Innovative Application of HEDIS Measures Using All Payer Claims Databases: Use of a Combined Effective and Preventive Care Score

In recent years, several states have established all-payer claims databases (APCDs) to collect health care claims data from all insurers across an entire state. These databases provide a rich source of data for analyzing utilization, cost, and quality of health care and for evaluating the effectiveness of delivery system reforms to reduce cost and improve quality. In particular, APCDs can be used to evaluate variation in preventive and effective care across populations using NCQA HEDIS specifications.

For this study, APCDs were used to assess variation in care across geographic areas and other sub-populations in Vermont, New Hampshire, and Maine. Using 13 different HEDIS measures, an overall composite measure of effective and preventive care was developed. The rationale for measure selection and method to construct the composite measure is presented. Benefits, pitfalls, and solutions to applying HEDIS measurement to APCD claims data are discussed.

Based on application of the composite measure to statewide APCD for the commercial insured population, recommended care was not received 3 in 10 times. Rates of variation between subpopulations will be presented and discussed. Across population groups, positive associations between increased rate of primary care utilization and likelihood of receiving effective care were found. There was some evidence that higher rates of effective care and preventive care were associated with lower rates of total per member per month costs.