What is HEDIS?
(Healthcare Effectiveness Data and Information Set)
Value-based healthcare has influenced a culture of continuous improvement in the provision of patient care with an overarching goal of improving outcomes without additional, or unnecessary, costs. This goal coincides with most consumers when choosing a health plan.
Most health plans measure their quality and performance with the Healthcare Effectiveness Data and Information Set (HEDIS), one of the most widely used healthcare performance measurement tools. HEDIS provides consumers with a set of measurement standards to compare health plan performance to help select their optimal healthcare coverage.
Goals of HEDIS
HEDIS consists of quality measures created by the National Committee for Quality Assurance (NCQA). This data is tracked from year-to-year to measure health plan performance and provides valuable information about the patient populations served. The measures track the actual care received, and not just what was ordered. The data collected is intended to identify opportunities for improvement and to:
- Monitor the health of the general population
- Evaluate patient treatment outcomes and procedures
- Provide an external performance measurement
The number of HEDIS measures vary from year to year as new measures are added and some are retired. Measures cover aspects of healthcare including preventative care, such as screenings and immunizations, management of physical and mental health conditions, access and availability of care, patient experience, healthcare utilization, and resource use.
Benefits of HEDIS
The scores on measures can assist health care plans to understand the quality of care provided to their members in the most common chronic and acute illness populations. Other benefits of HEDIS include that it:
- Provides a way to discover gaps in healthcare network performance and the provision of care
- Works to improve patient outcomes and decrease the cost of care through preventative services
- May provide beneficial data regarding public health issues affecting large patient populations such as cancer, heart disease, smoking, asthma, and diabetes
- Measure rates may enable providers to monitor the success of quality improvement initiatives
HEDIS Data Collection
There are three sources for HEDIS data collection, although the majority of data is derived from billing claims. This data is analyzed and reported to reflect the clinical care received by the plan’s membership.
Although billing claims are the major source for data collection, specific measures may allow plans to survey members or access medical records for data that are not readily available in claims. The goal is to encourage providers to submit claims with accurate coding that captures all the data required by HEDIS through administrative efforts to decrease or eliminate, the need for a hybrid review. The three sources for data collection include:
- Administrative – Measures claims for hospitalizations, medical office visits, procedures, and pharmacy data
- Hybrid – If additional data is necessary to provide a better overall picture of the care and services provided, then administrative data obtained from claims is combined with the member’s medical record information
- Patient Survey – Focuses on the patient experience with the provider through data collected with a survey conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS), which gains input about the patient’s satisfaction with their health care delivery
HEDIS and Healthcare Providers
To compete in markets, achieving higher HEDIS scores is helpful to encourage more consumers to choose a specific health plan. HEDIS measures have certain documentation requirements and specific parameters that contribute to the score. These scores are improved through the provision of timely and appropriate patient care with clear, accurate documentation in the claim codes of all the healthcare services provided.
Most providers choose healthcare to serve their patients, not specific standards. But a lack of awareness and not instituting efforts to meet quality and preventative care requirements can negatively impact HEDIS scores. As HEDIS rates increase, there may be a potential for the provider to earn additional revenue through pay-for-performance models.
Improving HEDIS Scores
One common problem that impacts HEDIS scores is a lack of, or inaccurate, claim coding and documentation. The utilization of electronic healthcare records (EHR) can assist in reducing obstacles for maintaining accurate information by providing reminders for patient care needs, encouraging adherence to standardized templates, and by having documentation follow the care of the patient. Other ways the provider can work to improve their HEDIS score include to:
- Understand measure requirements
- Focus on preventative screening
- Respond timely to requests for medical records for review
- Adhere to specified timelines
- Ensure claims are coded accurately
- Know before the patient arrives what their care gaps may be so they can be addressed during the visit
- Provide clear discharge instructions, and schedule the next appointment before the patient leaves, to decrease noncompliance
- Educate, and collaborate, with the patient on goals for their care
As healthcare continues to move toward more value-based care, the focus remains on the quality of healthcare delivered and working toward better patient outcomes. HEDIS provides consumers with the ability to compare health plans to ensure that the one they choose will provide optimal care for their healthcare needs.
- HEDIS and Performance Measurement
- How Payers Can Improve HEDIS Quality Measure Performance
- Top 3 Ways to Meet HEDIS Quality MEasures, Improve Performance
- What is HEDIS and What Does it Mean to You?
Maureen Bonatch MSN, RN is a freelance healthcare writer specializing in leadership, careers, and mental health and wellness. She is also a fiction author. She is the owner of CharmedType.com and MaureenBonatch.com