICly REPoRTING
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172 MEASURE N AT I o N A l C o M M
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180 APPENDIx 16A: VARIATIoN IN PlAN
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182 APPENDIx 16b: VARIATIoN IN PlAN
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184 REfERENCES N AT I o N A l C o M
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ACkNoWlEDGMENTS Health Plans The 20
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Continuous Improvement and the Expansion of Quality ... - NCQA

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