IV. Findings (continued)
2.3. Major Uses of Quality Improvement
Quality improvement activities are employed at each of the health plans to increase the appropriate delivery of clinical preventive services. Quality improvement activities are an important priority at each health plan—providing quality improvement staff and plan leadership with an opportunity to work closely with practitioners to improve patient care. One Clinical Advisor from the closed-panel plan indicated that "[quality improvement] is all we do. Every day is about trying to pick a priority and make it happen."
This section will present our findings on quality improvement. We begin with a discussion of how health plans use data to measure and monitor the delivery of clinical preventive services. Second, we discuss the challenges that health plans face with regard to using data for quality improvement purposes. Third, we move on to a discussion of different types of quality improvement activities, and specifically how these activities have been used to increase the delivery of Task Force recommendations. Finally, we address how plans encourage implementation of quality improvement activities at the practice and clinician levels.
Measuring and Monitoring the Delivery of Clinical Preventive Services. Health plans utilize their health IT tools to measure and monitor the delivery of clinical preventive services for quality improvement purposes. When members of the clinical staff deliver clinical preventive services to patients, a record of the service is integrated into the health plan's EMR or data monitoring system. Data are recorded in the EMR or data monitoring system regardless of whether a provider, nurse, or social worker provided the service.
Plans collect data on test results, lab screenings, delivery rates of clinical preventive services, claims data, and pharmacy data; data on compliant and non-compliant members with respect to various clinical preventive services; quality data for HEDIS; and administrative codes such as current procedural terminology (CPT) codes and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes.
Health plans evaluate the data frequently to determine whether it will be necessary to develop a quality improvement activity to increase the delivery of a clinical preventive service. Typically, health plans evaluate their data quarterly because of HEDIS reporting. Collecting and evaluating data for HEDIS measures is a particularly important priority for all of the plans. A Quality Improvement Staff member from the hybrid plan said that "the HEDIS measures get the most attention" in terms of quality improvement data.
Each of the four plans we spoke with also evaluate their data internally on a monthly basis. The closed-panel plan and governmental plan indicated that physicians' performance on certain measures is evaluated on a weekly basis to prompt further action when necessary. One Quality Improvement Staff member from the closed-panel plan discussed that the plan sets up reports each week for colorectal cancer screenings: "We set up a report every week to capture fall out for colorectal cancer screening, for example. We set it up so that the positive fecal occult blood test results would be flagged [in the EMR]. I would take that data and do chart reviews, and then provide the data to clinics so that they can follow up." The closed-panel plan utilizes these reviews as an opportunity to evaluate the data available for quality improvement purposes.
Staff acknowledge the importance of prioritizing quality improvement efforts for clinical preventive services. A Director of Quality Improvement at the governmental plan indicated that when there is a hot topic or a new clinical preventive service recommendation at the national level, some measures may be evaluated more frequently: "We have so many measures; we can't be monitoring everything."
Challenges with Using Data for Quality Improvement Purposes. Health plans measure and monitor data for a variety of clinical preventive services in order to assess performance and direct future quality improvement efforts. However, respondents from all of the plans described that using data for quality improvement purposes can be challenging for a variety of reasons. We asked respondents to describe the challenges they face in gathering and using data for quality improvement purposes. From claims lags and coding problems to data quality and tracking issues, health plans raised a variety of important issues that associated with using clinical preventive services data for quality improvement purposes. We discuss these challenges below and provide examples from health plans, when appropriate:
- Claims lag. Respondents indicated that a key source of data for measuring the appropriate delivery of clinical preventive services is their system's claims remittance data. One challenge cited was identifying whether a clinical preventive service recommendation was actually performed due to claims lag. Respondents described that a lag time exists between when a patient is seen by a provider and the subsequent time required for the claim to be processed, paid, and available as data. Respondents described that it is sometimes difficult to know when a patient actually received a clinical preventive service. For example, during a follow-up visit with a patient, a provider may be unaware that the patient had received a service up to two months before.
