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Health plan quality measures typically reported to consumers are a combination of clinical quality (doing the right thing, at the right time, to the right patient) and the health plan member’ experiences with care. Here are some examples of health plan quality measures that research evidence and practical experience suggest are appropriate for reporting to consumers.

Patient Safety Measures

• The percentage of health plan members on persistent prescription medications who are monitored.
• The percentage of elderly health plan members diagnosed with certain chronic conditions receiving contraindicated medications.

Effectiveness Measures

• The percentage of health plan members receiving recommended care (i.e., a treatment or an assessment) for a specific health condition. Most of today’s measures address diabetes, cardiovascular disease, musculoskeletal conditions, respiratory conditions, or behavioral health.
• The percentage of health plan members receiving preventive care such as immunizations, flu shots, smoking cessation counseling, and obesity counseling.
• The percentage of health plan members receiving screenings for cancers, lead, glaucoma, Chlamydia, and obesity.

Patient-Centeredness Measures

• Health plan members’ reports on the care and service they received from the health plan and the doctors and nurses associated with the plan.
• Rates of health plan member complaints or appeals over coverage decisions.

Timeliness Measures

• The percentage of health plan members who had an annual visit with a primary care or dental practitioner.
• The percentage of pregnant women receiving prenatal care during the first trimester or postpartum care after delivery.

Descriptive Measures

Descriptive measures can convey the health plan’s capacity for providing high-quality care and service. Examples include:

• Percentage of board-certified physicians.
• Status of health plan accreditation.
• Number of health plan members.

The availability of health plan quality measures varies depending upon the plan type [i.e., Health Maintenance Organizations (HMOs), Point-of-Service (POS) plans, or Preferred Provider Organizations (PPOs)].

Also in "Measures of Health Plan Quality"

• Examples of Health Plan Quality Measures for Consumers
• Major Health Plan Measurement Sets
• Databases Used for Health Plan Quality Measures