What Does Hedis Stand For In Healthcare?

What Does Hedis Stand For In Healthcare
Healthcare Effectiveness Data and Information Set (HEDIS) CMS contracts with NCQA to collect Healthcare Effectiveness Data and Information Set (HEDIS ® ) measures from Medicare Special Need Plans (SNPs). The HEDIS measurement set is sponsored, supported and maintained by NCQA.

Measures relate to many significant public health issues such as cancer, heart disease, behavioral health and diabetes.
SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement and provide a set of measurement standards that allow comparison with other plans.

HEDIS data help identify performance gaps and establish realistic targets for improvement. SNPs have reported the following measures since HEDIS Measurement Year (MY) 2016:

Colorectal Cancer Screening Care for Older Adults Use of Spirometry Testing in the Assessment and Diagnosis of COPD Pharmacotherapy Management of COPD Exacerbation Controlling High Blood Pressure Persistence of Beta-Blocker Treatment After a Heart Attack Osteoporosis Management in Women Who Had a Fracture Antidepressant Medication Management Follow-Up After Hospitalization for Mental Illness Potentially Harmful Drug-Disease Interactions in Older Adults Use of High-Risk Medications in Older Adults Transitions of Care (Reporting began in HEDIS MY 2020) Plan All-Cause Readmissions

Please see the link below for the most recent SNP HEDIS Performance Report. : Healthcare Effectiveness Data and Information Set (HEDIS)

What is the meaning of HEDIS?

Years Available 2001 to present Mode of Collection Abstraction of administrative claims data or data from other records. Description The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care and service.

More than 190 million people are enrolled in health plans that report quality results using HEDIS. Since 2008, HEDIS has also been available for use by medical providers and practices. Because so many health plans use HEDIS and because the measures are so specifically defined, HEDIS can be used to make comparisons among plans.

To ensure that HEDIS stays current, the National Committee for Quality Assurance (NCQA) has established a process to evolve the measurement set each year through its Committee on Performance Measurement. Selected Content HEDIS measures address a range of health issues including: asthma medication use; persistence of beta-blocker treatment after a heart attack; controlling high blood pressure; comprehensive diabetes care; breast cancer screening; chlamydia screening; antidepressant medication management; immunization status; and advising smokers to quit.

Population Covered Persons enrolled in health plans that report quality results using HEDIS.
Methodology NCQA collects HEDIS survey results directly from health plans and Preferred Provider Organizations (PPOs) through the Healthcare Organization Questionnaire and collects non-survey data through the Interactive Data Submission System.

Submission formats are defined for each type of health plan (e.g., commercial, Medicare, Medicaid) and data provider group. Schedules for data submission, analysis, and health plan ratings release are available on the HEDIS website. Response Rates and Sample Size HEDIS is used by more than 90% of America’s health plans.

What are HEDIS measures used for?

HEDIS Measures – HEDIS ® includes more than 90 measures across 6 domains of care:

Effectiveness of Care.Access/Availability of Care.Experience of Care.Utilization and Risk Adjusted Utilization.Health Plan Descriptive Information.Measures Reported Using Electronic Clinical Data Systems

What are the 6 domains of care for HEDIS?

An outlined set of performance measures across 6 domains of care is required for reporting: Effectiveness of Care, Access/Availability of Care, Experience of Care, Utilization and Risk-Adjusted Utilization, Health Plan Descriptive Information, and Measures Collected Using Electronic Data Systems.

Who collects data for HEDIS?

What Does Hedis Stand For In Healthcare Loading. NCQA collects HEDIS data from health plans, health care organizations and government agencies. Data are used to improve HEDIS measures and the health care system. Visitors to this page often check HEDIS FAQs, QRS FAQs, or ask a question through MyNCQA, What Does Hedis Stand For In Healthcare

Who runs HEDIS?

NCQA, which administers HEDIS ®, collects audited results from health plans for their respective populations.

What is an example of a data set would be HEDIS?

Examples of data tracked by HEDIS includes asthma medication use, beta blocker treatment after a heart attack, high blood pressure controls, diabetes care and breast cancer screening, just to name a few.

Is BMI a HEDIS measure?

The featured HEDIS measure. What is the measure? The measure focuses on members age 18-74 who had an outpatient visit with a body mass index (BMI) documented during the measurement (current) year or the year prior to the measurement year.

