Collection of Health Service Effectiveness Data and Information (HEDIS)

HEDIS is a set of performance measures used to compare health plan performance and measure the quality of health plans. These steps were created by the National Committee for Quality Assurance (NCQA). About 90% of health plans use HEDIS as the standard for measuring their plan’s performance. The data is tracked year by year to measure health plan performance and thereby provide information about the population served.

The data collected is used to monitor general public health, evaluate treatment outcomes, etc., and data is collected through administrative, hybrid, and survey methods.

HEDIS Size Domains:

About 95 HEDIS procedures are categorized under the following six “domains of care”.

Treatment Effectiveness

  • Controlling High Blood Pressure
  • Caring for Older Adults
  • Hemoglobin A1c Control for Diabetic Patients
  • Blood Pressure Control For Diabetics
  • Eye Examination for Diabetics
  • Breast Cancer Screening
  • Colorectal Cancer Screening

Access/Availability of Care

  • Adult Access to Preventive/Ambulatory Health Services
  • Risk-Adjusted Utilization and Utilization.

Nursing Experience (CAHPS)

  • CAHPS Health Plan Survey 5.1H, Adult Version
  • Risk-Adjusted Utilization and Utilization

Risk-Adjusted Utilization and Utilization

  • Healthy Child Visits in the First 30 Months of Life
  • Child and Adolescent Health Care Visits

Health Plan Descriptive Information

  • Membership Language Diversity
  • Risk-Adjusted Utilization and Utilization

Measures Collected Using Electronic Clinical Data Systems

  • Child Immunization Status
  • Breast Cancer Screening
  • Depression Screening and Follow-up for Adolescents and Adult

How is data collected for HEDIS?

The health plan collects and reports performance data about certain services and types of care to the NCQA. The NCQA rates health insurance on a 90-plus measure.

HEDIS data is collected through three methods:

  1. Administrative data: Data were collected from office visits, hospitalizations, and pharmacy data
  2. Hybrid data: Is a combination of administrative data from claims and also from the patient’s medical record
  3. Survey data: This is data collected through a questionnaire survey of members.

Why is the HEDIS score important?

The HEDIS score is very important for health care planning. HEDIS scores help payers understand the quality of care their members receive for chronic and acute conditions. The better the score, the more effectively the payer competes with other payers in the market.

Benefits of HEDIS action:

  • This helps health plans assess the quality and variety of health care provided to applicants.
  • It determines how best to plan chronic disease management and preventive care.
  • The use of preventive screening measures helps improve patient outcomes and reduce health care costs
  • Quality interventions are based on closing gaps in care and expanding prevention services such as vaccinations, pap smears, mammograms, and treatment of hypertension or cholesterol.
  • Star ratings allow providers to measure the success of their upgrade initiatives

Effect of HEDIS on Reimbursement:

CMS directly links medical reimbursement to patient outcomes. As a result, health insurance providers face the challenge of bridging the coverage gap and improving quality. By focusing on quality results, members can maximize their profits and ultimately make better use of limited resources.

HEDIS is recognized as the highest standard of reimbursement by healthcare providers and payers. Health care plans take HEDIS testing and quality measurements seriously because they know that money is at stake. Leaders need to be more aware of the importance of continuously engaging organizations in all quality improvement activities.

Ultimately, CMS penalizes a health plan if it performs poorly for more than three years. HEDIS as a whole is changing companies’ understanding of the importance of measuring quality, a basic concept underlying performance-related quality initiatives.

Effects of HEDIS on gaps in care

HEDIS measures can help identify gaps in care for participants who have not been screened for breast cancer or who have not been vaccinated against HPV. This can affect your quality score. Improving Star and HEDIS performance requires closing the gap. This gap can be filled by reaching out to these participants through home testing kits, home health care, and screening visits.

Why is HEDIS important for providers?

  • Ensuring timely and appropriate care for their patients.
  • Help identify and address gaps in patient care.
  • As HEDIS rates increase, providers can gain maximum or additional revenue through pay-for-quality, value-based service, and pay-for-performance models.

Why is HEDIS important to payers?

  • HEDIS scores help health plans understand the quality of care provided to people with chronic and acute conditions.
  • Help identify gaps in health network performance and care delivery
  • Help improve patient outcomes and reduce care costs through preventive services
  • HEDIS identifies public health impacts such as heart disease, cancer, smoking, and asthma which provides useful data on health issues.
  • Treatment is provided to help identify and treat at-risk groups who have not completed immunizations, dental work, screening, etc.

NCQA Healthcare Plan Rating vs Medicare Star Rating:

The Center for Medicare and Medicaid Services (CMS) uses a five-star rating system to rate how well Medicare Advantage (MA) health plans (Parts C and D) and providers serve their members. The results of the assessment are based on plan implementation, quality of care provided, and customer service. Ratings range from 1 to 5 stars. 5 is the highest score for very good performance, and 1 is the lowest score for poor performance.

The NCQA Health Plan Rating (HPR) and Medicare Star Rating are used to assess health insurance quality and performance, and assess and report on plan performance. The purpose of the HPR and star rating is to provide a plan with metrics to assess its current operational status. This allows us to ensure the quality of our plans so consumers can choose a quality health plan that fits their needs.

HEDIS and Star ratings are important because they represent the effectiveness of patient care provided by the healthcare organization, and HEDIS and Star ratings decrease when there are gaps in care. Another reason HEDIS and Stars need to maintain high ratings is for replacement purposes. Health care organizations with lower ratings are not eligible for bonus payments and are subject to fines.