The Healthcare Effectiveness Data and Information Set, or HEDIS, is one of healthcare’s most widely used performance improvement tools, with more than 200 million people enrolled in health plans that report the score. HEDIS measures more than 90 criteria across six domains of care, including: 

  • Effectiveness 
  • Access and availability 
  • Experience 
  • Utilization and risk-adjusted utilization 
  • Health plan descriptive information 
  • Measures reported using electronic clinical data system

These measures may vary from year to year, but their ultimate goals of improving health outcomes without additional and unnecessary costs remain constant.  

How Does HEDIS Measure 

Created by the National Committee for Quality Assurance (NCQA), HEDIS tracks year-to-year health plan performance and provides information about the patient population measured. Payers and payviders can use the data to monitor the general population's health, evaluate treatment outcomes, provide external performance measurements, and identify improvement opportunities.   

NCQA collects HEDIS data from health insurance claims, surveys, and clinical documentation released by hospitals, pharmacies, laboratories, and doctor’s offices. The agency also uses data from the Healthcare Organization Questionnaire and Interactive Data Submission System. The data collected is audited by an NCQA-approved auditing firm before being reported publicly.  

Consequences of a Low HEDIS Rating 

In the age of healthcare consumerism, members today are savvier and more selective when deciding which plan will give them the most value for money. Members are well-informed with access to tools like the Health Plan Performance Reports, which is partially based on HEDIS scores. This forces payers and payviders to constantly keep a close check on the quality of care provided and provide a diversified set of offerings targeted at improving member experience, and therefore retention 

A low HEDIS rating reflects the level of care provided in a healthcare setting. Low scores make the healthcare institution less attractive, and impact STAR ratings. Members will naturally choose better plans with higher ratings. Understanding STAR ratings ultimately dictate priority during open enrollment, it is critical health plans find ways to diversify their benefits to provide a comprehensive set of member-centric offerings, while also ensuring clinical and quality performance is front and center in design.   

5 Key Ways to Improve HEDIS Scores: 

1. Improve documentation  

Healthcare providers must maintain proper clinical documentation to ensure patient records are up-to-date and easily accessible—enabling them to demonstrate needs met under HEDIS quality measures.   

Each patient’s electronic medical record must be kept updated as it helps practitioners follow the care of a patient, which adds to an improved health outcome. The record also helps practitioners plan treatments and monitor vitals more systematically. 

In addition, proper records and documentation ensure that the deadlines of specific services are met. When those deadlines are not met, documentation can identify the gaps in care that need to be closed. The thesis rests on the clinical best practice to deliver care in-standard with benchmark protocols. Take a child’s immunization as an example: having a clear record can help practitioners complete the proper procedures before the child’s second birthday as planned.   

2. Outreach programs and preventative screening  

It is not easy for payers to achieve high HEDIS scores in silos. Working closely with providers and eligible members by involving them in their care plan is one of the best ways to ensure that care is provided efficiently.   

One best way to involve members in scheduling appointments, adhering to medication, and managing their health independently is by conducting outreach programs. When members hear about the importance of taking care of their health from various sources, the chances are higher for them to adhere to their care plans and for payers to improve their HEDIS scores.  

For example, UnitedHealthcare is giving up to $1000 to members who use wearable devices to complete health goals and activities. By incentivizing members to take an active role in managing their health, they can promote wellness and reduce costs.

3. Patient engagement 

In a traditional healthcare setting, providers send reminders about appointments via physical mail and emails, often ignored or forgotten. A better way to engage patients is by providing a more personalized touch and educating them on why it is crucial to adhere to their care plan.  

Telehealth and remote patient monitoring (RPM) make patient engagement more effective. From medication and appointment reminders to having the option to be monitored from the comfort of the patient's home, telehealth and RPM is the way forward in ensuring that patients receive care at the right time.  

4. Leverage patient data 

The more control payers and practitioners have over their clinical and operational data, the better they can position themselves when reporting out their HEDIS measures. And with advanced analytics, millions of data points can be parsed to determine patterns, predict trends, and automate care plans.   

Many successful health plans leverage data to continuously innovate and achieve better processes and patient care. From processing claims data to using historical data to predict patients who may develop overlapping conditions, these advanced technologies make improving patient care and, subsequently, the HEDIS score, hassle-free.  

5. Use Telehealth and RPM  

Telehealth and RPM allow payers to be more transparent about members’ conditions and care plans. These advanced tools also promote medication compliance and health literacy. All the resources needed to provide the best care for the patients are at their fingertips, giving both patients and caregivers much-needed peace of mind.   

By offering personalized care and seamless communication and care coordination, member satisfaction and, ultimately, HEDIS star ratings can be improved. 

How HRS Helps 

HRS’ proven solutions help payers and payviders improve population health initiatives, enhance member satisfaction, and reduce healthcare costs. With HRS’ advanced technology, tools, and insights, positive clinical, operational, and quality-related outcomes tied to HEDIS and star rating measures are assured.

HRS’ solution allows members to receive care safely and effectively in the comfort of their homes, and complementarily allows payers and health plans to more efficiently manage the total cost of care through early, thoughtful, and targeted intervention. 

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