HEDIS® and the Impact Act

Background

Increased attention to socioeconomic status (SES) and its potential effect on receiving health services, raised questions about how to account for a health plan’s proportion of members with low SES when measuring quality. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (H.R. 4994) directs the Secretary of Health and Human Services to study the effect of individuals' SES on quality, resource use and other measures for individuals in the Medicare program. 

The Centers for Medicare & Medicaid Services commissioned NCQA to assess whether Medicare Advantage plans that enroll a disproportionate number of vulnerable beneficiaries are systematically disadvantaged by programs that use performance measures to assess quality. Because previous studies suggested the existence of within-plan1  differences between low- and high-SES beneficiaries, NCQA explored addressing SES in select HEDIS Medicare measures. 

Approach

To determine whether plan measure performance is sensitive to the proportion of low-SES enrollees, NCQA used its established process for reevaluating HEDIS measures. This process included qualitative and quantitative analyses, with heavy input from a diverse range of stakeholders and experts in the area of health care disparities. We assessed the following HEDIS measures: 


Breast Cancer Screening
Colorectal Cancer Screening
Comprehensive Diabetes Care - Eye Exam
Comprehensive Diabetes Care - HbA1C
Control Comprehensive Diabetes Care - Medical Attention for Nephropathy
Controlling High Blood Pressure   
  Fall Risk Management
Osteoporosis Management in Women who had a Fracture
Physical Activity in Older Adults
Plan All-Cause Readmissions  


Adult BMI Assessment Breast Cancer Screening Colorectal Cancer Screening Comprehensive Diabetes Care - Eye Exam Comprehensive Diabetes Care - HbA1C Control Comprehensive Diabetes Care - Medical Attention for Nephropathy Controlling High Blood Pressure Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis Fall Risk Management Osteoporosis Management in Women who had a Fracture Physical Activity in Older Adults Plan All-Cause Readmissions  

Our qualitative assessment included interviews with health care disparity experts about how to address SES in measurement and with health plans about their barriers and strategies for achieving good performance on their low-SES populations. We also reviewed literature for each measure to determine whether a conceptual basis supported a need to account for SES. Our quantitative assessment included a series of studies to evaluate how the proportion of beneficiaries in a plan that is high- or low-SES affects its performance relative to similarly adjusted plans. We also explored whether other factors may be responsible for any observed SES differences in performance. Our work was guided by a Technical Expert Panel on Socioeconomic Status in Health Care. We posted a proposed strategy based on the results of our work for wide public comment. 

Results 

The qualitative analyses helped provide the basis and direction for NCQA’s quantitative work. Feedback from key informant interviews cautioned NCQA against using case-mix or risk adjustment for the measures, given the potential to mask differences in care between low- and high-SES populations. This concern was echoed by our advisory panels and those submitting to public comment. The literature reviews suggested there was a conceptual basis for addressing SES in the measures except the two that assess whether a clinician asked about health topics (Fall Risk Management and Physical Activity in Older Adults)

The quantitative analyses supported stratifying measure performance by SES for four of the measures in our study: Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Care - Eye Exam, and Plan All-Cause Readmissions. For the remaining measures, SES did not have a meaningful impact on results throughout the various analyses we conducted. When adjusting for disparity in performance between low- and high-SES populations, plan ranks were not substantially impacted. When accounting for clinical and demographic factors, we found that low-SES beneficiaries were as likely, or more likely, to receive care as high-SES beneficiaries. 

Although SES effects were minimal or inconsistent across most measures, an SES disparity persisted even after accounting for clinical and demographic factors for Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Control—Eye Exam and Plan All-Cause Readmissions. These findings provided support for a strategy to account for beneficiary SES in measure performance for these measures. 