Is HEDIS required?

HEDIS reporting is a requirement of health plans by NCQA and the Centers for Medicare and Medicaid Services (CMS) for use in health plan accreditation, Star Ratings, and regulatory compliance.

What is a HEDIS audit?

HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET. – The Healthcare Effectiveness Data and Information Set (HEDIS®) is an audit used among government regulators, healthcare providers and others for evaluating and bettering the quality of health care plans across the country.

The audit is divided into two parts, the first of which assesses a plan’s information systems capabilities, and the second is how they comply with HEDIS specifications.
Only certified auditors and licensed organizations are permitted to perform HEDIS® Audits, which are required for every health plan submitting HEDIS data to NCQA.

Learn more about HEDIS Compliance Audit Certification today.

What are 12 care domains?

The CHC assessment is divided into 12 care domains: behaviour cognition psychological and emotional needs communication mobility nutrition continence skin integrity (including wounds, ulcers, tissue viability) breathing drug therapies and medication: symptom control altered states of consciousness

Who invented HEDIS?

HEDIS HEDIS (Healthcare Effectiveness Data and Information Set) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds PA Health & Wellness accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.

Use of HEDIS Scores As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well.
State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts.

Physician specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs. Calculating HEDIS Rates A few HEDIS measures can be calculated in two ways: administrative data or hybrid data.

Administrative data consists of claim or encounter data submitted to the health plan.
Administrative only measures calculated using administrative data include: annual mammogram, annual Chlamydia screening, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, antidepressant medication management, annual dental care, access to PCP services, and utilization of acute and mental health services.

Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of participant medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data.

Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, annual PAP test, prenatal care, and well-child care. HEDIS and HIPAA As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations (HEDIS chart review) is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the participant/patient.

The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate. : HEDIS

What is the HEDIS measurement period?

Measurement Year (2022) – The 12-month timeframe between which a service was rendered – generally January 1 through December 31. Data collected from this timeframe is reported dur ing the reporting year (2021).

What is the introduction of HEDIS?

What is HEDIS®? HEDIS® is a standardized set of performance measures called Health Effectiveness Data Information Set which are developed by the National Committee of Quality Assurance (NCQA).

What is the HEDIS measure for blood pressure?

April 15, 2021 The Controlling High Blood Pressure (CBP) HEDIS ® star measure assesses patients (18–85 years of age) who had a diagnosis of hypertension reported on an outpatient claim and blood pressure adequately controlled (<140/90 mm Hg) as of December 31 of the measurement year. Per HEDIS specifications, blood pressure CPT ® II codes can now establish patient compliance with the CBP measure. We'll no longer need to review medical records to confirm blood pressure values when you add the CPT II codes to your patients' claims billed with an office visit, including telehealth, telephone, e-visit, or virtual visit. Blood pressure readings can be captured during a telehealth, telephone, e-visit, or virtual visit. Please note:

Patient-reported readings taken with a digital device are acceptable and should be documented in the medical record along with the date. Providers don’t need to see the reading on the digital device; the patient can verbally report it.

Read the CBP tip sheet to learn more about the measure and view a chart with blood pressure CPT II codes. For more information and/or questions regarding this article, email [email protected], HEDIS ® is a registered trademark of the National Committee for Quality Assurance (NCQA).

What type of healthcare organization uses measures found in the HEDIS?

Contents –

Child Measures Included Users Comparisons and Trends Benchmarking and Databases Service Delivery and Units of Analysis Length-of-Enrollment Requirements Data Issues Sample Sizes Resource and Burden Issues Development Process Criteria Used More Information and User Support

The Health Plan Employer Data and Information Set (HEDIS®) is a widely used measurement set focused on clinical services and utilization, initially designed for use by purchasers and managed care organizations (MCOs). HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA), which maintains and updates it annually under the direction of a broadly representative Committee on Performance Measurement.

Preventive and well care. Care for selected chronic conditions. Use of services. Perceptions of care (incorporating the managed care version of CAHPS). Descriptive measures.

HEDIS® 2003 was designed to collect data for measurement year 2002 for reporting in 2003. It contains 52 measures, including 23 measures designed for or applicable to children. The measures are categorized by NCQA-designated measure type as follows: Type: Effectiveness of Care. Measures for which clinical standards of care exist.