- Coding detail. Several respondents that have a strong familiarity with coding and reimbursement described the difficulties associated with coding detail. One key challenge described is posed by the lack of detail available in CPT and ICD-9 codes for classifying diagnoses and services. Specifically, the lack of a "not applicable" code was mentioned, as was the lack of codes going to the "fourth or fifth digit" (to provide greater diagnostic detail). In addition, some clinical preventive services do not have specific codes for health plans to track performance. The Health IT Director from the closed-panel plan used diabetic foot exam as an example of a service that is highly difficult to track due to coding detail issues. In addition, another issue is that multiple codes are used to measure similar preventive services. This lack of consensus is problematic for Health IT Directors and Staff who measure the delivery of these services. Overall, coding detail discrepancies are problematic because they reduce the validity of the data.
- Unprocessed claims. If a claim is not processed due to any number of factors, the information systems do not capture the fact that the service was delivered to the patient.
- Inaccurate coding. If coding is inaccurate (e.g., an incorrect diagnostic code was used on a previous patient visit) the patient may be inaccurately classified and therefore excluded from the delivery of important clinical preventive services in the future.
- Medical records data. The open-panel plan respondents discussed that the plan relies on claims data for quality improvement purposes since the plan does not have accessible medical record data. This is a key challenge because there may be some limits to the use of claims data for quality improvement purposes.
- Incomplete patient records. For the open-panel plan and the hybrid plan, incomplete patient records pose problems for monitoring the delivery of clinical preventive services. Members of these plans may receive services from non-affiliated providers, and the record of such services is never transmitted back to the plans and/or integrated into the plans EMR. Even in the closed-panel plan, where almost all of the members receive services from plan-employed providers, recordkeeping is an issue. A Clinical Advisor from the closed-panel plan described that "if people get their mammograms outside the system or medicines somewhere else, we have incomplete data."
- Counseling recommendations data. Respondents indicated that the quality of the data collected for counseling recommendations is problematic for a variety of reasons. First, counseling recommendations are more difficult to integrate into the EMR because many are not associated with discrete codes. Second, data from counseling recommendations is more difficult to collect because of its subjective nature (in contrast to data for lab tests). Third, as a Director of Quality Improvement from the closed-panel plan indicated, providers often forget or choose not to document that a counseling service was provided to a patient: "Physicians are salaried so they are not acutely aware of coding issues. They tell someone not to smoke, but unless you enter that you counseled for smoking as part of your encounter, you don't get credit for it." Finally, often counseling recommendations are not easily integrated into health plan EMRs because not all counseling recommendations result in claims. For example, tobacco use counseling is particularly problematic; one hybrid plan tobacco use, but often, the service does not result in a claim. As a result, the health plan is not able to capture that the counseling service was delivered.
- Using data to inform quality improvement. Using data to drive quality improvement activities is a key challenge. Balancing the cost-benefit equation for certain services is an issue that health plan staff identified as a key issue. Respondents from the closed-panel plan discussed that there are challenges to identifying whether a service will result in a large or incremental quality improvement for members.
- Claims systems integration. In the hybrid plan, the health plan uses multiple separate systems for claims data. One respondent indicated that the plan uses 13 different data sources. Pharmacy and medical claims are separated into two different systems. Similarly, mental health service data is delegated to another system. It is difficult for the various external entities to put the data together in a similar format, in order to bridge the separate claims systems. The different sources and different data formats pose problems for Health IT and Quality Improvement Staff as well.
- Evaluating patient outcomes. Currently, none of the plans have the capacity to evaluate patient outcomes relative to the delivery of recommended clinical preventive services. The closed-panel plan, which has the greatest integration of clinical preventive services using Health IT is not currently able to evaluate patient outcomes, but is moving in that direction. To measure patient outcomes relative to clinical preventive services, the hybrid plan uses an NCQA tool that allows the health plan to predict patient outcomes based on clinical preventive services delivery, while also taking into account population characteristics and other information.
