What Do You Really Know About HEDIS?


As the drive towards improving clinical quality of care continues, the HEDIS guidelines have been used by more than 90 percent of America’s health plans to help them assess performance and strive for improvement. First created in 1991, the guidelines known as HEDIS (Healthcare Effectiveness Data and Information Set) have undergone several iterations to improve their effectiveness. During the 1990s, they were perceived as offering little insight of any value into healthcare practices. To improve this, they were continually modified based on areas of success as well as feedback from providers and patients.

Today, there are 91 HEDIS measures. This number varies from year to year as new measures are adopted while others are discontinued. These guidelines are created and maintained by the National Committee for Quality Assurance (NCQA), and they are used by the Centers for Medicare and Medicaid Services (CMS) to assess quality and performance across managed care organizations. They are meant to facilitate an objective comparison of quality of care across health plans. They assist in evaluating performance in terms of clinical quality and customer service. HEDIS results are also one of 3 components required for ACOs to be accredited by the NCQA.

As these guidelines are constantly being evaluated and improved, their effectiveness relies heavily on the quality of data they receive and the number of organizations that participate. While Medicare plans are required to report HEDIS data, commercial and Medicaid plans participate voluntarily or as required by varying state regulations. Despite the differing participation requirements, the guidelines themselves are specifically defined to enable an apples-to-apples comparison of health plans for all patients, whether they are on Medicaid or Medicare. To ensure these guidelines remain relevant and reflective of current conditions, the NCQA has a Committee on Performance Measurement, comprised of employers, consumers, health plan representatives, and others, who debate and decide collectively on the content of HEDIS.

Despite the annual updates to specific measures, there are five different domains of care that are the focus of the collected data, and they have remained unchanged for several years. Those domains of care are:

  • Effectiveness of Care
  • Access/Availability of Care
  • Experience of Care
  • Utilization and Relative Resource Use
  • Health Plan Descriptive Information

It is important to note that data collection for HEDIS conforms to all HIPPA requirements, and does not require patient consent or authorization. The data is collected three ways:

  1. Administrative Data – retrieved from claims databases
  2. Hybrid Data – retrieved from claims databases and medical record reviews
  3. Survey Data – retrieved from member and provider surveys

For providers and physicians, they can have an important impact on improving the HEDIS data collection process. Earlier this year, a NCQA research paper highlighted the importance of reporting complete and accurate data by highlighting some areas where the reporting has suffered. They discovered that fewer than half of Medicaid and Medicare plans reported complete or partially complete data on spoken language, affecting outcomes targeting specific demographics, and populations. One of the researchers, Judy Ng, observed that “without demographic data, it is not possible to know whether more vulnerable members are experiencing health gaps or disparities. Not knowing this information may have important implications for a plan’s healthcare costs.” The study pointed out that Medicaid reimburses for language service costs to their patients, and is hopeful that this information encourages more accurate and complete reporting.

With the effectiveness of HEDIS guidelines heavily dependent on provider participation, it is important to know some ways that we can help better facilitate the HEDIS process. Some ways to do this include:

  • Increasung member satisfaction by improving engagement with effective self-management
  • Providing appropriate care within designated timeframes
  • Using incentives to drive usage of self-management tools
  • Documenting all care in a patient’s medical record
  • Developing reimbursement strategies to increase provider collaboration
  • Creating a dashboard that highlights quality-related information about current care gaps, such as lab work, immunizations or screenings required
  • Accurately coding all claims and recording all care. This can minimize the number of additional records requested
  • Responding to any requests for additional information or records in a timely manner

In addition to the above recommendations, taking advantage of the rapid expansion of technology platforms can also improve HEDIS outcomes. Technology platforms can quickly verify data, automatically catalog it according to universal guidelines, and quickly share it between providers. This increased ability to accurately network can aid all ACOs in reaching goals and tracking progress on risk-sharing and other beneficial arrangements. It can also aid in integrating clinical and administrative workflows, providing for clearer and easier communication between a health plan and provider. As you use these platforms, allow all the care team members who have access to review and comment on the care plan and show more than claims data in the provider portal. Show as much as you can about lab results, prescriptions filled, and other pertinent data.

The benefits of HEDIS have been seen across a broad range of health issues, such as controlling high blood pressure, comprehensive diabetes care, and behavioral health and pharmacy. Behavioral health improvements include ensuring continuity of care, better medication management and adherence, and better timing for initiating substance abuse treatment. By following the behavioral data collected, gaps can be identified in network performance for patient follow-up patterns, and interventions implemented to help improve outcomes and reduce the cost of care.

In early 2017, a study focused on 10 states that together account for 43 percent of the Medicaid population found that their development of payment incentives and other quality improvement goals were formulated based on HEDIS data. Most of the 10 states have begun a drive towards accountable care, and in so doing are trying to better integrate social and health services as a key strategy. Some states have established performance goals for providers that are now built into plan performance measurement.

As the healthcare industry continues moving towards increasing value for both patients and providers, focus on the quality of care continues to be a driving factor. The impact of HEDIS data in driving the success of these efforts, as well as the importance of our participation in its accurate collection, should be seen by us all as a valuable tool in achieving our shared goals.

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