Childhood immunization status. Adolescent immunization status. Chlamydia screening for women. Use of appropriate medications for people with asthma.

Type: Access/Availability of Care. Measures related to timely provision of needed care.

Children’s access to primary care practitioners. Annual dental visit.

Type: Satisfaction with the Experience of Care. Measures of perceptions of care.

The CAHPS® 3.0H Child Survey. This revised Consumer Assessment of Health Plans (CAHPS®) child instrument includes a screener for children with chronic conditions as well as several composite measures of health services related to such conditions. It also includes several HEDIS-specific items related to MCOs. NCQA protocols for administering CAHPS® 3.0H must be followed if the results are intended for use in NCQA accreditation. Online Resource: For more information on the CAHPS 3.0H Child Survey, go to: http://www.ahrq.gov/chtoolbx/measure2.htm#cahpsexpandedsurvey

Type: Use of Services: Measures of utilization, generally without standards of appropriate utilization levels. These include several measures related to older adolescents.

Well-child visits in the first 15 months of life. Well-child visits in the third, fourth, fifth, and sixth years of life. Adolescent well-care visits. Frequency of selected procedures: Myringotomy, tonsillectomy. Inpatient utilization: General hospital/acute care. Ambulatory care. Inpatient utilization: Nonacute care. Mental health utilization: Inpatient discharges and average length of stay. Mental health utilization: Percentage of members receiving services. Chemical dependency utilization: Inpatient discharges and average length of stay. Chemical dependency utilization: Percentage of members receiving services. Outpatient drug utilization. Births and average length of stay, newborns. Discharges and average length of stay, maternity care. Cesarean section rate. Rate of vaginal birth after cesarean section.

Return to Contents Users Use of HEDIS measures is widespread among employer-based MCOs, and the Center for Medicare & Medicaid Services (CMS) requires that Medicare+Choice MCOs use HEDIS measures. HEDIS® is also widely used by State Medicaid agencies to assess their contracted MCOs and, to a lesser extent, their primary-care case management programs (PCCMs).

In its survey of State Medicaid programs, the National Academy for State Health Policy found that 34 States collected HEDIS® measures from their risk-based managed care programs in 2000.
That same survey found that 19 States collected HEDIS measures for stand-alone risk-based State Children’s Health Insurance Programs (SCHIPs).

States using HEDIS® measures include New York and Washington State. Online Resource: For some State examples, go to: http://www.ahrq.gov/chtoolbx/measure8.htm Return to Contents Comparisons and Trends When HEDIS® specifications are followed, HEDIS® results (other than those designated as “descriptive”) are reliable and valid.

The results can be used for statistically significant comparisons with HEDIS results produced for other plans or programs and at other times (trending), provided that comparable populations are used.
HEDIS results based on samples can be generalized to the relevant universe.
Auditing of results to ensure consistent application of specifications and protocols helps ensure comparability of results.

NCQA requires auditing of HEDIS® results submitted for MCO accreditation purposes and for public reporting through NCQA’s Quality Compass. Online Resources: For more information on HEDIS, go to: http://www.ncqa.org/hedis-quality-measurement For more information on Quality Compass, go to: http://www.ncqa.org/hedis-quality-measurement/quality-measurement-products/quality-compass Some States or other users customize HEDIS® measurement specifications.

Such customization can limit the comparability of measurement results. However, results produced using customized specifications can be credibly compared if other users have adopted the same changes. If the same customized specifications are used year after year, results can be compared over time to derive trends.

Return to Contents Benchmarking and Databases Since 1998, the American Public Human Services Association (APHSA) has worked with NCQA to improve the availability and robustness of Medicaid HEDIS® benchmarks. The project received initial funding from The Commonwealth Fund and is currently being supported by CMS.

APHSA has produced several reports that present national Medicaid averages on key measures. The fifth-year (2002) report on this project includes data from 176 MCOs in 33 States, the District of Columbia, and the Commonwealth of Puerto Rico. Thirteen HEDIS measures are covered, five of which are child specific.

