HEDIS 101: Measuring the performance of managed healthcare plans

In a world of health IT acronyms, HEDIS is one of the most complex. We’re breaking down the specifics of the program and what you need to know, below.

Table of Contents

What is HEDIS?

The Healthcare Effectiveness and Information Set (HEDIS) is a set of performance measures developed by the National Committee for Quality Assurance (NCQA) as a tool for measuring the performance of managed healthcare plans.

Why was HEDIS created?

HEDIS 1.0 originated as a collaboration between the HMO Group and a group of employers in 1991 and has evolved over the last 30 years to become the standard for consumers and purchasers to compare health plan performance

Who uses HEDIS?

HEDIS measures are used by commercial plans, Medicare Advantage (MA) plans, Qualified Health Plans (QHPs) purchased on the state or federal exchanges, and Medicaid plans.

How many HEDIS measures are they, and how do they work?

There are over 90 HEDIS measures. They evaluate six overarching domains of care provision:

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

How are these performance measures used?

A selection of HEDIS performance measures are used in both the NCQA’s Health Plan Ratings program and also in the Medicare Part C and D Star Ratings program. HEDIS measures are implemented across both programs to evaluate members’ experience of plan performance and delivery of preventative care and treatment.

In addition, HEDIS measures are incorporated in the Centers for Medicare & Medicaid Services (CMS) core set of measures for adults and children enrolled in Medicaid and Children’s Health Insurance Program (CHIP). These measures are used by CMS to evaluate state performance in Medicaid programs.

How is HEDIS created?

HEDIS measure development is supported by clinical subject matter experts, in-depth research, and exhaustive field testing. HEDIS measures are updated in response to changes in the healthcare environment, sensitive to emerging population health concerns and advances in clinical care.

How does HEDIS differ from other CMS Quality Measure Programs?

HEDIS measures are informed through abstraction of administrative claims data or data from other records submitted to health plans from providers. Health plans develop their own incentive programs for contracted providers independently of CMS. Consumers can compare plan performance regionally, but neither NCQA or the Medicare Stars Rating programs make performance on individual clinician or facilities available for comparison. 

By contrast, CMS quality programs are informed by clinical or administrative data collected directly from clinicians and healthcare facilities, or through claims submitted by clinicians and facilities. CMS penalizes or incentivizes clinician or facility performance directly. Consumers can also access individual clinician and facility measure performance.

To learn more about the changes happening at CMS, read about updates to the Quality Payment Program here.

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