A quick guide to HEDIS measures and measurement-based care

What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is a government-sponsored measurement tool that most US insurance companies rely on to gauge how their insured patients are being cared for.

These insurance companies receive a HEDIS score from the government. If their scores exceed a certain threshold, insurers and providers alike may receive Medicare financial incentives and reimbursement.

HEDIS was created and is overseen and updated by the National Committee for Quality Assurance (NCQA), which contracts with the Centers for Medicare & Medicaid Services (CMS) to regularly update its measures.

As of 2024, the HEDIS is a tool used by over 90% of US health plans. Because so many health plans throughout the US rely on HEDIS, and because its measures are clearly outlined, HEDIS is often used by employers or patients to make comparisons between plans.

It’s used by nearly all providers nationwide to track performance on important dimensions of care. Doing so not only ensures that organizations are set up to receive financial benefits, but also supports better health outcomes by prompting regular reviews of the patient experience.

Overall, the purpose and goal of HEDIS are simple: to reduce the number of overall visits patients make to providers while simultaneously increasing the efficacy of care. As such, HEDIS rewards preventative care, a focus that will become more and more important as the population of patients needing ongoing care continues to rise with time.

What are HEDIS measures?

There are more than 90 HEDIS measures that span six domains of care, including:

1. Effectiveness of care
2. Access or Availability of care
3. Experience of care
4. Utilization and risk-adjusted utilization
5. Health plan descriptive information
6. Measures reported using electronic clinical data systems

Broadly speaking, HEDIS measures are related to public health issues. This includes conditions such as cancer and heart disease as well as behavioral health. They aim to improve outcomes for patients and help organizations discover opportunities for improvement within their operations.

That’s not all that HEDIS performance data can offer healthcare organizations, though. They can also make it easier to:

• Track the success of existing quality improvement initiatives
• Provide a set of measurement standards that allow patients to compare services
• Comply with organizational performance improvement goals
• Deliver measurement-based care to patients
• Establish realistic goals for improvement

Examples of HEDIS Measures

Out of the nearly 100 HEDIS measures that currently exist, many are focused on behavioral healthcare and related services.

Below are some examples of HEDIS measures relevant to behavioral health providers, many of which you’re likely familiar with:

• Antidepressant Medication Management (AMM)
• Follow-Up After Emergency Department Visit for Mental Illness (FUM)
• Diagnosed Mental Health Disorders (DMH)
• Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (EMS-E)

Each measure has a specific definition and is designed to help providers identify patients who may need additional support. The data reported for each measure can also reveal crucial information about not only your organization but your patient population.

Why do HEDIS measures matter?

By now, it’s evident that HEDIS measures are useful tools for healthcare organizations and providers. Creating systems and accessing resources that simplify the process of collecting HEDIS data can, therefore, lead to significant performance improvement.

HEDIS measure rates provide crucial insights to organizations.

Without HEDIS measures, healthcare organizations would have little to no way to monitor the success of their quality improvement initiatives.

Relying solely on self-reported experiences and anecdotal evidence to identify whether changes are making a difference can be risky, inefficient, and potentially harmful to your organization.

HEDIS improves patient outcomes and experiences.

One of the most important benefits of HEDIS measures is their ability to help providers discover gaps in their healthcare network’s performance. In other words, HEDIS measures and the data they collect can point out areas of the care process that are currently failing to meet patient needs.

As a result, HEDIS supports better patient outcomes and can decrease the overall cost of care by boosting the efficacy of preventive services.

HEDIS provides essential data related to public health issues.

Also important to consider is the fact that HEDIS data can be leveraged by CMS and other bodies to access important public health data.

Information on widespread public health issues that affect large patient populations, such as cancer or diabetes, can shape new policies and decisions that affect patients nationwide.

Collecting and implementing HEDIS data

While most data is obtained via billing claims, there are technically three methods for HEDIS data collection. In some cases, specific HEDIS measures might allow the access of data that are not readily available in claims.

Data collection for HEDIS can come from the following sources:

1. Administrative Data. These data include information from billing claims for hospitalizations, procedures, medical office visits, and pharmacy data.

2. Hybrid Data. When additional data is required to create a more complete picture of the care and services an organization offers, medical record information may be combined with administrative data from claims.

3. Patient Survey Data. Government-administered patient surveys, such as surveys conducted by the Consumer Assessment of Healthcare Providers and Systems (CAHPS), can collect input about the patient experience and apply it to HEDIS measures.

Providers are encouraged to submit billing claims that use accurate coding and capture all of the data required by HEDIS; doing so reduces the need for hybrid reviews and cuts down on the time it takes to receive the rewards of complying with HEDIS.

Overall, one of the best ways to ensure that accurate claims can be submitted quickly and that your organization has access to patient health data is to use technology designed to automate or streamline the process.

Regular clinical assessments and other methods for capturing patient experiences and needs at different points in the care process can also help organizations meet HEDIS standards without creating a massive administrative burden.