As the healthcare industry continues to evolve, many Americans find themselves dissatisfied with their health coverage. However, very few health plans have managed to attain the coveted 5-star rating from the National Committee for Quality Assurance (NCQA). Achieving high Healthcare Effectiveness Data and Information Set (HEDIS®) scores is essential for health plans as it impacts their marketability, member satisfaction, and even eligibility for CMS bonuses, especially for Medicare and Medicaid plans. This competitive edge can increase enrollments and strengthen a plan’s reputation among consumers.
As stakeholders strive to enhance the quality of care provided, HEDIS® and its associated quality measures remain pivotal in achieving high NCQA ratings. With more than 227 million people enrolled in health plans that report HEDIS results, it has become one of the industry’s most widely used performance improvement tools. Improving HEDIS scores can help payers develop strategic approaches to meet the NCQA’s stringent standards and deliver high-quality healthcare that exceeds consumer expectations.
What Are HEDIS Measures & Why Do They Matter?
HEDIS is a standardized performance measurement tool developed by the NCQA in 1991. It was created to address the need for a consistent, objective way to evaluate the quality of healthcare services across different health plans. Initially focused on a small set of clinical performance measures, HEDIS has expanded to over 90 measures spanning preventative care, chronic disease management, access to care, patient experience, and more. They are designed to help identify gaps, monitor improvement success, and offer standards for easy plan comparison.
The Role of HEDIS in Healthcare Quality Measurement
HEDIS serves as a benchmarking system that enables health plans, policymakers, and regulators to assess how well healthcare organizations deliver high-quality, evidence-based care. It provides standardized metrics that allow for apples-to-apples comparisons between health plans, helping employers, consumers, and regulators make informed decisions.
For Medicare and Medicaid plans, HEDIS scores are directly tied to CMS Star Ratings, impacting plan marketability, financial incentives, and eligibility for government bonuses. Health plans with higher HEDIS scores attract more enrollees, while low-scoring plans may face regulatory scrutiny or funding reductions.
How HEDIS Benefits Healthcare Organizations & Patients
For health plans and providers, HEDIS measures help organizations identify performance gaps, track improvement efforts, and meet regulatory requirements. Health plans can proactively enhance care delivery and optimize outcomes by focusing on key quality indicators—such as preventive screenings, chronic disease management, and patient access to care.
For patients, a high HEDIS score indicates a strong commitment to quality care, ensuring that members receive preventive services, timely interventions, and well-coordinated treatment plans. It promotes better health outcomes by encouraging adherence to evidence-based care guidelines, ultimately leading to longer, healthier lives for enrollees.
By understanding and leveraging HEDIS measures, health plans can improve care quality, enhance member satisfaction, and achieve greater financial and competitive success in an evolving healthcare landscape.
What Are the Six HEDIS Domains of Care?
HEDIS measures are designed to assess performance in key healthcare areas that can significantly impact patient health. The NCQA has categorized these measures into six primary domains:
- Effectiveness of care
- Access and availability of care
- Experience of care
- Utilization and risk-adjusted utilization
- Health plan descriptive information
- Measures reported using electronic clinical data systems
Each domain measures critical aspects of healthcare quality that directly impact patient outcomes.
Effectiveness of Care
Effectiveness of Care evaluates how well healthcare organizations meet preventive and chronic care standards, such as vaccination rates, cancer screenings, and diabetes management. By focusing on proactive care, these measures support early intervention, reduce long-term costs, and improve patient quality of life.
Access and Availability of Care
Access and Availability of Care assesses a patient’s ability to obtain timely healthcare services, measuring factors like appointment wait times and access to primary care providers. Improved accessibility leads to earlier diagnoses, faster treatments, and better health outcomes.
Experience of Care
Experience of Care captures patient satisfaction with provider interactions, communication, and respect. High scores indicate strong patient-provider relationships, promoting better treatment plan adherence and improved health management.
Utilization and Risk-Adjusted Utilization
Utilization and Risk-Adjusted Utilization tracks how frequently healthcare services are used, including hospital visits, ER visits, and follow-ups, while adjusting for patient risk factors. Balancing appropriate utilization with cost-effectiveness helps ensure patients receive necessary care without unnecessary spending.
Health Plan Descriptive Information
Health Plan Descriptive Information provides insights into a health plan’s structure, membership demographics, and network reach. Evaluating this data ensures that health plans can meet diverse patient needs while maintaining quality care standards.
Measures Reported Using Electronic Clinical Data Systems
This domain evaluates a health plan’s use of digital tracking and reporting tools. Accurate data collection enhances care coordination, enables real-time performance monitoring, and supports compliance with HEDIS standards.
How Can Health Plans Improve HEDIS Scores & Health Outcomes?
Improving HEDIS scores is an ongoing effort that requires strategic initiatives, collaboration, and data-driven decision-making. Here are key strategies that health plans can implement.
Leverage Advanced Technology and Analytics Solutions
Advanced data analytics and AI-driven insights can help identify care gaps, predict health risks, and improve care coordination. Implementing predictive analytics tools enables more proactive and personalized healthcare interventions.
Incentivize Providers and Enhance Engagement Programs
Align healthcare professionals with HEDIS improvement goals by offering incentives for technology adoption and quality care improvements. Stronger provider engagement leads to better patient care and adherence.
Foster a Culture of Continuous Improvement
Encourage ongoing performance reviews and innovation-driven strategies to ensure sustained improvements in HEDIS scores and care quality.
Promote Collaboration Among Healthcare Professionals
Encourage cross-provider collaboration to share best practices and coordinate care more effectively. Integrating social determinants of health (SDOH) factors can further improve patient adherence and outcomes.
Implement Beneficiary Incentives and Education Programs
Offer member incentives for preventative screenings and wellness visits. Transparency in care options and patient feedback programs can drive higher engagement and satisfaction.
Enhance Data Collection and IT Systems
Invest in robust data infrastructure to ensure accurate tracking, streamlined reporting, and better clinical documentation. Efficient IT systems help eliminate reporting errors and provide real-time insights.
Adopt of Value-Based Payment Models
Shift towards value-based care reimbursement models that reward quality over quantity. Tying provider incentives to patient outcomes helps close HEDIS care gaps.
Build Strategic Partnerships within the Community
Strengthen community health programs that address social determinants of health, such as transportation, housing, and nutrition programs. This holistic approach improves access to care and HEDIS performance.
Find Support from the Experts
Elevate your HEDIS score improvement strategy with guidance from a team of seasoned consultants dedicated to enhancing healthcare quality. Clearlink’s clinical management services provide expert insights, proven best practices, and access to industry benchmarks that empower you to meet and exceed NCQA standards. Connect with us to explore tailored strategies that drive impactful results— schedule a meeting today to optimize your HEDIS performance.