HEDIS is a standardized set of measures used by >90% of US health plans to measure performance in different areas of care and service.1
NCQA developed HEDIS as a means to1:
- Provide the managed care industry with a way to compare performance among plans
- Allow health plans a way to obtain information about specific areas that need improvement
- Assist consumers in selecting the health plan that best meets their needs
HEDIS measures are reviewed and updated on an annual basis. As of 2018, HEDIS consists of 94 measures across 7 domains of care that include preventive care services and chronic disease management.1,2
Description: Use of spirometry testing in assessment and diagnosis of COPD.3
Reporting: Assesses the percentage of adults aged ≥40 years with a new diagnosis of COPD or newly active COPD who receive spirometry testing to confirm the diagnosis.3
- Commercial insurance, Medicaid, and Medicare
This HEDIS measure assesses COPD exacerbations for adults 40 years and older who had appropriate treatment therapy to manage an exacerbation. A COPD exacerbation is defined as an inpatient or emergency department visit with a primary discharge diagnosis of COPD.5
The HEDIS 2018 Relative Resource Use (RRU) measures are suspended and will not be collected.4
RRU indicates how intensively health plans use physician visits, hospital stays, and other resources to care for members, compared with other plans.6
National Quality Forum (NQF) endeavors to promote and ensure patient protections and health care quality through measurement and public reporting. The federal government relies on NQF-defined measures or health care practices as the best, evidence-based approaches to improving care. In addition to the federal government, states and private-sector organizations use NQF’s endorsed measures, which must meet thorough criteria, to evaluate performance and share information with patients and their families.7
In 2012, the National Quality Forum (NQF) Board of Directors endorsed 19 measures related to pulmonary conditions and the critical care setting. The measures focus on treatment processes and outcomes for asthma, chronic obstructive pulmonary disease (COPD), and pneumonia.
2012 Pulmonary and Critical Care Measures for COPD8
- 0091: COPD: spirometry evaluation (AMA-PCPI)
- 0102: COPD: inhaled bronchodilator therapy (AMA-PCPI)
- 0577: Use of spirometry testing in the assessment and diagnosis of COPD (NCQA)
- 1825: COPD - management of poorly controlled COPD (ActiveHealth Management)
Additional pulmonary measures for COPD were added in 20139
- 0506: Hospital 30-day all-cause Risk-Standardized Readmission Rate (RSRR) following pneumonia hospitalization (CMS)
- 1891: Hospital 30-day all-cause Risk-Standardized Readmission Rate (RSRR) following chronic obstructive pulmonary disease (COPD) hospitalization (CMS)
The Affordable Care Act of 2010 established the Hospital Readmissions Reduction Program (HRRP) to publicly report 30-day readmission rates for patients with heart failure, heart attack, and pneumonia. Penalties for 30-day readmissions began in fiscal year (FY) 2012.10
In 2014, COPD was added to the list of conditions that trigger readmission penalties. Hospitals may be penalized up to 3% in Medicare reimbursements.10
MIPS, along with Advanced Alternative Payment Models (APMs), make up the Medicare Quality Payment Program, which is intended to improve Medicare by helping physicians focus on quality and patient health. The Quality Payment Program is for physicians and staff who are in an Advanced APM or bill more than $30,000 in Part B–allowed charges per year and provide care for more than 100 Medicare patients per year. MIPS provides physicians a performance‐based payment adjustment based on the data they submit.11
COPD-related quality measures under MIPS12:
- Prescribing long-acting inhaled bronchodilator therapy
- Performing spirometry evaluation
- Preventive care and screening
- Tobacco use—screening and cessation intervention
Under the Hospital Inpatient Quality Reporting Program, CMS collects quality data from hospitals paid under the Inpatient Prospective Payment System. The program aims to drive quality improvement through measurement and transparency by publicly displaying data to help consumers make better-informed decisions about their health care.13
Reporting is viewable on the Hospital Compare website14:
VBP is a CMS initiative that rewards acute-care hospitals with incentive payments for the quality of care provided to Medicare beneficiaries.15
Domains and weighted impact on incentives for 2018 are15:
- Safety: 25%
- Clinical Care: 25%
- Efficiency and Cost Reduction: 25%
- Patient and Caregiver-Centered Experience of Care/Care Coordination*: 25%
*Beginning with fiscal year 2019, CMS will rename the “Patient and Caregiver-Centered Experience of Care/Care Coordination” domain to “Person and Community Engagement.”15
CMS uses a Star Rating system to measure how well Medicare Advantage plans that include prescription drug coverage and stand-alone Part D plans perform in categories such as customer service, member complaints, pricing, and the array of services each offers. Ratings range from 1 to 5 stars, with 5 being the best.16,17
- Rewards accountable care organizations (ACOs) that promote accountability in patient care, coordinated services, and improved infrastructures to support improved patient outcomes and value of care18
- ACO participation is voluntary18
CMS and the Agency for Healthcare Research and Quality (AHRQ) developed the HCAHPS Survey, also known as Hospital CAHPS, to measure patients' perspectives on hospital care. It is administered to a random sample of patients continuously throughout the year. CMS publicly reports the results.19
- National Committee for Quality Assurance. HEDIS and quality compass. http://www.ncqa.org/HEDISQualityMeasurement/WhatisHEDIS.aspx. Accessed January 22, 2018.
- National Committee for Quality Assurance. HEDIS and performance measurement. http://www.ncqa.org/hedis-quality-measurement. Accessed January 22, 2018.
- National Committee for Quality Assurance. Use of spirometry testing in the assessment and diagnosis of COPD. http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2017-table-of-contents/spirometry. Accessed January 22, 2018.
- National Committee for Quality Assurance. Summary table of measures, product lines and changes. http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2017/HEDIS%202017%20Volume%202%20List%20of%20Measures.pdf?ver=2016-06-27-135433-350. Accessed January 22, 2018.
- National Committee for Quality Assurance. Pharmacotherapy management of COPD exacerbation. http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2017-table-of-contents/copd-exacerbation. Accessed January 22, 2018.
- National Committee for Quality Assurance. Data and reports. http://store.ncqa.org/index.php/data-and-reports.html. Accessed May 2, 2018.
- National Quality Forum. NQF’s history. https://www.qualityforum.org/about_nqf/history/. Accessed January 22, 2018.
- National Quality Forum. NQF endorses pulmonary and critical care measures. https://www.qualityforum.org/News_And_Resources/Press_Releases/2012/NQF_Endorses_Pulmonary_and_Critical_Care_Measures.aspx Accessed May 25, 2018.
- National Quality Forum. NQF endorses two additional pulmonary measures. https://www.qualityforum.org/News_And_Resources/Press_Releases/2013/NQF_Endorses_Two_Additional_Pulmonary_Measures.aspx. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. Quality payment program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-Quality-Payment-Program-webinar-slides-10-26-16.pdf. Accessed May 9, 2018.
- Eramo L. How to improve care, hit quality metrics for COPD patients. Medical Economics. http://www.medicaleconomics.com/medical-economics/news/how-improve-care-hit-quality-metrics-copd-patients. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. Hospital inpatient quality reporting program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html. Accessed January 22, 2018.
- Medicare.gov. Medicare hospital spending by claim type. https://www.medicare.gov/hospitalcompare/data/spending-per-hospital-patient.html. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. Hospital value-based purchasing. MLN booklet. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. 2017 star ratings. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-10-12.html. Accessed March 23, 2018.
- Centers for Medicare & Medicaid Services. Star ratings. https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx. Accessed March 23, 2018.
- Centers for Medicare & Medicaid Services. Shared savings program. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html. Accessed January 22, 2018.
- Centers for Medicare & Medicaid Services. Survey of patients’ experiences (HCAHPS). https://www.medicare.gov/HospitalCompare/Data/Overview.html. Accessed February 22, 2018.