- Tracking patient data. Quality Improvement Staff from the hybrid plan discussed the unique challenges associated with tracking patient outcomes over the long-term in a hybrid plan. One respondent told us that "when you are talking about [clinical preventive] services that are going to have an impact down the road, we struggle with whether the data will be there." When members receive services from plan-affiliated providers who utilize the system-based EMR, it is easier for quality improvement staff to track patient outcomes. However, the Quality Improvement Staff noted that the hybrid plan's members often change primary care physicians. Since about 50% of providers do not use the system EMR, patient data may or may not be recorded and available, making it difficult for the health plan to monitor long run trends.
- Member turnover. The challenging of tracking patient data for quality improvement is further exacerbated by member turnover. Employers frequently shift health plans to secure better rates and health plan members may change jobs, resulting in member turnover. According to Quality Improvement Staff at the hybrid plan: "It's easy if [members] stay in the health plan; that's not as much of a problem. Sometimes they fade in and out." As a result, plans face serious challenges tracking and monitoring patient outcomes over the long-term.
Quality Improvement Activities. Health plans are engaged in practice change and quality improvement activities, specifically related to clinical preventive services. According to respondents, health plans have implemented quality improvement activities to increase the delivery of screenings for colorectal cancer, cervical cancer, and breast cancer, and to improve the delivery of tobacco cessation counseling and flu immunizations. Health plans employ a variety of quality improvement techniques, many of which integrate health information technology.
To explore the major uses of quality improvement at health plans, we asked respondents a series of questions focused on the types of quality improvement activities that improve the delivery of clinical preventive services. We also examined whether quality improvement activities are used to increase the delivery of Task Force recommendations, specifically:
- Is your system engaged in practice change or continuous quality improvement activities?
- Can you provide a few examples of activities that were designed to increase the appropriate delivery of a Task Force recommendation?
- When [the health plan] designs a practice change or continuous quality improvement activity to increase the appropriate delivery of a Task Force recommendation, how do you encourage implementation at the practice or clinician level?
The governmental plan has been using quality improvement activities to increase the delivery of screenings for colorectal cancer and breast cancer as well as tobacco counseling, all of which are Task Force recommendations. The open-panel plan has a variety of quality improvement activities focused on increasing the delivery of Task Force recommendations such as flu immunizations, breast cancer screenings (mammography), and other immunization programs. The open-panel plan also focuses on addressing process improvement issues related to medical recordkeeping practices and provider accessibility to members. The hybrid plan has developed a sophisticated quality improvement program to increase the delivery of colorectal cancer screenings to plan members.
The closed-panel plan is particularly sophisticated in its quality improvement techniques for clinical preventive services. According to a Director of Quality Improvement, the closed-panel plan follows the chronic care model:
"From the clinician end, we do everything from newsletters, emails, and posters to electronic reminders in our medical record. We have brochures and flyers around the office, depending on the issue. We have lists of people who are overdue for their mammograms, which are sent to radiology staff and technicians that actually call people and remind them they are overdue."
The closed-panel plan also orchestrates a variety of aggressive quality improvement campaigns to improve the delivery of clinical preventive services—some of which are publicized via nationwide television commercials. According to Clinical Advisors, the closed-panel plan's regional priorities for quality improvement are mammograms and diabetes care; secondary priorities are asthma, immunizations, and coronary heart disease. Recently the plan also won a national award for controlling hypertension.
The health plans have implemented a wide range of quality improvement activities focused on improving delivery rates of clinical preventive services. A sample of common techniques is provided below.
