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

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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
ExECUTIVE SUMMARy
The Healthcare Effectiveness Data and Information Set (HEDIS ® ) continually changes to capture
better information and new medical knowledge and to reflect purchaser and consumer needs.
HEDIS was developed by forward-thinking employers and quality experts in the late 1980s; since
the early 1990s, it has been the national standard for health plan performance reporting. NCQA’s
goal is for HEDIS measures to have strong evidence and be meaningful, valid and practical.
With the addition of preferred provider organization (PPo) performance results to HEDIS, we
can now compare PPos with HMos. We consider these comparisons—some surprising, many
encouraging—to be the key findings of this year’s State of Health Care Quality report.
PPos on the rise, show they Improve by Measuring, too
With some exceptions, commercial HMo performance is typically higher than PPo performance.
one reason may be that HMos have traditionally had more tools to manage care: care
coordination processes, selective contracting and more bargaining power over providers.
Differences in information collection or populations could be factors, as could benefit design.
HMos usually have lower cost sharing for services than PPos, and higher PPo cost sharing
might reduce use of recommended services. That said, some PPos offered by health plans that
also offer HMos perform very well.
Differences between HMos and PPos in how they collect data for hybrid measures have
traditionally made it difficult to compare results. but there are indicators where PPos perform
at virtually the same level as HMos—for example, in the Use of Appropriate Medications for
Asthma measure. PPos are catching up on other measures, as well, by making bigger year-toyear
gains.
Interestingly, there are also performance differences between commercial HMos and PPos for
some patient experience measures. Many readers will recall that health plan members preferred
PPos to HMos because of fewer restrictions and larger networks. In 2005, PPo members were
more likely to give a high rating than HMo members were. but times have changed, and there
is a widening gap in performance: in 2010, HMo results were 6 percentage points higher than
PPo results.
The gap might be related to the rise in cost sharing—including deductibles—for PPos.