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 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 lead to increased enrollments and a stronger reputation among consumers. As stakeholders strive to enhance the quality of care provided, the Healthcare Effectiveness Data and Information Set (HEDIS®) and its accompanying measures for healthcare organizations remain a pivotal factor in achieving high NCQA ratings.
According to NCQA, more than 227 million people are enrolled in health plans that report results from HEDIS, making it one of the industry’s most widely used performance improvement tools. Understanding how to improve HEDIS scores can help payers adopt a strategic approach to meeting the stringent standards set by NCQA and pave the way for a healthcare landscape that exceeds the expectations of the American population.
What Are HEDIS Measures & Why Do They Matter?
HEDIS measures have been established by NCQA to assess performance in healthcare across specific areas in which improvements have the potential to make a meaningful difference in people’s lives. They are designed to help identify gaps, monitor improvement success, and offer standards for easy plan comparison.
More than 90 measures cover six domains of care:
- 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.
1. Effectiveness of Care
The “Effectiveness of Care” domain measures how well healthcare organizations meet standards for preventive and chronic care, such as vaccination rates, cancer screenings, and diabetes management. These metrics support early intervention and disease management, helping reduce long-term costs and improving quality of life.
2. Access and Availability of Care
This domain assesses a patient’s ability to obtain timely healthcare services, measuring factors like appointment wait times and access to primary care. Ensuring accessible care fosters early diagnosis and treatment, which are essential for positive health outcomes.
3. Experience of Care
“Experience of Care” captures patient satisfaction with provider interactions, including communication and respect. High scores in this domain reflect strong patient-provider relationships, encouraging adherence to care plans and promoting better overall health outcomes.
4. Utilization and Risk-Adjusted Utilization
Utilization metrics measure the frequency and appropriateness of services, including hospital visits and emergency care, adjusted for patient risk. This domain helps identify overuse or underuse, balancing quality care with cost-effectiveness to support both patient outcomes and resource management.
5. Health Plan Descriptive Information
This domain provides insights into a health plan’s structure, membership demographics, and network reach. It helps assess whether the plan can meet diverse needs, supporting quality care and accessibility across different populations.
6. Measures Reported Using Electronic Clinical Data Systems
This domain evaluates a health plan’s use of electronic data systems for accurate tracking and reporting. Reliable data capture enables precise outcome measurement, supports care improvements, and helps health plans meet HEDIS standards.
HEDIS measures matter because they reflect a healthcare organization’s effectiveness in delivering patient care or a payor’s effectiveness at implementing preventive healthcare initiatives. Any deficiencies can decrease HEDIS scores and impact a commercial, Medicaid, or Medicare payer’s status as a quality health plan. Remedying these gaps and improving the patient experience are essential steps in enhancing HEDIS scores.
How Can Health Plans Improve HEDIS Scores & Health Outcomes?
Improving your health plan’s HEDIS scores and member health outcomes is an ongoing effort that can require a strategic and multifaceted approach. Here are key tactics to consider.
1. Leverage Advanced Technology and Analytics Solutions
Advanced technology and analytics can transform population health management, providing healthcare organizations with targeted insights to address health disparities and proactively focus on preventive care. By embracing these tools, healthcare providers can streamline data processes and access actionable information to improve patient outcomes.
2. Incentivize Providers and Enhance Engagement Programs
Align healthcare professionals with HEDIS improvement goals by incentivizing technology adoption and provider engagement programs. By supporting physicians in adopting innovative solutions, health plans can build stronger, goal-aligned relationships that enhance patient care quality.
3. Foster a Culture of Continuous Improvement
Promoting a culture of continuous improvement empowers healthcare providers to embrace innovation, routinely assess practices, and drive sustained HEDIS score improvements. Consistent advancement in care practices benefits both providers and members.
4. Promote Collaboration Among Healthcare Professionals
Foster a collaborative ecosystem where healthcare professionals share best practices and insights, leading to stronger collective outcomes. Integrate with technology partners and encourage SDOH-based referrals to address both medical and non-medical patient needs, enhancing adherence and overall patient health.
5. Implement Beneficiary Incentive and Education Programs
Empower patients through incentive programs that encourage active participation in their care. Transparency programs can help patients make informed decisions, while gathering patient feedback offers valuable insights into care experiences and areas for improvement, strengthening the patient-provider relationship.
6. Enhance Data Collection and IT Systems
Invest in data collection and IT infrastructure to gain deeper insights into patient populations. Supporting providers with clinical documentation tools and information systems helps identify improvement areas, tailor interventions, and improve HEDIS score reporting.
7. Adoption of Value-Based Payment Models
Shift to value-based payment models that reward quality over quantity, tying reimbursements to health outcomes rather than service volume. This approach closes HEDIS gaps by prioritizing patient care quality and aligning provider incentives with meaningful health outcomes.
8. Explore Member Education Programs
Provide patients with educational resources and workshops on preventive care and chronic condition management. Informed members are more engaged in their health decisions, supporting better outcomes and improving adherence to care plans.
9. Build Strategic Partnerships within the Community
Strengthen community partnerships that address social determinants of health, such as transportation and food security. This approach expands the support network for members, enhancing health outcomes and advancing HEDIS goals.
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 start optimizing your HEDIS performance.