- Provider "report cards." The health plans use provider report cards to monitor physician performance with regard to the delivery of clinical preventive services. The open-panel plan conducts retrospective reviews of physicians' delivery of CPS such as childhood immunizations (e.g., the immunization schedules are analyzed for children in various age brackets to determine whether appropriate immunizations are being delivered). The open-panel plan provides feedback to providers as part of its general medical record review audit. Feedback focuses on the delivery of childhood screenings, immunizations, and medical recordkeeping practices. The governmental plan has a performance improvement committee that examines whether individual practitioners are meeting performance standards with respect to delivery of clinical preventive services. The closed-panel plan develops quality report cards, updated monthly, for every provider. According to one Clinical Advisor respondent from the closed-panel plan, the use of statins has increased as a result of communication and feedback resulting from the quality report cards. Another Clinical Advisor from the closed-panel plan indicated that "report cards" are a powerful quality improvement tool: "If it's [a recommendation] that we agree with, we'll put it on the report card for measurement, because that which is measured is that which is done." A Director of Quality Improvement from the closed-panel plan further explained that "every participating physician gets a report card for measures. There are 20 measures on the report. If the provider is not on target, it's red; if they are, it's green. Everybody always wants to turn their red to green."
- Internal work groups and meetings targeted at improving performance on specific CPS measures. The open-panel plan has a work group each year to improve the delivery of flu vaccinations. The work group focuses on developing newsletters, phone messages and other communications directed at increasing the number of members that get their flu shots each year. At the closed-panel plan, the quality improvement committees at each health center meet monthly to discuss ways to improve diabetes screening. Several of the tactics employed include distributing materials about the importance of screenings in each waiting room and posters in every other department to help raise awareness. Breast cancer screening is also a key priority for the plan, further described in Best Practices Box 1.
- Monitoring and compliance. A Director of Quality Improvement for the open-panel plan indicated that the plan monitors compliance with quality guidelines.
- External programs and campaigns. The open-panel plan strives to increase the number of breast cancer screenings by communicating to providers and members through external programs. One of the programs offers incentives to members, such as an opportunity to register for a $100 gift certificate drawing when members go for their mammography. The governmental plan set up flu clinics to encourage members to get immunizations and started a "Women's Health Day" to improve breast cancer screening rates. The closed-panel plan mobilized a campaign targeted at reducing osteoporosis.
- The Internet as a quality improvement and outreach tool. The open-panel plan uses the Internet to promote preventive services to its members. The provider section of the Web site contains the provider manual, clinical newsletters, and provider feedback.
- Patient outreach and education through letters, notices, and phone calls. The open-panel plan's Director of Health IT describes that quality improvement initiatives are directed at members rather than physicians: "We tend to concentrate more on the member side rather than the physician side regarding the Task Force recommendations. We think that the provider is likely to provide the screening if asked, but the first step is that the member needs to make the appointment to do it." A Director of Quality Improvement for the open-panel plan discussed that notices are mailed to eligible members to get mammograms and Papanincolaou smears to screen for cervical cancer and breast cancer, respectively. In addition, the open-panel plan sends members newsletters to "market" clinical preventive services, such as flu immunizations, to the plan's "customers." At the hybrid plan, nursing staff on the quality improvement team call members who have not received their mammograms to schedule them for the exams. A specialized call center was developed at the hybrid plan to schedule patients for colonoscopies as well; this effort is further described in Best Practices Box 2. A Clinical Advisor respondent from the governmental plan described that the plan has significantly improved its process for scheduling colonoscopies; the plan's quality improvement department calls eligible patients and follows up with letters.
- Barrier analysis. Quality Improvement Staff from the hybrid plan indicated that they engaged in barrier analysis based on the results of their projects: "We try to determine where we can make improvements. Is it an education issue with the members? Is it just a coding issue, based on claims? We'll try to do that level of detailed analysis on the barriers and react to that."
- Member satisfaction surveys. The open-panel plan actively provides member satisfaction surveys that draw upon member experiences with their providers, provider offices, and services. A member complaint system also investigates member complaints through a medical records audit.
