One of the most important tools utilized by payers across the country is the Health Effectiveness Data and Information Set (HEDIS), which is maintained by the National Committee for Quality Assurance (NCQA). HEDIS is a measurement set used to determine the efficacy of a payer to care for its members. The performance data collected through HEDIS assists payers in identifying areas for improvement as well as tracking successes through a measurement set that allows them to be compared to other payers. Ultimately, HEDIS helps to ensure that members are getting the care and benefits they need without unnecessary costs being incurred by the payer or the member.
The main objective of HEDIS is the improvement of both measurement standards and of patient care, the latter of which is aided by avoiding excessive and unnecessary costs. By tracking the health of an overall population and reviewing the treatment outcomes and procedures, HEDIS can supply an external performance measurement that can be used to gauge the quality of care. The focus is on preventive screenings and treatment data for chronic diseases and illnesses, which payers use to ensure providers are offering such services to their patients, to ultimately cut down on the overall cost of care.
HEDIS measurement standards provide both potential plan members and plan members standards with which to compare payer performance and make sure they are getting adequate coverage. The measures vary from year to year with some being retired and other measures being added. There are over 90 measures across 6 different domains of care. These domains include effectiveness of care (which includes prevention/screening and measures such as COA, COL, CCS, BPD, HBD, EED, etc.), access/availability of care (with measures such as AAP), experience of care, utilization and risk adjusted utilization, payer descriptiveness, and measures reported using electronic clinical data systems. HEDIS tracks the actual care received in conjunction with what was ordered to make sure the members are being served properly.
As an example, within the access/availability of care domain, the measure AAP (Adults’ Access to Preventative/Ambulatory Health Services) evaluates whether adult enrollees have had a preventative or ambulatory visit to a physician. This measure helps health plans assess how many individuals are receiving preventative services or counseling. By analyzing AAP data, health plans can identify correlations between preventative care, addressing acute issues, and identifying chronic conditions, providing valuable insights into the quality of care the patients receive.
Several sources are used to collect data for HEDIS purposes. An administrative source reviews claims for hospitalizations, medical office visits, procedures and pharmacy data. Hybrid sources are used when clarification of the measure is needed, and in this case, data obtained from an administrative source is combined with the patient’s medical record. The third source, a program run by the Agency for Healthcare Research and Quality (AHRQ). The Consumer Assessment of Healthcare Providers and Systems, or CAPHS, is a self-reported experience barometer which relies on the patient’s completion of a post-encounter survey and gauges the patient’s level of satisfaction for the care they received.
It is estimated that over 190 million people are enrolled in health plans that utilize HEDIS to measure the quality of their care. This means it is essential for providers to not only provide great care, but to also have accurate documentation of that care. Electronic health records (EHRs) are one way to avoid issues with improper recording and storing of patient data. Providers need to understand what the measures are asking for, collaborate with the patient for specific needs and identify gaps in care, ensure that medical coding is accurate, and respond to record requests in a timely manner. Payers use this data to achieve strong HEDIS scores, which enhances reimbursement rates, incentives, and the quality of care for their members.
MRO plays a crucial role in streamlining HEDIS management for both payers and providers. The information payers need for HEDIS data collection needs to be returned quickly and accurately. It also needs to fulfill the requirements of the measure being requested. Improving the exchange of data between payers and providers can boost HEDIS scores and ensure a streamlined process for payers, providers, and members alike. If you’re interested in learning more about MRO’s solutions, contact us today.
