What Are The HEDIS Measures?

More than 90% of American health insurers use the Healthcare Effectiveness Data and Information Set (HEDIS) to evaluate provider quality across key service and care metrics. There are a total of 92 measurements in HEDIS, spread out across six different areas of healthcare. Health plan performance may now be compared on a level playing field thanks to the HEDIS audit because so many plans gather the data, and the measures are clearly defined.

The National Committee for Quality Assurance (NCQA) owns the trademark for HEDIS. Value-based healthcare has encouraged a culture of continual improvement in the delivery of patient care, with the ultimate aim of enhancing results without increasing expenditures. Most people who are shopping for a health insurance plan have this same goal in mind.

The HEDIS is by large the most extensively used healthcare performance evaluation tool and is utilized by the vast majority of health plans to evaluate their own quality and efficiency. Consumers can use HEDIS’s measuring standards to compare health plans’ performance and decide which one best suits their needs.

HEDIS Measurement Methods 

NCQA was hired by CMS to devise a plan for gauging SNPs’ ability to deliver high-quality medical services. The NCQA has developed the Healthcare Effectiveness Data and Information Set (HEDIS) metrics for SNPs.

To help buyers and users of health insurance more accurately compare health plans, HEDIS has developed a complete set of standardized performance measures. Many major public health concerns are connected to HEDIS Measures, including cancer, heart disease, smoking, asthma, and diabetes. HEDIS performance data can be used by SNPs to gauge how well their quality improvement programs are faring, keep tabs on their progress, and compare their results to those of other plans. Information can be used to spot problem areas and set attainable goals for development.

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In HEDIS 2016, SNPs reported the following indicators:

  •     Reducing Hypertension
  •     Achieving Board Certification
  •     Health Management for the Elderly
  •     Prescription Drugs After Discharge
  •     Plan All-Cause Readmissions
  •     Routine Testing for Colorectal Cancer
  •     Diagnostic and Evaluation Spirometry for Chronic Obstructive Pulmonary Disease
  •     Pharmacotherapy Management of COPD Exacerbation
  •     Utilization of Beta-Blockers following a Heart Attack
  •     Annual Monitoring for Patients on Persistent Medications
  •     Potentially Harmful Drug-Disease Interactions in the Elderly
  •     Use of High-Risk Medications in the Elderly
  •     Management of Osteoporosis in Women With a Fracture
  •     Depression Medication Administration Management
  •     Follow-Up After Hospitalization for Mental Illness

What Is The Purpose Of HEDIS Scores?

Health plans and providers must pay more attention to HEDIS scores as state and federal governments shift toward a quality-driven healthcare system. Healthcare purchasers at the state level often look at aggregated HEDIS rates to assess the effectiveness of health insurers’ efforts to increase members’ access to preventative care.

Prevention efforts at your office might also be rated based on individual doctors’ performance. E.g., the premiums you receive from physician incentive programs like Pay for Performance and Quality Bonus Funds are based on your practice’s HEDIS score.

How Are HEDIS Rates Determined?

Both administrative data and hybrid data can be used to determine HEDIS rates. Submittals of claims or encounter data to the health plan are examples of administrative data. A hybrid dataset includes both administrative data and a subset of data taken from medical records.

Moreover, Hybrid data necessitates the analysis of a subset of members’ medical records to extract information about care provided that was not captured by claims/encounter data. Medical record reviews can be avoided or reduced with timely and accurate claim/encounter data. Unbilled or incorrectly billed services are excluded from the total.

How Can You Improve Your HEDIS Scores?

  •     Include all service encounter information in your claim submissions.
  •     Verify that all billed services are accurately reflected in the accompanying medical records.
  •     Require billing (or encounter submission reporting) for all rendered services, regardless of contract status.
  •     Verify the timeliness and accuracy of all claim/encounter information.
  •     CPT II codes, which provide more information and help cut down on requests for patient records, should be considered.


Remember that HIPAA Privacy Rules (45 CFR 164.506) allow for the use and disclosure of protected health information (PHI) for treatment, payment, and health care operations without the member’s or patient’s knowledge or authorization. Staff and/or the vendor conducting the medical record review will be in possession of a valid HIPAA-compliant Business Associate Agreement.

HEDIS Objectives

NCQA developed the quality measures that make up HEDIS. Health plans use this information to gauge their effectiveness over time and better serve the people they serve. The metrics monitor the delivered care as opposed to only the prescribed treatment. Collecting this information will help find weak spots and fill them in, as well as:

  •     Check up on people’s health as a whole
  •     Analyze the results and methods of patient treatment
  •     Offer a metric for gauging success from the outside

Since certain HEDIS measures are retired while others are introduced, the total number of measures changes from year to year. Preventive services like screenings and immunizations, as well as the treatment of existing physical and mental health problems, are all included in the scope of what can be measured in healthcare, along with other factors like service accessibility, patient satisfaction, service efficiency, and healthcare resource consumption.

HEDIS’s Positive Impact

Quality of care for the most prevalent chronic and acute illness populations can be better understood by health plans using the metrics scores. HEDIS also has the following advantages:

  •     Offers a method for identifying areas where healthcare networks aren’t meeting patients’ needs in terms of performance and care delivery
  •     Promotes better health outcomes for patients and lower overall healthcare costs by emphasizing preventative measures.
  •     Cancer, heart disease, smoking, asthma, and diabetes are all public health concerns that affect huge patient populations, and our research may provide light on these challenges.
  •     Providers may be able to gauge the efficacy of quality assurance programs by analyzing measure rates.

 HEDIS Data Collection

Although most HEDIS data comes from billing claims, there are three other places where this information can be found. The analysis and reporting of this information is meant to depict the quality of clinical treatment that the plan’s members actually got.

Although medical billing claims are the primary source of information, certain measures may enable plans to survey members or gain access to medical records for information that is not included in claims. An administrative effort to reduce or do away with the necessity for a hybrid review is being made in an effort to increase the likelihood that providers will submit claims with proper coding that essentially captures all the data required by HEDIS. As for the data itself, it comes from three different places:

Administrative – Claims data from hospitals, doctors’ offices, surgical centers, and pharmacies are all part of the administrative measurements.

Hybrid – The hybrid model combines the member’s medical record data with administrative data gathered through claims if further information is needed to paint a complete picture of the treatment and services delivered.

Patient Survey – Consumer Assessment of Healthcare Providers and Systems (CAHPS) collects information about patients’ opinions of their health care providers based on their responses to a questionnaire.

HEDIS & Healthcare Providers

Gaining a better HEDIS score can help a health plan stand out from the crowd and win over a larger share of the market. Certain paperwork is needed for HEDIS measures, and certain parameters are factored into the score. All healthcare services performed must be clearly documented with proper claim codes in order to enhance these scores, which are then used to determine reimbursement.

Most healthcare providers make decisions based on how best to treat patients rather than on adherence to any particular set of guidelines. However, HEDIS scores can be lowered if quality and preventative care requirements are not met and no action is taken to do so. Providers may be able to enhance their income via pay-for-performance schemes when HEDIS scores rise.

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