Health Plan & Provider Performance
What is HEDIS®?
Healthcare Effectiveness Data and Information Set is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance.
Using information from NCQA's accreditation program (a rigorous and expert evaluation of how managed care plans are organized and how they operate), in combination with HEDIS data provides the most complete view of Health Plan quality available to guide choice among competing Health Plans. HEDIS provides purchasers and consumers with an unprecedented ability to evaluate the quality of different health plans along a variety of important dimensions and to make their plan decisions based on demonstrated value rather than simply on cost.
If you'd like to learn more about HEDIS, follow this link to visit the NCQA Web site.
What is QARR?
Quality Assurance Reporting Requirements was developed by the New York State Department of Health (NYSDOH) to enable consumers to evaluate the quality of health care services provided by managed care plans throughout New York state. Using QARR, you can determine how well a Health Plan performed in the areas of provider network, child and adolescent health, women's health, adults living with illness, behavioral health, and access and service.
QARR measures are largely adopted from the National Committee for Quality Assurance's (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) with the New York state-specific measures added to address public health issues of particular importance in New York.
If you’d like to learn more about QARR and see performance of Health Plans in New York State, follow this link to visit the New York state DOH Web site.
What is CAHPS®?
The term CAHPS refers to a comprehensive and evolving family of surveys that ask consumers and patients to evaluate the interpersonal aspects of health care. CAHPS initially stood for the Consumer Assessment of Health Plans Surveys, but as the products have evolved beyond Health Plans, CAHPS now stands for Consumer Assessment of Health Providers and Systems. CAHPS surveys probe those aspects of care for which consumers and patients are the best or only source of information and those aspects of care that consumers and patients have identified as being important.
Items from the CAHPS survey are used to calculate a set of six composite scores and four overall ratings that are then reported by Health Plans, and are used by NCQA for accreditation processes and report cards. Each composite score is made up of plan level aggregations of member responses to two or more CAHPS questions. The six composite scores measured are: Getting Needed Care, Getting Care Quickly, How Well Doctors Communicate, Courteousness of Office Staff, Customer Service and Claims Processing. The four overall ratings questions ask members to rate their personal doctor, the specialist they have seen in the last 12 months, the health care they have received in the last 12 months and their Health Plan.
NCQA and the Centers for Medicare & Medicaid Services conduct CAHPS surveys annually for managed care members.
For more information on CAHPS, follow this link to visit the CAHPS Web site.
There are a number of measures of quality at the individual physician level. In the future, summaries of this data will be available for public view. Profiles, where they exist, include a number of clinical and resource measures related to acute and chronic care and patient satisfaction. Medical record reviews are performed each year on a sample of Health Plan physicians, measuring adherence to a set of standards. Member complaints and potential quality concerns are evaluated for all physicians and trends are tracked.
There are several tools available to compare hospitals. You are encouraged to discuss this information with your physician as you make health care decisions.
Our network providers drive overall quality and cost improvements through performance improvement tools. Controlling the cost of health care in our communities is a result of the significant collaboration between our providers and Excellus BlueCross BlueShield to improve efficiency and effectiveness.
Excellus BCBS is committed to strengthening network provider performance. We have a dedicated Provider Performance Improvement (PPI) team that works to identify ways in which collaboration can help increase accountability for the quality and affordability of care delivered to the community.
First in the state in their development, these programs can be used by regional leadership to support collaborative activities and build significant relationships. Joint planning occurs to determine which program offers the best fit with a hospital's strategy to improve overall quality and cost. The health plan provides supportive funding to providers when they join a collaborative; the amount varies by program. Since program inception, about 90% of network hospitals have participated in at least one program.
Hospital Performance Incentive Program (HPIP) and Small Hospital Incentive Program (SHIP)
This pay-for-performance program is rolled out as hospital contracts open for negotiation. The Plan, Do, Study, Act (PDSA) project driven incentive program utilizes all payer data, rather than just our own, for measurement and applies it to all lines of business contracted with the hospital. The program exists best as a component of multi-year agreements and models a prospective payment methodology. Using nationally recognized measures, annual performance targets are established to define expectations for improved performance. If the hospital achieves the target outcomes agreed upon jointly, the negotiated extra payment for quality applies the following year.
Hospital Quality Improvement Programs (HQIP)
The American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) is a nationally validated, risk-adjusted, outcomes-based program that measures and improves the quality of surgical care, with the goal of improving surgical outcomes and reducing the costs associated with them. Eighteen hospitals across upstate New York are currently participating. Since the program's inception, the UNYSQI participants have made notable improvements in surgical care. Visit http://www.unysqi.org/ for more information and hospital participants.
Excellus BCBS recognizes hospitals that have stepped forward to participate in our Hospital Quality Improvement Program as a result of their ongoing commitment to quality health care!
Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_8830_C.
This page last updated 10-01-2022.