Improving quality with HEDIS: Why it's vital for providers, payers, and patients

Improving quality with HEDIS: Why it's vital for providers, payers, and patients
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Working with a healthcare partner for HEDIS data collection helps you improve efficiency and patient quality of care.

What is HEDIS, and what does it measure?

HEDIS (Healthcare Effectiveness Data and Information Set) is a set of performance measures used to evaluate healthcare quality in the U.S. It’s vital for improving healthcare quality and helping patients get the best care — and a requirement for health plans under the Centers for Medicare & Medicaid (CMS) and the National Committee for Quality Assurance (NCQA)

Over 200 million people participate in health plans that report HEDIS results, making it one of healthcare’s most essential tools for improving patient care. Additionally, it’s critical for health plan accreditation, Star Ratings, and regulatory compliance.


What are the six domains of HEDIS?

Developed by the NCQA, HEDIS includes more than 30 measures across six domains of healthcare. 

The six domains include: 

  1. Effectiveness of care: Evaluates patients' quality of care, including preventive care like mammogram screenings, chronic disease management, and other aspects of care.

  2. Access/availability of care: Measures the accessibility and availability of healthcare services, including timely access to care, availability of appointments, and other factors affecting access to care.

  3. Experience of care: Assesses the quality of patient care and identifies areas for improvement, including provider communication, customer service, coordination of care, and a patient’s overall satisfaction with their health plan. 

  4. Utilization and risk-adjusted utilization: Evaluates if patients use healthcare services appropriately and how resources are used, including measuring the use of preventive services, high-cost services, and other factors affecting utilization.

  5. Health plan descriptive information: Measures health plans' structure and operation, such as provider networks and member demographics.

  6. Measures reported using electronic clinical data systems: Calculates healthcare services' results, including patient satisfaction, health status, and other factors affecting health outcomes.


How is HEDIS data collected? 

HEDIS data is collected through administrative data and medical record reviews. However, the specific methods for data collection can vary depending on the evaluated measure (e.g., claims data or pharmacy records). For example, medication management measures use pharmacy data to determine whether patients receive appropriate medications and dosages.

Other measures require medical record reviews to gather more detailed information about patient care. For example, preventive care measures may need medical record reviews to determine whether patients have received recommended immunizations.

NCQA provides detailed guidance on collecting and reporting HEDIS data, including specific requirements for data collection, sample sizes, and data validation. The data is gathered annually by organizations participating in the HEDIS reporting process, but people can enroll year-round. 


Why is HEDIS important? 

HEDIS provides a standardized way to measure the quality of healthcare provided to patients, allowing providers to identify areas of improvement and track progress over time. 

For providers, HEDIS measures can provide valuable feedback on the quality of care they provide, allowing them to make improvements and demonstrate their commitment to patients. This can improve post-visit care, such as ensuring a patient returns for a follow-up. 

For payers of health plans, HEDIS measures can help them evaluate healthcare providers' performance and decide which providers to include in their networks.


Five-star quality rating system

The Centers for Medicare and Medicaid Services uses the Five-Star Quality Rating System to evaluate healthcare plans based on a scale of 1 to 5 stars, with five stars indicating the highest level of quality.

HEDIS measures are a critical component of this rating system as one of several quality measures used to calculate the star ratings for these plans. The measures evaluate a plan's performance, including clinical care, access to care, and patient experience. Health plans that perform well can receive higher star ratings, which can be important for consumers when choosing a plan. 


What are the benefits of working with a healthcare partner for data collection?

Working with a healthcare partner for HEDIS data collection can help you improve the quality of care, reduce costs, and improve efficiency.

Some of these benefits include:

  • Allowing staff to focus on healthcare: Working with a healthcare partner can help with administrative tasks associated with data collection, such as sample selection, medical record retrieval, and data validation — allowing staff members to focus more on patient care.

  • Accessing guidance from data professionals: A healthcare partner is familiar with the requirements and guidelines for data collection, and can provide advice and support that data collection is consistent and standardized.

  • Gaining insight into services and areas to improve star ratings: A healthcare partner can perform regular audits and checks to ensure data is accurate and meets the required standards, so you can ensure your data is accurate and complete. 

  • Identifying trends: A healthcare partner can help identify trends, compare your performance to industry benchmarks, and provide recommendations for improvement.


Our HEDIS services

As a healthcare partner, ADEC Innovations provides services to help healthcare providers and payers optimize their performance on HEDIS measures and improve their quality of care. Our services include:

  • Identifying the measures required for medical record review and developing a data collection plan.

  • Collecting medical record data for the measures, including medical records and claims data.

  • Analyzing medical data to ensure it meets the requirements and identifying improvement areas.

  • Maintaining medical record data, ensuring it’s up-to-date and accurate, and supporting future processes and business decisions.

Our team can help you meet your healthcare requirements. Contact us today to learn how your members can benefit from our tools.

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