The National Committee for Quality Assurance (NCQA) was organized a few decades ago to accredit health plans. In 2008, the mission of NCQA expanded to healthcare providers and medical practices. NCQA’s primary focus is the Healthcare Effectiveness Data and Information Set, also known as HEDIS, which is used as a performance tool for health plans and providers. Almost 200 million lives are enrolled in health plans that report HEDIS data to NCQA. The purpose of this article is to review HEDIS, its benefits, how it impacts lab testing, and how it reduces healthcare costs.

HEDIS measures 90 aspects of patient care within six domains:

  • Effectiveness of Care
  • Accessibility/Availability of Care
  • Experience of Care
  • Utilization and Risk Adjusted Utilization
  • Health Plan Descriptive Information
  • Measures Reported Using Electronic Clinical Data Systems

The amount of HEDIS data generated by hundreds of health plans on millions of patients is enormous and can be overwhelming. For example, comprehensive diabetes care is measured under “Effectiveness of Care” and consists of hemoglobin A1c testing, eye exam, medical attention for nephropathy, and blood pressure control. Uncontrolled diabetes can lead to heart disease, stroke, blindness, kidney disease, and shortened life span. Implementing these tools which are HEDIS measurements when caring for patients with diabetes will promote proper management, reduce complications, and potentially prolong patient life.  Aggregated data regarding diabetes evaluation and management is sent to NCQA by payors. NCQA subsequently analyzes the data which may allow the identification of population health trends and payor-specific patterns in patient diabetes management and care. This may promote the institution of recommended changes in care.

Diabetes management is just one aspect of HEDIS that is measured and reported to NCQA. Cancer screening, cardiovascular disease management, opioid dosage, vaccination rates, and postpartum depression screening are all examples of HEDIS data. Participating health plans may be accredited and rated based on a 5-star system by NCQA depending on the broad measurements and patient domains.  Individuals may use accreditation and ratings when selecting a health plan. Furthermore, the Centers for Medicare & Medicaid Services (CMS) works with NCQA to measure the quality of healthcare provided by Special Needs Plans (SNPs). As the name implies, SNPs are coordinated care plans for individuals with special needs.

The data collected is not just used to measure and rate health plans; it allows healthcare providers to identify gaps in patient care so enhancements can be applied through quality improvement initiatives.  For example, a Family Medicine clinic in Salt Lake City, UT, used HEDIS data to improve medical attention to the investigation of nephropathy by over 10% in their diabetic patient population. Improving this metric enhances patient care. Another example is the state of Illinois used HEDIS data to measure patient care and cost effectiveness when they started the Illinois Health Connect and Your Healthcare Plus programs as a part of Medicaid reform in 2006. The program was successful with a savings of $1.46B; a 30% cost savings for in-patient care; and a 5% reduction in ER visits. It was the HEDIS metrics that allowed for a standardized method to measure cost savings and improvement in patient care.

HEDIS provides a uniform method for measuring patient care for millions of individuals in the United States. HEDIS facilitates the identification of healthcare gaps and implementation of quality improvement measures which may cut costs and improve patient care. NCQA uses HEDIS data across many different aspects of patient care, including preventative care and screening for chronic conditions such as diabetes, cardiovascular disease, and cancer. This standardized process which generates a massive amount of data measures healthcare improvements and sets benchmarks among the hundreds of health plans in the United States.



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