Skip to main content

Program Performance

Process and Outcome Measures

The following process and outcome measures are collected and reported with various frequencies from monthly to annually depending on the nature of the indicator, what is being measured and the availability of data.

These measures are collected, analyzed and reported by a collaborative group of quality and analytic professionals with knowledge in data management, analysis and clinical expertise. Benchmarks and/or goals are developed for all measures. For those publicly reported measures, national and regional benchmarks are utilized and then goals set based on differences between the plan's performance and benchmarks. For internal developed measures or measures with no benchmarks available, goals are set based on plan's trends and objectives.

Results are presented at various committees (see section 4 Organizational Structure) and shared with members and providers as appropriate via newsletter and the member and provider portal.

Healthcare Effectiveness Data & Information Set (HEDIS)®

Annually, Horizon participates in Healthcare Effectiveness Data & Information Set (HEDIS)® reporting for its Combined HMO/POS/DA, PPO, and Marketplace products. Data is collected, analyzed, evaluated, and compared to regional and national benchmarks. The results are compared against national benchmarks, and Horizon's Quality Management team uses the information to identify opportunities for improvement.

HEDIS® is a set of standardized performance measures designed to ensure that consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS® are related to many significant public health issues such as cancer, heart disease, opioid use, asthma and diabetes. HEDIS® is sponsored, supported and maintained by the National Committee for Quality Assurance (NCQA).

Horizon's staff collects, consolidates and reports HEDIS hybrid and administrative rates. It contracts with an NCQA certified software vendor, Inovalon, to report HEDIS data through the use of Inovalon's QSI tool. Relevant data are extracted by experienced trained nurses using Inovalon's QSHR data collection tool.

Upon completion of all relevant chart audits, Inovalon has measure-specific logic to automatically consolidate data from multiple chart reviews and administrative data to determine a member's compliancy to a measure or whether the member should be excluded from the denominator.

To ensure all measures are accurately reported, an NCQA certified auditor reviews data files and documentation. The Quality Management team then reviews and finalizes the interactive survey tools prior to submission to NCQA. HEDIS rates are reported via the IDSS (Interactive Data Survey System) to NCQA and/or Centers for Medicare and Medicaid Services (CMS).

Consumer Assessment of Healthcare Providers and Systems (CAHPS)®

The CAHPS® survey is a measurement tool, used for all products which ask members to report and evaluate their experiences with health care in areas of customer service, access to care, claims processing and provider interactions. The products for CAHPS® surveys are grouped as HMO/POS, and PPO. The Direct Access product is considered a POS product and is included in one sample under the HMO/POS. An NCQA certified vendor conducts the survey.

Quality Rating System (QRS)

As part of the Quality Health Plan program for Marketplace products, Horizon participates annually in CMS' Quality Rating System (QRS). CMS developed the Quality Rating System to: inform consumer selection of Qualified Health Plans (QHPs) offered through a Health Insurance Marketplace (Marketplace), facilitate regulatory oversight of QHPs, and provide actionable information to QHPs for performance improvement. CMS also developed the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey), which yields consumer experience data that will be used in the QRS.

CMS has defined a set of QRS measures that consist of clinical measures and survey measures, the latter of which are based on a subset of QHP Enrollee Survey questions. The measures address areas of clinical quality management; enrollee experience; and plan efficiency, affordability, and management.

Using a standardized methodology, CMS calculates QHP scores and ratings based on the QRS clinical and survey measure data that QHP issuers submit for each of their products in the Marketplace. The methodology includes rules for combining and scoring QRS measures through a hierarchical structure, resulting in one global score. Based on the scores, CMS will assign each QHP a star rating using a 1 to 5 scale.

Public reporting of quality rating information will be displayed on Marketplace websites to allow consumers to compare plans.

Quality Improvement Systems (QIS)

Horizon participates in Quality Improvement Systems (QIS) initiatives for Marketplace members.

The CMS QIS statutory requirements call for QHP issuer use of market-based incentives to improve the quality and value of health care and services specifically for Marketplace enrollees. CMS specifies two types of market-based incentives that issuers may include in their quality improvement strategies: (1) increased reimbursement or (2) other incentives.

Horizon reports annually to CMS on the status of their Marketplace QIS initiatives.

Other Process/Outcome Measures

Examples of other measures that would be utilized to assess effectiveness of the quality of care and services provided to Horizon members include the following:

  • Member satisfaction with Chronic Care Program
  • Analysis of the impact of population health management activities on member care process or outcome, utilization and member experience
  • Member experience with Horizon Behavioral Health
  • Analysis of member complaints
  • Timeliness of UM decisions and notifications
  • Average Length of Stay (ALOS)
  • Readmission rate 30 and 60 days
  • Emergency Room (ER)/1,000 members
  • Admits/1,000 members
  • Average number of primary and specialty visits per member per year
  • Access to primary care, specialty care and behavioral health services
  • Adequacy of primary care, specialty care and behavioral health network
  • Drug treatment adherence (percent of members refilling specific prescriptions)
  • Average Speed of Answer (ASA)/Call abandonment rate for Customer Service phone unit
  • Timeliness of member appeals
  • Percent member appeals upheld