Stand Tall Amongst Competition: Key to Success in Medicaid is Clear

Health plans diligently strive to be the best and first choice for delivering excellent healthcare services.  Many seek accreditation with various organizations such as the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), and, most recently, the Malcolm Baldrige National Quality Award (MBNQA) as confirmation they provide their members with the utmost quality healthcare services.

Currently, the managed healthcare industry widely uses the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) to measure performance.  Over 90% of America’s health plans use HEDIS, and over 500 health plans use CAHPS, to measure performance and monitor how well consumers are satisfied with the care and service they receive.

The HEDIS tool measures performance across five dimensions related to care and service:  Effectiveness of Care; Access/Availability of Care Member; Experience of Care Member; Utilization and Relative Resource Use; and Health Plan Descriptive Information.  There are 81 specific measures for which the plan must collect data in order to be compared with other health plans.  A feature of HEDIS is the tool allows for the cross-comparison between health plans to be relatively equal, on an “apples-to-apples” basis.  Subsequently, health plans are also encouraged to use Quality Compass, the largest database of comparative health plan performance information to conduct competitor analysis, examine quality improvement, and benchmark plan performance.  In turn, it can be an effective tool in developing a more focused quality improvement plan.

While member experience may often correlate to member satisfaction, it is not always so.  Member satisfaction can be influenced by a number of factors in and outside the control of the health plan.  In turn, members may have similar experiences but different expectations and report having different levels of satisfaction.  The CAHPS survey is an initiative of the U.S. Department of Health and Human Services (HHS) for Healthcare Research and Quality and refers to a family of standardized and scientific surveys that ask consumers and members to report on their experiences with certain aspects of care such as: Getting Needed Care; Getting Care Quickly; How Well Doctors Communicate; Customer Service; Claims Processing; Rating Personal Doctor; Rating Specialist; Rating Health Care; and Rating Health Plan.  Health plans and providers can use CAHPS questions about specific aspects of care to identify areas of care that are strong as well as those that need improvement. Asking respondents to provide both ratings and reports about their care experiences enables survey users to learn how specific experiences influence general ratings.

Overall, it’s important to recognize that health plans are rigorously competing for each and every healthcare dollar.  Quality, more than ever, is the key to stand tall amongst the competition.





CMS is poised to release in the coming weeks what stakeholders and advocates are calling an “epic rule” that will completely overhaul the Medicaid managed care marketplace. John Gorman discusses here >>

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