Do HEDIS measures reflect cost-effective practices? Original Research Article

Purpose Whether the Health Plan Employer Data and Information Set (HEDIS) performance measures for managed care plans encourage a cost-effective use of society’s resources has not been quantified. Our study objectives were to examine the cost-effectiveness evidence for the clinical practices underlying HEDIS 2000 measures and to develop a list of practices not reflected in HEDIS that have evidence of cost effectiveness. Data sources Two databases of economic evaluations (Harvard School of Public Health Cost-Utility Registry and the Health Economics Evaluation Database) and two published lists of cost-effectiveness ratios in health and medicine. Study selection For each of the 15 “effectiveness of care” measures in HEDIS 2000, we searched the data through 1998 for cost-effectiveness ratios of similar interventions and target populations. We also searched for important interventions with evidence of cost-effectiveness (<$20,000 per life-year [LY] or quality-adjusted life year [QALY] gained), which are not included in HEDIS. All ratios were standardized to 1998 dollars. The data were collected and analyzed during fall 2000 to summer 2001. Data extraction Cost-effectiveness ratios reporting outcomes in terms of cost/LY or cost/QALY gained were included if they matched the intervention and population covered by the HEDIS measure. Data synthesis Evidence was available for 11 of the 15 HEDIS measures. Cost-effectiveness ranges from cost saving to $660,000/LY gained. There are numerous non-HEDIS interventions with some evidence of cost effectiveness, particularly interventions to promote healthy behaviors. Conclusions HEDIS measures generally reflect cost-effective practices; however, in a number of cases, practices may not be cost effective for certain subgroups. Data quality and availability as well as study perspective remain key challenges in judging cost effectiveness. Opportunities exist to refine existing measures and to develop additional measures, which may promote a more efficient use of societal resources, although more research is needed on whether these measures would also satisfy other desirable attributes of HEDIS.