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APA is expressing serious concerns about a document that could be used by both the public and purchasers of health care to judge the quality of managed care plans.
The third edition of the Health Plan Employer Data and Information Set (HEDIS), currently in draft form, will be published by the National Committee for Quality Assurance (NCQA), the organization that accredits managed health care plans.
HEDIS is a 600-page document describing a set of standardized performance measures that can be used by consumers and purchasers to compare managed care plans.
Designed as a comprehensive assessment of the performance of managed care plans, with the imprimatur of a recognized accrediting body, the HEDIS has the power to influence the shape of managed care. The document's mental health performance standards, however, are seriously flawed, say APA leaders.
Mary Graham, director of APA's Office of Economic Affairs and Practice Management, told Psychiatric News that APA has been working with the NCQA to improve the document and has offered a number of its own performance measures by which to evaluate the success of managed care plans.
In a letter to the NCQA last month, APA President Harold Eist, M.D., outlined the Association's complaints about the HEDIS document.
Eist noted that the HEDIS document omits any assessment of inpatient fee structures or the comparability of fees with other local managed care organizations.
Eist also told NCQA that the document omits discussion of a host of mental illnesses: dysthymic disorders, panic disorders, generalized anxiety disorder, and dual diagnosis.
"There are no measures to address suicide or suicide attempt rates, absenteeism from or loss of jobs, or marital separation," Eist wrote. "There is also no consideration of factors leading to recidivism; if recidivism is used as a measure without understanding why it occurs, managed care companies will seek the healthiest populations and try to 'dump' chronic patients."
The performance measures for those conditions that the HEDIS document does address are highly questionable from a clinical standpoint, Eist noted in his letter.
Among the most egregious of the measures is one that calls for schizophrenia patients to be seen just four times a year, as a minimum standard.
"Concerning alcohol and chemical dependency," Eist wrote to NCQA, "measures need to check to see if Prime MD or similar standard tests for mental health or substance abuse are being used, and then address follow-up positive findings. In addition, screening should only be seen as effective if testing accompanies a verbal, face-to-face assessment. Simply having the patient fill out a questionnaire as to whether or not he or she is an alcoholic would be pointless."
Eist also highlighted the HEDIS document's measures assessing follow up after discharge from the hospital.
Remarkably, the document states that a patient should be followed up within 30 days of discharge from an acute psychiatric hospitalization.
Graham commented, "APA and several other associations have repeatedly requested that this measure be changed and will continue to protest this issue collaboratively."
She added that APA is protesting two other disturbing omissions in HEDIS: the failure to include psychiatrists in a list of substance abuse providers and the failure to address evaluation and management billing codes along with psychiatric codes.
More information about HEDIS or about APA's efforts to improve the document is available by contacting the Office of Economic Affairs and Practice Management at (202) 682-6200.
(Psychiatric News, October 18, 1996)