Health Plan Employer Data and Information Set

The Health Plan Employer Data and Information Set (HEDIS) is a set of performance measures for managed care health insurance plans produced by the National Committee for Quality Assurance (NCQA), an independent, not-for-profit association founded in 1990. HEDIS measures were developed to facilitate comparison of the performance of managed care plans to each other and to national benchmarks. They have also been used to study trends in managed care over time.

Four types of managed care plans are included in the HEDIS measures. Health maintenance organizations (HMOs) offer a range of benefits for a set monthly fee; managed behavioral health care organizations (MBHOs) are similar to HMOs but provide care for mental health and substance abuse disorders; point of service (POS) and preferred provider organizations (PPO) plans provide free or highly subsidized care within a specified network of health care providers and a lesser subsidy for care provided by doctors outside that network.

NCQA evaluates managed care plans in five dimensions. Access and service evaluates the quality of customer service and access to care provided by plans, including availability of sufficient primary care physicians and specialists and consumer-reported difficulties in getting care. Qualified providers evaluates the training and licensure of the physicians within the plan, sanctions and lawsuits filed against them, and consumer satisfaction with the plan's physicians. Staying healthy evaluates the quality of preventive care provided by the plans, including appropriate use of tests and screening procedures, and plan guidelines to physicians concerning preventive care. Getting better reviews managed care plan activities intended to help people recover from illness, including access to the most up-to-date care and provision of health behavior programs such as smoking cessation. Living with illness evaluates plan activities related to the management of chronic illnesses such as diabetes and asthma.

NCQA also grants or denies accreditation to managed care plans, with several levels of grading. For HMOs and POS plans, the highest level of accreditation is excellent, which is granted to plans that meet or exceed HEDIS requirements for clinical quality and service, and are also in the highest range of regional or national performance. The next level is commendable, which is granted to those that meet or exceed HEDIS requirements for clinical quality and service. Accredited signifies that a plan met most of the HEDIS basic requirements, and denied indicates that the plan did not meet these requirements. For PPOs, the highest level of accreditation is full, which is comparable with excellent for HMOs and is granted for a 3-year period. PPOs that meet most but not all standards may be granted 1-year accreditation that is reviewed after a year to see if the plan qualifies for full accreditation.

Participation in HEDIS is voluntary, but more than 90% of managed care plans in the United States participated in 2006. Data used in HEDIS evaluations are collected by each participating managed care plan and analyzed by NCQA; plans may elect to have the HEDIS results verified by an independent auditor. HEDIS data and reports are available for purchase through the HEDIS Web site, and brief information about individual plans, including scores on the five dimensions and overall accreditation status, is available through the HEDIS Web site.

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