Performance Measurement

NCQA did not create the field of health care performance measurement, but we have refined the process and led the development of objective measures since the mid-1990s when our standardized measurement tool, the Healthcare Effectiveness Data and Information Set (HEDIS), was broadly adopted by the industry.

Since then, NCQA has expanded the scope of HEDIS from a narrow collection of process measures to a comprehensive set that assesses a range of important health care interventions and outcomes. The current HEDIS set addresses preventive services, chronic disease management, behavioral health care, appropriateness/overuse of services and value. HEDIS includes measures for high-burden diseases such as diabetes, asthma, heart disease and depression, as well as preventable hospitalizations and patient satisfaction.

A performance measure is a set of technical specifications that define how to calculate a “rate” for some important indicator of quality. For instance, one HEDIS measure defines very precisely how plans should calculate the percentage of members who should have received beta blockers that actually were given a prescription. Using these measures, plans can determine what their rate is and how they compare to other plans.

The ability to draw apples-to-apples comparisons among plans is extremely important — imagine if every health plan calculated the rate using a different methodology. A plan with an 80% rate using one methodology might actually be doing better than a plan reporting a 95% rate using another (if, for instance, the latter plan only measured a small sample of patients from its best clinic). HEDIS allows for standardized measurement, standardized reporting and accurate, objective side-by-side comparisons.

NCQA takes the responsibility of managing the evolution of HEDIS very seriously, insisting that all measures meet three key criteria: relevance, soundness and feasibility. We work to make sure that all measures address important issues, are scientifically sound and are not overly burdensome or costly to implement. As with our oversight programs, HEDIS is developed with the input and support of many different constituencies.

HEDIS includes performance measures related to dozens of important health care issues. Selected measures include, but are not limited to:

  • Antidepressant medication management
  • Breast cancer screening
  • Cervical cancer screening
  • Children and adolescent access to primary care practitioners
  • Childhood and adolescent immunization status
  • Comprehensive diabetes care
  • Controlling high blood pressure
  • Flu vaccinations for Adults
  • Medical assistance with smoking and tobacco use cessation
  • Medication management for people with asthma
  • Plan all-cause readmissions
  • Potentially harmful drug-disease interactions in the elderly
  • Prenatal and postpartum care
  • Relative Resource Use for People with COPD 

Since 1997, NCQA has produced The State of Health Care Quality, an overall assessment of the performance of the American health care system. The report is issued just before the annual “open enrollment” season, when most Americans choose their health plan for the following year. Consequently, the report generates an enormous amount of media attention, and has been covered everywhere from the Wall Street Journal and the New York Times to U.S. News & World Report,Newsweek, CNN and your local newspaper.

For more than five straight years, these reports have shown that participating commercial health plans recorded meaningful improvements across a wide range of clinical quality measures. For example, since NCQA began measuring beta-blocker treatment rates, performance in this critical area has gone from about 60% to well over 90%. Consequently, thousands of Americans every year will avoid a potentially fatal or debilitating second heart attack.

Performance measurement isn’t just for health plans. Physicians are increasingly participating in performance measurement activities, especially in the context of pay-for-performance initiatives that are taking shape across the country. Measurement at all levels of the system is fast becoming the norm in health care.