I AM: A Doctor / Provider
The Quality Improvement Provider Resource Guide and toolkit is designed to provide health plan network Primary Care Providers (PCP) with information on quality measures and what they mean to the health plan.
The health plan requests collaboration with providers to improve the quality for our members, and your patients. The information provided within this guide is the most recent and up to date information that was available at print time. This resource guide will be up dated annually or as changes are implemented.
Health plans are measured based on quality and value by the National Committee for Quality Assurance (NCQA). Accreditation evaluates core systems and process that make up a health plan, as well as actual results the plan achieves on key evaluations of the health care system. Providers play a key role in helping the health plan meet their accreditation goals. This in turn allows the health plan to set improvement goals and projects each year.
A performance measure is a set of technical specifications that define how a rate is calculated for an important quality indicator. HEDIS is the most widely used set of performance measures in the managed care industry.
HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS was developed, and is maintained by the National Committee for Quality Assurance (NCQA). NCQA take HEDIS measurement very seriously. All measures that are implemented meet three key criteria: relevance, soundness and feasibility. NCQA takes great care in making sure that all measures address important issues, are scientifically sound and are not overly burdensome or costly to implement.
For further information on HEDIS, please see the HEDIS section of the Quality Improvement Provider Resource Guide and toolkit.
The Centers for Medicare & Medicaid Services (CMS) also measure the health plan's performance. CMS has a five-star rating system that incorporates the HEDIS measures directly related to Medicare beneficiaries. For further information on the Star-rating system and what it measures, please refer to the CMS Star-Rating section of the quality improvement provider resource guide and toolkit.
The health plan has taken careful consideration to make the resource guide and toolkit an all-encompassing resource for providers and their office staff. In each informational section (listed below) there is a section that suggests how providers may be able to help the health plan achieve their quality and performance goals.
Included in the resource guide and tool kit is the general information on performance measures and why they are important to the health plan.
Informational sections on:
This section includes information that is meant to be a tool for providers and office staff.
The HEDIS high-level overview for providers is a tool meant to be used as a quick-glance reference. It includes all of the performance measures along with supporting information. This guide is divided into sections: