Why You Should Take Heed of HEDIS

Already used by more than 90% of US health plans, HEDIS®1 measures will only grow in significance as value-based care and population health programs gain momentum.

In 1992, the National Committee for Quality Assurance (NCQA) developed the set of measures that would become the Healthcare Effectiveness Data and Information Set (HEDIS) measures. Over its three-decade history, HEDIS has emerged as the known and accepted standard for objectively quantifying plan performance. HEDIS results are used by more than 90% of U.S. health plans, representing more than 200 million plan members, to objectively measure and communicate plan performance annually.

HEDIS measures are calculated using administrative claims data, clinical EHR data, and patient survey data collected from the Consumer Assessment of Healthcare Providers & Systems (CAHPS®2) survey and the Medicare Health Outcomes Survey. HEDIS data influence more areas of healthcare than many realize, informing risk adjustment, determining health plan ratings and Medicare Special Needs Plan performance, assessing pay-for-performance provider arrangements (plans use HEDIS to determine the quality of provider care), and informing population health improvement initiatives. Since HEDIS measures inform many clinical and quality analyses and financial arrangements, it is important to consider their broad applicability and the quality of the data used to calculate these measures.

HEDIS measures: What are they? What do they cover?

HEDIS measures provide insights into member care satisfaction and how well appropriate care is provided. For example, the measures determine whether, and to what extent, regular cancer screenings and preventive care visits occur. They also determine if high blood pressure is controlled appropriately; whether heart disease, diabetes care, mental health, asthma, and other medical conditions are managed well; track screening for alcohol misuse and tobacco use cessation assistance; and evaluate members’ level of access to the care they need.

Each quality measure falls under one of six domains of care:

  1. Effectiveness of Care
  2. Access/Availability of Care
  3. Experience of Care
  4. Utilization and Risk Adjusted Utilization
  5. Health Plan Descriptive Information
  6. Measures Reported Using Electronic Clinical Data Systems

Plan Performance

HEDIS scores are critical in measuring plan performance for commercial, Medicare, and Medicaid health plans. These comprehensive measures are standardized to allow both purchasers and consumers of health insurance to compare plans reliably and in detail. NCQA has also established specific HEDIS measures for special needs plans, or SNPs, which allows SNPs to identify performance gaps and establish viable improvement targets. The Centers for Medicare & Medicaid Services note that “SNPs can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, track improvement, and provide a set of measurement standards that allow comparison with other plans.”

Star Ratings

Medicare Advantage plans (Part C) and/or Medicare prescription drug plans (Part D) are annually awarded a CMS Star Rating, which rates how well plans are delivering care. Payers whose plans are considered high quality (i.e., rated four or five out of five stars) are eligible for quality bonus payments. In 2022, these payments averaged $352 per enrollee. Star ratings are calculated based on several quality scores, including HEDIS measures.

Quality Ratings System

CMS also uses the Quality Rating System (QRS) to score qualified health plans (QHPs) offered through state and federal Health Insurance Exchanges. The ratings, which may change from year to year, are calculated using a five-star scale and are based on third-party clinical quality measures from HEDIS, the Pharmacy Quality Alliance (PQA), and QHP enrollee survey responses. QHPs that offered coverage through an exchange in the prior year are required to submit this data to CMS as a condition of continued certification.


In 2005, CMS started implementing pay-for-performance (P4P) programs in an effort to move from a fee-for-service healthcare model to a more value-based model. In P4P arrangements, providers are incentivized to close care gaps and engage more fully with members to ensure compliance with health screening guidelines, regular wellness visits, and other preventive measures. Such programs continue to be adopted by public and private health providers, with no signs of slowing, and commonly rely on HEDIS measurements to measure provider performance. States who use a P4P model in their Medicaid plans, for example, typically base a number of their measurements on HEDIS.

Population Health Management

Broadly speaking, “population health” refers to the health outcomes — and the distribution of health — within a group of individuals, whether that group be defined geographically, according to ethnicity, according to a disease state, or by another parameter. The NCQA, in its definition of “population health management” (PHM), specifies that PHM addresses health needs along the entire continuum of care, as well as health disparities, and that its goal is psychosocial well-being in addition to physical health.

With the emphasis on health disparities and social determinants of health, the field of population health and the practice of PHM continue to gain traction. NCQA points directly to HEDIS measurements as a way to evaluate PHM. According to NCQA, HEDIS and other performance measurements facilitate “assessment of the effects of population health management on provider organization performance.”

Government Entities also rely on HEDIS

With its detailed measures that adapt to reflect the current healthcare environment, HEDIS is an important information source for several organizations. PQA measures, as mentioned above, are applied in quality ratings. PQA — a “measure developer, researcher, educator and convener” in its own right — looks to HEDIS for determining some of its standards, such as the medication safety “Use of High-Risk Medications in the Elderly” measure.

HEDIS measures are also used by state governments. Michigan uses HEDIS measures for an annual “Medicaid HEDIS Results Statewide Aggregate Report,“ and Washington state uses a number of HEDIS scores in its Common Measures Set, which “provides the foundation for health care accountability and measuring performance.”

Verinovum knows HEDIS

The NCQA has introduced HEDIS Digital Quality Measures (dQMs) and added a new reporting method, the Electronic Clinical Data Systems (ECDS), to support healthcare’s ongoing digital transformation. Introduced in 2015, ECDS “encourage interoperability of health data systems and collection and use of clinical and patient-reported outcomes data.” Some states, such as New York, require ECDS in HEDIS reporting.

In a 2021 issue brief, NCQA points to the importance of data standardization in realizing the transition to electronic data reporting, increased interoperability, and greater data sharing. “Data aggregators can work to align data formats with quality measure specifications,” the report states, and “to ease the burden of auditing aggregated clinical data for HEDIS reporting.”

The relatively new NCQA Data Aggregator Validation program helps measure an organization’s ability to correctly aggregate and output the clinical data used to inform quality measurement programs like HEDIS.

The program requires a rigorous assessment that can take up to 18 weeks to complete and establishes that the accuracy of the clinical data used to inform HEDIS measures is trustworthy.

In 2022, Verinovum earned the “Validated Data Stream” designation through the program. In a Verinovum press release, NCQA President Margaret E. O’Kane said the program “sets a high bar for how data are managed,” adding, “we are excited that organizations like Verinovum are working to improve trust in clinical data and help ensure the data’s accuracy and broader usability.”

Verinovum’s Data Curation as a Service (DCaaSSM) solution improves clinical data quality and can help to accurately inform programs that impact HEDIS measurements. High-quality actionable data lead to HEDIS measurements that accurately reflect the quality of care a plan’s members receive.

The DCaaS Proof-of-Concept can be piloted within a matter of weeks at no-risk. Learn more.

1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
2CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).