Identifying and Improving Your HEDIS® Score

Blog Posts  |  22 November 2022

Written by: Cheryl Reifsnyder, PhD

The National Committee for Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality, developed the measurement system known as the Healthcare Effectiveness Data and Information Set, or HEDIS® measures, under contract to the Centers for Medicare and Medicaid Services (CMS). Under continuing contract to the CMS, each year the NCQA:

Currently, there are more than 90 different HEDIS measures in use, for collecting data in 6 specific domains of care: effectiveness of care; availability of care; experience of care; utilization and risk-adjusted utilization; health plan descriptive information; and measures reported using electronic clinical data systems. Some of the common HEDIS quality measures include:

  • Immunizations
  • Cancer screenings
  • Diabetes care management
  • Medication adherence
  • High blood pressure management

How HEDIS measures are used

HEDIS measures have become one of the most widely used performance improvement tools in the healthcare industry today, with over 200 million people enrolled in plans that report HEDIS numbers. More than 90% of U.S. health plans use HEDIS measures to report quality results.

Today, HEDIS measures are used to evaluate the quality of care provided through different health plans, thereby providing consumers and purchasers with the information needed to reliably compare the performance of those health plans. At the same time, they are also used to pinpoint opportunities for providers and medical practices to improve; to track the success of initiatives implemented for the purpose of improving quality of care; and to keep track of health plans’ overall improvement.

Improving HEDIS scores has a significant role in the healthcare industry because doing so is directly related to closing gaps in care as well as decreasing the use of expensive acute care by encouraging the implementation of preventive services.

Payers face numerous challenges when trying to improve HEDIS measures

Success in today’s evolving payment landscape requires healthcare payers to work to improve HEDIS scores for those in their healthcare networks. However, health insurance companies have faced numerous challenges in their attempts to improve their HEDIS measure performance. For instance, HEDIS measures are used to evaluate the quality of healthcare plans, although individual plans are contracting with doctors, medical practices, hospitals, imaging centers, and so on—and those are the locations where HEDIS measures are actually determined.

Another challenge payers face is the administrative burden that comes from handling an increasing volume of quality of care data from their network members. In recent years, the healthcare industry has had to deal with a significant increase in the amount of healthcare quality data available. The process of collecting and reporting this volume of quality data has decreased overall levels of provider satisfaction and also led to higher levels of physician burnout. However, achieving higher HEDIS scores requires providers to have accurate clinical documentation for their patients. Checking off completed versus still-needed patient services is also helpful in identifying gaps in care.

Payers are further challenged by the fact that many of the providers they work with have failed to adopt healthcare IT that will help track and influence HEDIS scores. When providers fail to adopt the necessary healthcare IT, it becomes much more difficult to collect the data required for calculating HEDIS quality measures.

Similarly, payers are challenged by working with numerous providers who persist in providing low rates of preventive screenings for their patients. If providers in the network fail to improve their rates of preventive screenings, this will have a direct impact on their HEDIS scores, keeping them from improving. Despite this, the National Cancer Institute and Centers for Disease Control and Prevention have found that preventive screenings for breast, colorectal, and cervical cancer were all failing to meet the benchmarks required by Healthy People 2020, a program that tracks data in a variety of health areas with the goal of promoting good health and quality of life for all social groups. Rates of cervical cancer screening have decreased in recent years.

Veradigm® Quality Analytics(formerly Qualit8)

Health plans that are attempting to improve their HEDIS scores need a data-driven solution to help them identify targets for closing quality gaps and improving quality scores. Veradigm Quality Analytics does exactly that.

Quality Analytics uses advanced analytics and precision targeting to identify and prioritize quality gaps in your healthcare network, and then pinpoint those most worth your attention. Quality Analytics identifies gaps in:

  • Star Ratings
  • Quality Rating Systems
  • Pharmacy Quality Alliance quality measures
  • State-specific quality measures
  • And more

Veradigm Quality Analytics also evaluates plan member data against each set of quality measures.

On top of that, Quality Analytics received the NCQA Measure Certification™ for HEDIS® MY2022 from the NCQA for the third year running. This certification is the most rigorous assessment in the industry. Earning it demonstrates Quality Analytics’s devotion to delivering both value and administrative efficiency to their health plan customers.

The combination of Quality Analytics Quality Improvement Analytics and the NCQA-certified HEDIS Measurement Certification Program provides health plans with the ability to optimize gap closure workflows and, at the same time, improve HEDIS measure performance. Once Quality Analytics has identified health plan members who could benefit from intervention, Quality Analytics evaluates those members’ histories and their patterns of behavior to help with prioritization. These tools enable payers to achieve maximum efficiency.

Contact us to learn more about how Quality Analytics could help optimize gap closure workflows and improve HEDIS quality measures in your practice and, as a result, help you to improve care for your patients.

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