reports

Strategies for assessing health plan performance on chronic diseases: selecting performance indicators and applying health-based risk adjustment

Hamilton, NJ, USA: Center for Health Care Strategies.

University of Maryland, Baltimore County, and Johns Hopkins Bloomberg School of Public Health, USA

As Medicaid managed care programs mature, states are looking to refine their methods of measuring and improving the performance of participating health plans. Along with other private and public health insurers, states are developing strategies to “pay for performance” and implement “value-based purchasing.” Many states are also shifting their focus to evaluate the care provided to enrollees with chronic diseases, as SSI eligibility groups are incorporated into managed care programs. The main goal of our project was to pilot an approach to measure health plan performance using administrative data that other states could adopt to evaluate the care provided to enrollees with chronic diseases. There are many benefits to developing a reliable source of administrative data for use in performance measurement. States can assess the care delivered to specific populations (e.g., adults with disabilities). If a state is interested in evaluating performance in an area that is not addressed by existing HEDIS® measures, the state may develop its own targeted measures. The analysis of administrative data provides states with the ability to examine data from several perspectives and “drill down” on unanticipated results. Overall, the use of administrative data provides states more flexibility in analysis.