- Practice patterns analysis. A Director of Health IT discussed that the open-panel plan currently conducts quarterly practice patterns analyses of physician performance on various measures, some of which are preventive health measures: "Based on the measure, if [the physician] is an outlier, we have somebody go out and have a conversation to try to figure out why."
Best Practices Box 1: Improving the Delivery of Mammograms
Improving breast cancer screening rates is a regional priority for the closed-panel plan. In order to raise its delivery rate of mammograms from mid-70% to 80%, the plan developed a quality improvement effort targeted at its large urban population. One Clinical Advisor from the closed plan described that there are unique challenges to improving the delivery of mammograms in urban health care centers for its urban population: "We've been struggling with mammography. We want to get rates for centers like mine—the urban centers—up to or above 80%."
The closed-panel plan uses a variety of quality improvement tactics to raise awareness of breast cancer in the urban population. Providers utilize every patient visit as an opportunity to communicate the importance of mammography. In addition, risk-stratified lists are developed and employed to perform aggressive outreach. According to a Clinical Advisor, the plan is determined to reduce the barriers to mammography for its urban population:
"We've talked about strategies like same-day mammograms. We've had women with breast cancer call women who are afraid to get mammograms to talk to them." Providers are also providing additional outreach to the African-American population, identifying and addressing potential obstacles to mammograms: "There seems to be some bias in the African-American community against mammography and breast cancer screening. We look at obstacles: are they systemic, personal, transportation, fear? We try to reduce the obstacles, whether it's a systems obstacle, logistical obstacle such as transportation, cost-related obstacle such as co-pays, or time constraints. We come up with strategies to address these obstacles."
The medical centers also conduct activities related to improving delivery of breast cancer screenings. "We communicate the importance of mammography to members, to physicians, and give physicians reports of rates. We also use our EMR to provide clinical reminders." The plan's EMR alerts providers if members have not received their mammograms and then clinical assistants make outreach phone calls. The plan also has an automated system that makes outreach calls for breast cancer screening, as well as for prostate and colorectal cancer screenings.
Best Practices Box 2: Improving the Delivery of Colorectal Cancer Screenings
Improving the delivery of colorectal cancer screenings is an important quality improvement priority for the hybrid plan. The plan's efforts had previously focused on the delivery of fecal occult blood testing to patients as the primary prevention method for colorectal cancer. However, according to Clinical Advisors from the plan, "we have not been very successful as an organization thus far [with regard to colorectal cancer screening]." The hybrid plan developed a multi-pronged quality improvement approach to improve the delivery of colorectal cancer screenings. Internally, the plan organized a team of internists, gastroenterologists, family physicians, nurse practitioners and managers to examine different recommendations for colorectal cancer screening. The plan focused the quality improvement program on patients aged 50 years and older, specifically to encourage them to have a colonoscopy.
Quality improvement staff abstracted data from the system's EMR to determine the number of patients in need of a colonoscopy. Records concluded that approximately 70,000 members would need a colonoscopy. A Clinical Advisor from the plan was initially concerned about resource availability: "We then realized that our availability of resources within the system was limited—obviously we couldn't do 70,000 colonoscopies over the next month." In effect, the plan examined the availability of resources against the needs of patients and stratified the risks of patients. Since the peak incidence of colorectal cancer is age 76, the plan decided that it would be optimal to initially target patients aged 65 to 69. The plan employed three quality improvement strategies, which made the program a success:
- To address the issue of system capacity—namely the concern that plan providers would not be able to deliver an adequate number of colonoscopies across all of the plan's regions—the hybrid plan developed a quality improvement effort that was staggered across regions over time. For example, the plan first drew upon its excess capacity in gastroenterology in the central region, and then moved on to test patients in other regions.