We discussed these results with independent advisory panels who agreed that NCQA should pursue a strategy to account for SES when a clear and consistent disparity existed. Ultimately, NCQA proposed stratifying Medicare performance rates by beneficiary status for the subset of measures for which an SES disparity persisted. To further assess this proposal, we modeled beneficiary-level stratified reporting in our testing data These analyses suggest that stratified reporting can show meaningful within-contract differences given their beneficiary profile. Therefore, stratified reporting offers a clear demonstration of which contracts are best for beneficiaries with low-SES status. We received broad support for this strategy; generally, the comments confirmed that this approach would increase transparency and allow for a more complete picture of performance among contracts. 

Conclusion  

Overall, our analysis findings supported a strategy to account for beneficiary SES in measure performance for four measures: Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Care—Eye Exam, Plan All-Cause Readmission (measure-specific conclusions are shown in the table below). With transparency in mind, NCQA determined that, of the potential strategies, stratifying Medicare contract performance meets the goal of accounting for LIS/DE and disability status in measurement. Stratified reporting has the potential to highlight disparities, facilitate fairer plan comparisons, and provide a more complete picture of performance on key health care services. 

Measure specification recommendations 

Measure Conclusion Rationale
Physical Activity in Older Adults No Changes No conceptual basis for adjustment
Fall Risk Management No Changes No conceptual basis for adjustment
Adult BMI Assessment No Changes Analysis did not indicate a clear and consistent effect of SES status on measure performance and plan rank.
Comprehensive Diabetes Care— Medical Attention for Nephropathy No Changes Analysis did not indicate a clear and consistent effect of SES status on measure performance and plan rank.
Comprehensive Diabetes Care—HbA1C Control No Changes Analysis did not indicate a clear and consistent effect of SES status on measure performance and plan rank.
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis No Changes Analysis did not indicate a clear and consistent effect of SES status on measure performance and plan rank.
Osteoporosis Management in Women who had a Fracture No Changes Analysis did not indicate a clear and consistent effect of SES status on measure performance and plan rank.
Breast Cancer Screening Stratify Measure Stratification of contract performance by beneficiary LIS/DE and Disability Status.
Colorectal Cancer Screening Stratify Measure Stratification of contract performance by beneficiary LIS/DE and Disability Status.
Comprehensive Diabetes Care - Eye Exam Stratify Measure Stratification of contract performance by beneficiary LIS/DE and Disability Status.
Plan All-Cause Readmissions Stratify Measure Stratification of contract performance by beneficiary LIS/DE and Disability Status.


Recommendation 

NCQA proposed stratifying Medicare plan performance by beneficiary LIS/DE or disability status, for Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Care - Eye Exam, and Plan All-Cause Readmissions in HEDIS 2018. 

This original proposal requires Medicare plans to report four mutually exclusive performance rates and an aggregate total rate for each measure:  

  • Beneficiaries who have neither low-income subsidy, dual eligibility nor disability status. 
  • Beneficiaries who have low-income subsidy or dual eligibility status only. 
  • Beneficiaries who have a disability status only. 
  • Beneficiaries who have low-income subsidy, dual eligibility, and disability status. 
  • Total. 

Additionally, NCQA proposed that all plans use the CMS Monthly Membership Reports (MMR) file to get the data and calculate the strata. 

We conducted field testing to ensure that the proposed files and data were available, and that the calculations were appropriate for the strata selected. In the testing process, NCQA partnered with HEDIS auditors, vendors and Medicare Advantage plans that report quality measures. We recruited 4 plans to conduct feasibility testing. We started with informational interviews and confirmed that the plans receive the MMRs from CMS, and that the files contain fields to identify the beneficiaries. We conducted feasibility testing to confirm that our proposed logic is correct and usable. 

Based on our work with vendors, auditors and health plan data, NCQA confirmed that the plans will use the MMR files, but we made further revisions to the logic for plans to calculate the SES strata in the four HEDIS measures.




1  Within-plan disparities are differences between subgroups within a given plan. These differences may indicate differences that result from patient characteristics and may be outside of the plan’s control, whereas between-plan disparities may represent differences in quality between plans that may be within the plan’s control.