The fourth-year (2001) report on this project contained data on 13 HEDIS measures from 167 MCOs in 28 States and the Commonwealth of Puerto Rico. Results for the third-year (2000) report cover 12 HEDIS® measures from 167 MCOs in 27 States plus the Commonwealth of Puerto Rico Additionally, NCQA makes health plan performance benchmarks (commercial, Medicaid, and Medicare) available in its annual State of Health Care Quality Report,

For the commercial market and Medicaid, NCQA releases detailed plan-specific performance information through its Quality Compass. NCQA also makes its HEDIS®/CAHPS® database available to researchers. Online Resources: For the State of Health Care Quality Report, go to: http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality For Quality Compass, go to: http://www.ncqa.org/hedis-quality-measurement/quality-measurement-products/quality-compass Return to Contents Service Delivery and Units of Analysis HEDIS was designed to assess the performance of MCO service delivery systems.

However, some States, including Colorado and Massachusetts, are using HEDIS® to assess services delivered to Medicaid beneficiaries enrolled in their fee-for-service (FFS) and PCCM programs as well as their MCOs. Some HEDIS® results are published on a statewide basis as well as for individual plans and programs.

With the assistance of a workgroup of Medicaid experts, NCQA produced a report discussing the methodological issues involved in using HEDIS in FFS and PCCM settings. Return to Contents Length-of-Enrollment Requirements Many HEDIS® measures have length-of-enrollment (or “continuous enrollment”) requirements that identify those individuals whose treatment information can be included in calculations of measures assessing the performance of MCOs.

To be included in the calculation of rates for HEDIS® measures involving services or treatments delivered in set time frames (e.g., preventive services, screenings, well-care visits), managed care plan members must be enrolled for a minimum of 12 months, with no more than one break of 45 days.

For other measures, the required period of continuous enrollment varies. Because HEDIS® measures are based in part on the premise that MCOs are accountable for providing defined services to enrolled members, the minimum period of enrollment is designed to give MCOs a reasonable opportunity to fulfill that responsibility prior to measurement.

There are no continuous length-of-enrollment requirements for HEDIS® use-of-services measures other than well-child and adolescent well-care visits, as no set periodicity requirements exist. CAHPS® 3.0H enrollment requirements are the same as for CAHPS 3.0.

Return to Contents Data Issues Data sources for the calculation of HEDIS® measures are administrative data, medical records, or, for CAHPS® 3.0H, survey data. Encounter data or claims data are potential HEDIS® data sources when applied to FFS or PCCM systems. Data completeness and accuracy are critical issues.

Issues involving the data sources for HEDIS® include the following:

MCO administrative databases may not be current or complete, especially for services covered under a capitation arrangement. Accessing medical records is costly and time consuming. Medical records may be incomplete and hard to decipher. Encounter data are often incomplete or inaccurate. Claims databases were designed to track the flow of money, not care, and may lack important data elements.

Improvement is always possible, however. States and others with experience can share lessons learned and examples of progress. Online resources: For additional information on data sources, go to: http://www.ahrq.gov/chtoolbx/develop.htm#data For additional information on encounter or claims data, go to: http://www.ahrq.gov/chtoolbx/develop.htm#encounter Return to Contents Sample Sizes HEDIS requires samples or groups large enough to produce statistically reliable results.

HEDIS® measurement technical specifications are very detailed. Online resource: For specifications, go to: http://www.ncqa.org/hedis-quality-measurement/hedis-measures Return to Contents Resource and Burden Issues The production of performance measures is a data-driven activity. MCOs with little experience in producing HEDIS® results will need to devote noticeable resources to this in the first years, with senior staff oversight.

Application to FFS and PCCM programs requires particular attention in early years. In all instances, senior-level agency responsibility and sufficient staff resources are needed to ensure useful results. Return to Contents Development Process The HEDIS® measurement development process involves numerous components:

Review of the existing research literature and additional in depth research. A committee with expertise on the particular issue. NCQA staff support. Consensus on the best measurement approach according to set criteria of:

Relevance to purchasers and consumers. Scientific soundness. Feasibility.

Development of precise and detailed measurement specifications, including instructions on sampling. Statistical testing. Field testing by MCOs. Final approval by the broad-based Committee on Performance Measurement.

Return to Contents Criteria Used Criteria used in developing HEDIS® measures include: Relevance:

Is the measure relevant for consumers, purchasers, health plans? Does it measure prevalent conditions? Serious conditions? Does it assess activities with high cost? Does it encourage the use of cost-effective, clinically effective options? Are there actions that health plans can take to improve their performance? Is there potential for improvement?

