HEDIS®
Healthcare Effectiveness Data and Information Set (HEDIS)® is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) which allows comparison across health plans. Through HEDIS, NCQA holds MHS accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.
Use of HEDIS Scores
As both State and Federal governments move toward a healthcare industry that is quality-driven, HEDIS rates are becoming more important, not only to the health plan, but to the individual provider as well.
State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s ability to demonstrate an improvement in preventive health outreach to its members. Physician-specific scores are being used as evidence of preventive care from primary care office practices. These rates then serve as a basis for physician profiling and incentive programs.
Calculating HEDIS Rates
HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan.
Measures typically calculated using administrative data include:
- Annual mammogram
- Annual Chlamydia screening
- Annual Pap test
- Treatment of pharyngitis
- Treatment of URI
- Appropriate treatment of asthma
- Cholesterol management
- Antidepressant medication management
- Access to PMP services
- Utilization of acute and mental health services
Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data.
Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include:
- Comprehensive diabetes care
- Control of high-blood pressure
- Immunizations
- Prenatal care
- Well-child care
HEDIS and HIPAA
As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The medical record review staff and/or vendor will have a signed HIPAA compliant Business Associate.
Health Plan Report Card
The following mid-year report card provides a snapshot of how Managed Health Services (MHS) performed against state, NCQA and MHS standards in the first 6 months of 2009, and what MHS is doing to improve its health outcomes.
Managed Health Services’ Health Plan Report Card 2009 (PDF)
HEDIS is a registered trademark of the National Committee of Quality Assurance
