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.
View the 2019 HEDIS Measures on the Provider Guides page.
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:
- Breast Cancer Screening
- Annual Chlamydia screening
- Annual Pap test
- Testing of pharyngitis
- Appropriate Treatment for 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-childhood and adolescent
- Prenatal care including iniation of care, frequency of ongoing prenatal care and post partum care
- Well-child care
- Cholesterol Management
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 MHS mid-year report card provides a snapshot of how our health plan performed against state, NCQA and MHS standards, and what we’re doing to improve our health outcomes.
View the most recent Health Plan Report Card on the Provider Guides page.
HEDIS is a registered trademark of the National Committee of Quality Assurance.