HEDIS Measures

The Healthcare Effectiveness Data and Information Set, better known as HEDIS, is a tool used by more than 90 percent of America's plans to measure performance on important dimensions of care and service. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA). HEDIS consists of 75 measures across 8 domains of care that address important health issues. HEDIS is also one component of NCQA's accreditation process.

HEDIS measures are specified for one or more of three data collection methods: Administrative, Hybrid and Survey. Clinical measures use the Administrative and/or Hybrid data collection methodology as specified by NCQA. All HEDIS results must be audited by an NCQA-approved auditing firm for public reporting and are included in Quality Compass, an interactive, web-based comparison tool that allows users to view plan results and benchmark information.

Administrative methodology requires that the health plan identify the eligible population for the specific HEDIS measure through use of electronic records of service to include insurance claims and registration systems from hospitals, clinics, medical offices, pharmacies and labs, and secondly determine the number of that population who are found to have received the service required for that measure. Measures that are captured through administrative data include Breast Cancer Screening and Antidepressant Medication Management. It is critical that ICD9 codes and/or CPT codes approved by NCQA be submitted to ensure the member receives the necessary screening and the provider receives credit for performing the screening.

The Hybrid method of data collection consists of selection of random sample of the population and allows for supplementation of Administrative data with data collected during medical record reviews. there are 14 measures in which JHHC uses this methodology. A few examples are Pre-natal and Post-partum Care, Comprehensive Diabetes Care and Childhood Immunizations.

CAHPS is a survey which measures members' satisfaction with their care in areas such as claims processing, customer service and getting needed care quickly. Data collection relating to the CAHPS 5.0 survey must be conducted by an NCQA-approved external survey organization.

Reporting of HEDIS data provides the managed care industry with a mechanism for performance comparison amongst health plans. The health plans themselves also use analysis of HEDIS data to obtain valuable information related to areas where quality improvement efforts may need to be focused. Consumers may use HEDIS data to assist in selecting the health plan that best meets their needs.

USFHP HEDIS Measures Tips