HEDIS Reporting: What You Need to Know


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When it comes to measuring how successful, or unsuccessful, a certain healthcare plan is, HEDIS is used around the world in the managed care industry. It is a tool to measure performance of healthcare plans, and the measures are revised every year. As so many organizations use this method of reporting, it means that many different healthcare plans can be assessed on a level playing field, using the same measures to evaluate the plans. It is useful for healthcare organizations, employees and people choosing what healthcare plans they want to use, and is used almost universally to measure healthcare plan performance and highlight areas that need improving, as well as areas of success. Here are just a few basic facts about HEDIS reporting.

What Does HEDIS Stand for?

HEDIS stands for Healthcare Effectiveness Data and Information Set, and was created in 1991 by the NCQA, the National Committee for Quality Assurance. HEDIS reporting consists of 90 different measures, that fall into 6 domains of care:

  • Experience of care
  • Effectiveness of care
  • Access/availability of care
  • Utilization and relative resource use
  • Health plan descriptive information
  • Measures reported using electronic clinical data systems

These measures are reviewed every year, with measures being added, removed or revised accordingly. The results of HEDIS reports are useful for both the organization and current or potential patients. Analyzing the performance of healthcare plans allows the organization to plan, make changes and alterations when required, as well as see what elements of the plans work best. For patients, the results can lead a plan to becoming ‘accredited,’ which shows that it meets the rigorous criteria and has a good ranking among other healthcare plans. This could be a factor that can inform the decision of a patient when they are looking into which healthcare plans to choose.

What Does HEDIS Do?

HEDIS provides a set of measures by which healthcare plans can be assessed. The data to achieve this is collected through medical charts and insurance claims for hospital stays, surveys conducted by external, NCQA approved organizations, visits to medical offices, pharmacies, labs and procedures. Once the data has been collected, the NCQA rates plans based on the 90 measures. This helps the organizations see where they are doing well, and where they can improve to move up the rankings.

Who Uses HEDIS?

An estimated 90% of healthcare plans in the US use HEDIS to evaluate their performance. Around 191 million people are enrolled in healthcare plans that use HEDIS reporting, and the results can also help make programs accredited. When auditing is taking place, the auditors generally use data from the first half of the year, which means they can feed back and suggest areas for improvement. Auditing is the process of an external body or individual analyzing parts of the organization, usually in relation to finances and accounts.

Auditing takes place in many different businesses and industries, and aims to provide a range of objective insights into the business. 

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