Scientific Soundness:

Does clinical evidence document links among interventions, clinical processes, and outcomes? Is the measure reliable—that is, does it produce the same results when repeated with the same population in the same setting? Is the measure valid—that is, does it make sense logically and clinically (face validity)? Does it correlate well with other measures of the same aspects of care (construct validity)? Does it capture meaningful aspects of this care (content validity)? Is the measure an accurate gauge of what is actually happening? If the measure is appreciably affected by variables beyond the health plan’s control, is an appropriate case-mix or risk-adjustment strategy in place? Are there safeguards to ensure reasonable comparability of data sources?

Feasibility:

Are there clear operational definitions, data specifications, and data collection and reporting specifications? Is the burden imposed on the health plan justifiable in terms of improved outcomes? Is the data collection method in keeping with accepted standards of member confidentiality? Are the data available to the health plan during the required period? Can the measure be audited to prevent manipulation?

Return to Contents More Information and User Support NCQA sells HEDIS® documents describing specifications and protocols for the administration of HEDIS® (including CAHPS® 3.0H, which has some unique protocols) and provides several levels of user support for a variety of charges. Go to: http://store.ncqa.org/index.php/performance-measurement.html Return to Contents

What is CDC HEDIS?

June 4, 2020 Patients with diabetes require consistent medical care and monitoring to reduce the risk of severe complications and improve outcomes. Interventions to improve diabetes outcomes go beyond glycemic control as diabetes affects the entire body.

That’s why the comprehensive diabetes care composite measure includes HbA1c control, retinal eye exams, medical attention for nephropathy, and blood pressure control.
The HEDIS ® Comprehensive Diabetes Care (CDC) measure is a composite measure meant to provide a comprehensive picture of the clinical management of patients with diabetes.

All comprehensive diabetes care measures are used for HEDIS reporting. View the CDC tip sheet to learn more about what’s included in the measure, new exclusions to the measure including advanced illness and frailty of the patient, and ways you can close care gaps for diabetic patients.

Who invented HEDIS?

Use of HEDIS Scores As both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s preventive health outreach efforts.

Administrative data consists of claim or encounter data submitted to the health plan.
Administrative only measures calculated using administrative data include: annual mammogram, annual Chlamydia screening, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, antidepressant medication management, annual dental care, access to PCP services, and utilization of acute and mental health services.

Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, annual PAP test, prenatal care, and well-child care. HEDIS and HIPAA As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care operations (HEDIS chart review) is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the participant/patient.

The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate. : HEDIS

What is CDC in HEDIS?

Comprehensive Diabetes Care – NCQA Assesses adults 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:

Hemoglobin A1c (HbA1c) testing.HbA1c poor control (>9.0%).HbA1c control (<8.0%).Eye exam (retinal) performed.Medical attention for nephropathy.*BP control (<140/90 mm Hg).

*This indicator is only reported for the Medicare product line.

What does the CDC HEDIS measure evaluate?

How Is HEDIS Used? – Fundamentally, HEDIS is used as a measure of effectiveness of care, access to care, and the experience of care. Its most “official” use is through the CMS five-star metrics measures. Higher star ratings for organizations enrolled in Medicare Advantage will receive quality bonus payments (QBPs) and rebates.

Specifically, four- or higher-star ratings will trigger direct bonus payments to plan operators and rebates that can be returned to their beneficiaries.
Likewise, low scores also have consequences.
CMS has instituted a “three strikes” rule for plans that fail to achieve at least a three-star rating for three consecutive years.

As of February 2016, low-performing plans receive nonrenewal notices – meaning they cannot enroll members during the following calendar year and will need to raise their ratings in order to begin enrollment again. While the government only officially uses HEDIS as a means to determine payments related to Medicare Advantage, its widely accepted application as a common quality measure has seen it increasingly used to determine payment to hospitals, physicians, and other healthcare providers.

It is now used by more than 90% of America’s health plans as an opportunity to identify areas for improvement in care. Despite its increasing use by payers and providers, it is important to remember that the original intent of HEDIS was to inform consumers about the difference in the quality of care in available health plans.

The NCQA publishes its annual Health Insurance Plan Ratings online for consumers,