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Maximizing Healthcare Quality: HEDIS Measures and Managed Care Plans

Utilize advanced HEDIS software and TRC HEDIS measures to enhance healthcare effectiveness data and information sets. Optimize HEDIS program performance with tailored solutions for diabetes measures and comprehensive managed care plans in healthcare. Discover industry-leading managed care plans and HEDIS measures offered by top service providers.

What is HEDIS?

HEDIS, or the Healthcare Effectiveness Data and Information Set, is a comprehensive tool utilized to assess and measure the performance of managed care plans. HEDIS measures are standardized metrics that gauge the effectiveness and quality of healthcare services provided by these plans. By focusing on key indicators, HEDIS ensures a consistent evaluation of healthcare outcomes, facilitating a data-driven approach to improve the overall quality of care within managed care settings.

Why does HEDIS matter?

  • HEDIS is designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of health care plans
  • Health plans use HEDIS results to guide and measure quality of care and service improvement activities
  • Measures preventive health services
  • Monitors management of chronic illness, utilization of services, access to care, demographics
  • HEDIS is required by CMS and DHCS (Department of healthcare services)

There are 2 primary methods for calculating HEDIS data:

Administrative

  • Data captured from claims, encounters, pharmacy, and labs

  • Rates are calculated for the entire eligible population who qualify for a HEDIS measures.

  • Data captured from claims, encounters, pharmacy, and labs.
  • Rates are calculated for the entire eligible population who qualify for a HEDIS measures.

Hybrid

  • A combination of administrative data and medical record review
  • A statistically valid sample of members (~411) drawn from the eligible population
  • Select measures only

We have total of 92 measures grouped in 6 domains

  • Effectiveness of care
  • Availability/access to care
  • Utilization and risk adjusted utilization
  • Experience of care (CAHPS)
  • Measures reported using Electronic Clinical Data Systems
  • Health plan descriptive information

Additional HEDIS data collection methods

  • Survey: The CAHPS survey collects data on member experience CAHPS is becoming increasingly important to our HEDIS Report rating.

  • Electronic Clinical Data Systems (ECDS) Data from databases containing clinical data, such as Electronic Health Records and quality management databases.

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