- The hybrid plan sent an initial mailing to eligible members. The letters were addressed from both the health plan and the American Cancer Society (ACS), and described that members should call the plan to schedule a colonoscopy. According to Clinical Advisors from the plan, partnering with ACS in this effort was highly effective: "In the letter we sent out, we included educational materials, and co-marketed it with the American Cancer Society. We used their input and their logo to reinforce to patients that it was beyond [our plan] and was an important recommendation."
The hybrid plan developed an Access Center, essentially a group of trained professionals that staffed an appointment hot-line and provided support to the program. The Access Center played a key role in several respects: (1) scheduling patients who called in for colonoscopies; (2) calling patients who did not respond to the letter; and (3) entering patient information into the plan's EMR. The Center staff was able to identify whether the member had a colonoscopy that was not documented in the EMR. This technique was crucial: approximately one-third of patients that called to schedule an appointment had already had a colonoscopy, though it was not recorded in the EMR. The Access Center updated the EMR records for these members.
The hybrid plan completed colonoscopies for members in the central region and is pursuing its western and eastern regions. A Clinical Advisor from the plan indicated that the program was effective in delivering colonoscopies to a large population: "I can recommend colonoscopy in the office to my patients face to face, but it is a recommendation that can be implemented in a more systematic way."
Strategies Used to Encourage Implementation of the USPSTF Recommendations. Respondents described a number of strategies used to encourage the implementation of quality improvement activities at the practice or clinician level. Provider feedback is the most common strategy employed at all of the plans. Respondents described that provider feedback is the biggest driver of change, alerting clinicians of their performance in comparison to their colleagues.
Some health plans, such as the open-panel plan, offer provider education. The open-panel plan sends literature to medical offices and sometimes quality "field staff" to work with providers on certain quality efforts. The open-panel plan also distributes quarterly provider mailings and a regular newsletter about preventive medicine. The governmental plan is active in provider education as well, offering specialized training sessions for clinicians to teach them how to use new tools. For example, recently a new clinical reminder was added to the governmental plan's EMR. Health IT staff held training seminars to teach clinicians how to use the new tool, giving them an opportunity to ask questions prior to using the tool in a clinical setting. All of the plans use clinical reminders to encourage the implementation of quality improvement at the clinician level. Finally, the government plan provides medical education offerings to give clinicians an extra incentive to participate in quality improvement activities.
Another key strategy employed by a few of the plans is to reward providers for quality improvement. According to a Quality Improvement Staff respondent at the closed-panel plan: "You reward, in every way you can, that group, in an effort to ensure that they will continue to work with [the quality improvement program]." The closed-panel plan incentivizes its physicians to strive for improvements. One respondent indicated that the plan's quality improvement staff examine the results of prevention screenings criteria and other clinical HEDIS measures to identify high-performing medical centers. Staff of high-performing centers are rewarded with group meals, a trophy or plaque, or public recognition. In the majority of the health plans, the reimbursement structure rewards the delivery of clinical preventive services, which also contributes to quality improvement.
2.4. The Impact of the Reimbursement Structure on the Delivery of Clinical Preventive Services
We were interested in learning whether the health plan's reimbursement structure was designed to foster quality improvements in the area of preventive health. We asked respondents about the impact of the reimbursement structure on the delivery of clinical preventive services. Specifically, "does the reimbursement structure at [the health plan] reward the appropriate delivery of clinical preventive services?"
We found that the majority of the health plans utilized the reimbursement structure to reward the delivery of clinical preventive services—but to varying degrees. In the case of the hybrid plan and the governmental plan, individual physicians are financially rewarded for performing well on certain performance measures related to clinical preventive services. These plans indicated that their reimbursement structures have a "pay-for-performance" component, whereby financial incentives for medical teams and physicians are tied to health care quality. The open-panel plan is currently developing a pay-for-performance component for preventive health.
