Comparison of administrative-only versus administrative plus chart review data for reporting HEDIS hybrid measures.

OBJECTIVE: Health plans, medical groups, and commercial vendors are using administrative data to measure clinical performance at the plan or physician level. We compared results of using administrative claims data alone versus administrative data combined with chart review for selected Healthcare Effectiveness Data and Information Set (HEDIS) measures.

STUDY DESIGN: Cross-sectional comparison of health plan performance rates using different methods of data collection.

METHODS: We analyzed data reported by 283 commercial managed care plans in 2004 and 2006 for 15 HEDIS hybrid measures. Hybrid specifications included the use of administrative data supplemented with medical record review and required plans to report performance rates based on administrative data only and for administrative data supplemented with chart review. We calculated differences in rates and changes in quartile rankings of health plans between the 2 reported rates.

RESULTS: Performance rates using administrative data alone were substantially lower than rates using combined data (average difference of 20.4 percentage points). On average, more than half of the plans had different quartile rankings based on administrative-only rates versus combined data rates. Measures relying on laboratory claims or laboratory results had the largest discrepancies.

CONCLUSIONS: Currently available health plan administrative data alone do not appear to provide sufficiently complete results for ranking health plans on HEDIS quality-of-care measures with hybrid specifications. The results suggest that reporting of clinical performance measures using administrative data alone should include prior testing and reporting on the completeness of data, relative rates, and changes in rankings compared with the use of combined administrative data and chart review.