Enhancing Healthcare Quality Through HEDIS Measures and Managed Care Plans

Leverage advanced HEDIS software and TRC-specific measures to improve the effectiveness of healthcare data and reporting. Enhance your HEDIS program performance with customized solutions focused on diabetes care and comprehensive managed care strategies. Explore industry-leading managed care plans and HEDIS services delivered by top-tier providers.

What is HEDIS?

HEDIS (Healthcare Effectiveness Data and Information Set) is a standardized performance measurement tool used to evaluate the quality and effectiveness of services provided by managed care plans. Developed to ensure consistent and objective assessment, HEDIS focuses on key healthcare indicators, enabling data-driven insights that support continuous quality improvement. By measuring outcomes across various domains, HEDIS plays a vital role in enhancing care delivery within managed care environments.

Why HEDIS Matters

HEDIS plays a critical role in promoting transparency, accountability, and continuous improvement in healthcare. Here's why it's important:

  • Informs Decision-Making: HEDIS provides reliable, standardized data that allows purchasers and consumers to compare the performance of health plans.
  • Drives Quality Improvement: Health plans use HEDIS results to evaluate and enhance the quality of care and service delivery.
  • Supports Preventive Care: Measures the delivery of essential preventive health services.
  • Monitors Key Areas: Tracks chronic disease management, service utilization, access to care, and patient demographics.
  • Regulatory Requirement: Reporting HEDIS data is mandated by CMS (Centers for Medicare & Medicaid Services) and DHCS (Department of Health Care Services).

Primary Methods for Calculating HEDIS Data

HEDIS data is calculated using two main methodologies:

Administrative Method

  • Relies on data from claims, encounters, pharmacy records, and lab results.
  • Rates are calculated for the entire eligible population that qualifies for specific HEDIS measures.
  • Provides a broad, data-driven overview of care delivery.

Hybrid Method

  • Combines administrative data with medical record reviews for greater accuracy.
  • Uses a statistically valid sample (typically around 411 members) from the eligible population.
  • Applied to select measures where clinical documentation is needed to supplement claims data.

HEDIS Measures Overview

HEDIS includes a total of 92 measures, organized into six key domains:

  • Effectiveness of Care – Evaluates how well care meets clinical guidelines.
  • Access/Availability of Care – Assesses how easily members can obtain needed care.
  • Utilization and Risk-Adjusted Utilization – Measures the use of healthcare services, accounting for patient risk factors.
  • Experience of Care (CAHPS) – Captures member satisfaction and experience through standardized surveys.
  • Electronic Clinical Data Systems (ECDS) – Reports select measures using electronic health records and clinical data systems.
  • Health Plan Descriptive Information – Provides context about plan characteristics, enrollment, and operations.

Additional HEDIS Data Collection Methods

In addition to administrative and hybrid methods, HEDIS incorporates the following data collection approaches:

Survey (CAHPS)

The CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey gathers insights into member experiences with health plans and providers.
CAHPS results are becoming an increasingly important component of overall HEDIS ratings and quality assessments.

Electronic Clinical Data Systems (ECDS)

ECDS utilizes clinical data from electronic sources such as Electronic Health Records (EHRs), health information exchanges, and quality management databases.
This method supports more timely and comprehensive reporting of certain HEDIS measures, enhancing accuracy and data integration.