The closed-panel plan rewards its medical teams based on performance, but does not financially reward individual physicians. Respondents indicated that physicians were salaried at the closed-panel plan, and rewards are provided at the macro-level rather than the individual physician-level. Individual physicians do not receive financial compensation for high performance. Rather, the regional plan recognizes district medical teams that perform well on quality targets (e.g., bringing screening rates for breast cancer up to 85%, etc.) through group meals and gift certificates. Quality targets are sometimes based on the HEDIS measures. One Clinical Advisor indicated that "[physicians] are pretty much on a straight salary that doesn't have much to do with how well or how poorly we do. Organizationally, we have team-based incentives that are always tied to quality."
The hybrid plan has a sophisticated pay-for-performance program which provides financial rewards to high performing health plan staff as well as physicians. The hybrid plan has only implemented its pay-for-performance program for a diabetes care initiative thus far, though it plans to incorporate other preventive health services in the future. A Clinical Advisor respondent from the plan indicated that the plan has a "tiered reward structure" whereby the highest performing health center site is in the top tier, the second highest performing site is in a slightly lower tier, etc. Each site is rewarded according to its tier's ranking. Health plan staff, such as providers, nurses, radiology technicians, and clerical workers who perform in the top tier, receive a reward every six months; staff in lower tiers receive smaller rewards. This is a particularly interesting aspect of the hybrid plan's reimbursement structure because staff are also eligible to receive rewards (in addition to providers). Physicians also have quality summaries that reward them according to their performance on USPSTF recommendations such as mammograms for breast cancer, Papanincolaou smears for cervical cancer, and childhood and adolescent immunizations.
While the governmental health plan physicians are salaried by the Federal government, recently there has been a movement towards adopting performance based reimbursement. The Clinical Advisor respondents were most familiar with this shift in the reimbursement structure, indicating that a small percentage of a physician's bonus would be determined by performance on clinical preventive services as well as other services. Other respondents indicated that physicians were strictly salaried, and were unfamiliar with the pay-for-performance aspect of the reimbursement structure. A Medical Director from the governmental plan discussed that the shift in the governmental plan's reimbursement structure is relatively recent. Physicians who meet certain quality benchmarks based on certain measures would be rewarded for their performance (e.g., a score of 85% or better on a particular performance measure). According to the Medical Director, physicians that do comply with the governmental plan's clinical preventive services guidelines will receive a larger bonus. Approximately 5% of their bonus is determined by individual performance, while another 5% is based on the performance of the facility as a whole. As a result, salaries are not only based on individual provider performance but also on peer performance.
The open-panel plan's reimbursement structure is not currently utilized to encourage quality improvement with regard to the delivery of clinical preventive services. Few of the respondents at the open-panel plan commented on the plan's reimbursement structure. The open-panel plan recently piloted a small effort related to pay-for-performance, and is currently in the development stage for a broader pay-for-performance that will include a focus on preventive services.
2.5. The Role of HEDIS in the Delivery of Clinical Preventive Services
For the past decade, HEDIS has been used to evaluate the quality of outpatient care in many large managed health care plans, making it an interesting variable for further consideration during our interviews. Empirical literature suggests that the HEDIS performance measurement set has profoundly influenced the way preventive care is delivered.65 Respondents confirmed the importance of HEDIS performance measures in their health plans.
Respondents occasionally confused the USPSTF recommendations and HEDIS measures. Only a handful of the respondents actually make a distinction between the two. For example, a Director of Quality Improvement at the hybrid plan indicated that HEDIS criteria are "as you know, equal to the USPSTF [criteria]" for breast cancer screening. Many respondents were highly familiar with clinical preventive services in terms of HEDIS measures, but unfamiliar with the USPSTF recommendations.
Respondents across health plans conveyed that HEDIS strongly influences which clinical preventive services are provided and how frequently services are tracked and measured. It appears that the USPSTF recommendations associated with HEDIS measures are evaluated and tracked more frequently than USPSTF recommendations that are not associated with HEDIS measures. According to a Quality Improvement Director, one of the plans provides financial incentives for health groups to deliver mammograms in the 90th percentile for HEDIS.
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