Measuring and reporting managed care performance: lessons learned and new initiatives

Area of Science:

• Healthcare Management
• Health Services Research
• Quality Improvement

Background:

• Performance measurement in US healthcare has significantly expanded from hospital settings.
• The growth of managed care and large administrative databases fuels interest in broader performance assessments.
• Public reporting of health plan and physician performance is increasing.

Purpose of the Study:

• To summarize recent developments in healthcare performance measurement within managed care.
• To discuss the Health Plan Employer Data and Information Set (HEDIS) and its application in report card projects.
• To explore emerging initiatives in physician profiling and outcomes reporting.

Main Methods:

• Review of performance measurement initiatives in US managed care.
• Description of the Health Plan Employer Data and Information Set (HEDIS) and its auditing.
• Discussion of physician profiling and outcomes reporting methodologies.

Main Results:

• Increased focus on performance measurement for health maintenance organizations and individual physicians.
• HEDIS data and its external auditing present specific challenges and lessons learned.
• Physician profiling and outcomes reporting are emerging as key areas of performance assessment.

Conclusions:

• Performance measurement is a dynamic field in US healthcare, extending into managed care and physician practices.
• Effective implementation of tools like HEDIS requires careful consideration of auditing processes.
• Future directions include enhanced physician profiling and outcomes-based reporting for quality improvement.