‘We don’t have enough data, and we don’t have it at the right time’
For over a quarter century, the National Committee for Quality Assurance has worked with
employers, health plans, providers and patients to develop quality performance measures. But reporting required for its Healthcare Effectiveness Data and Information Set, or HEDIS, and other quality reporting has triggered a backlash by providers. Modern Healthcare Editor Merrill Goozner recently spoke with NCQA President Margaret O’Kane about recent controversies swirling around quality measurement. The following is an edited transcript.
Modern Healthcare: Tell us a little bit about the NCQA.
Margaret O’Kane: We started this whole movement about quality 26 years ago by aligning employers who wanted to contract with high-quality health plans. We started an accreditation program that was designed by employers sitting at the table with what they considered the best health plans. We also had consumers. We use multiple stakeholders in all the things we do.
We came up with an accreditation program. We used a system of quality measurement called HEDIS, and those two things ran in parallel for a while. But now HEDIS really drives a lot of the outcomes of our accreditation program.
MH: HEDIS, the Healthcare Effectiveness Data and Information Set. What is that?
O’Kane: It’s a system of measurement of things that we think plans can be accountable for. Did people get the preventive health services that they should get? For that, we follow the U.S. Preventive Services Task Force. Did women get mammograms? Did people get colon cancer screening? Did children get their immunizations? Did adults get flu shots?
We look at chronic conditions. Diabetes, which afflicts so many Americans, depression, asthma, cardiovascular disease—if all these things are managed appropriately, the outcomes are incredibly different than if they’re not managed right.
MH: What’s the trend on performance on the HEDIS measures?
O’Kane: There are some that are stubbornly not moving up. Behavioral health in this country is not working. There are kind of shining areas where people are doing demonstration work that is very good, but in general we’ve carved out behavioral healthcare from plans so nobody really feels responsible for it.
MH: Are there some areas where we’re doing better?
O’Kane: There are areas where we can point to some tremendous improvement. Colon cancer screening, which really affects outcomes, has had a very big improvement. Hypertension control, cardiovascular disease control, putting people on statins who are at high risk for recurring heart attacks—there are lots of success stories. Asthma care is better. Immunization rates have really risen tremendously over the years.
MH: Collecting this data is a huge issue for physicians and physician practices across the country and for hospitals. What are you doing to streamline measurement?
O’Kane: The plans worked around the practitioners in many cases to collect HEDIS measures. The complaint was much more, “I have to put up with these people coming into my office to peek in my charts to make sure I did the things that they couldn’t find in the claims data.” HEDIS was heavily driven by claims data, and so the practitioners weren’t affected that much unless the plan was giving them bonuses.
But now with Medicare demanding quality information with pretty big consequences—starting at 4% of pay potentially and going to 9% over five years (under MACRA)—there’s a kind of a shock to the system. They say, “Do we have too much data?”
(But) we don’t have enough data, and we don’t have it at the right time. It really shouldn’t be that the first time I find out as a practitioner, for example, that my hemoglobin A1c control rate is lower than average is when I get my measure results. I should have the data at the point of care, and I should be able to
“People are working around the deficiencies of electronic health records. If the electronic health record companies are smart, they’ll fix their products so that they work better.”
“Each organization seems to have to learn its own lessons, which is a ridiculous waste of money and time and human energy.”
kind of get a report out of my medical record that says, “You’re at 70%” or “You’re at 60%” or wherever you are, “and here are the people that you need to work with or have your care manager in the practice work with.”
MH: The government just spent $30 billion on EHRs. Everybody has them. We have the claims data. Why don’t we have this clinical information in real time?
O’Kane: We will be able to one of these days, and some places are able to because they have been scrambling to adjust by putting boltons on their EHRs that give them reports. Progress is slow (and) it’s way too expensive. Each organization seems to have to learn its own lessons, which is a ridiculous waste of money and time and human energy.
We have health information exchanges in some parts of the country that are doing an amazing job of getting the data to the practitioners at the time they need it. So people are working around the deficiencies of electronic health records. If the electronic health record companies are smart, they’ll fix their products so that they work better.
MH: Where are the good health information exchanges at the state level?
O’Kane: My Health in Tulsa, Okla., which is now statewide. It’s got up-inthe-cloud claims data, EHR data, lab outcomes, drug information, and it all goes back to the practitioners. CRISP in Maryland is also doing a terrific job of giving people the information they need to manage their populations and their sick people.
MH: Are hospitals, which have been buying physician practices, doing a better job than individual physician practices in making quality data available in real time?
O’Kane: The jury is out on hospitals. I have empathy. People that have been administrators of hospitals or even practitioners in hospitals have been able to be successful with a model where heads in beds was a good thing, ER visits were a good thing, expensive care was a good thing, whether or not it was better or cheaper care for the patient.
Now we’re about to turn that model upside down. And so how do they go about the journey—to this kind of being accountable for quality and costs and the patient’s experience—from where they were mostly accountable for growing their revenue and lately for quality? It’s a huge change.
MH: How well are they doing on making this change?
O’Kane: There are always points of light. Intermountain Healthcare. A lot of the Kaiser hospitals are doing incredible work. Mission Health in North Carolina is a hospital that does a really good job. There’s great stuff happening in Boston.
I’m hopeful, but there are a lot of entities to change, and it’s a big change. So it’s scary.