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Terms of Use © 2021 copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc., an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield Healthcare Solutions. 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 Home State accountable for the timeliness and quality of healthcare services (acute, preventive, mental health, etc) delivered to its diverse membership.
Use of HEDIS ScoresAs both State and Federal governments move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and 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 preventive health outreach efforts. 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 RatesHEDIS 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 PCP services, and 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, and well-child care. HEDIS and HIPAAAs a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or health care 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. Learn the Lingo: Key Terms for Navigating the Value Based Care WorldWith the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG. Definition: HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information needed for reliable comparison of health plan performance.1-3 Performance is evaluated using over 90 measurements across 6 domains of care: effectiveness of care, access/availability of care,
experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems.2 Claims and survey data are aggregated and analyzed retrospectively to depict the quality of care and customer service delivered to patients.1,2 How it relates to ACO/PCMH: HEDIS measures are commonly included as required metrics in value-based payment programs, such as MIPS, and quality
rating programs (e.g., Star Ratings).3 HEDIS measures are used in evaluating the quality of care provided by health care practitioners, and meeting HEDIS measure targets is a factor in determining quality incentive payments.2,3 Many HEDIS measures are clinically focused on acute and chronic conditions, and some focus specifically on medications.1 Pharmacists’ medication- and health-related expertise can be leveraged to impact these measures to reach goals,
resulting in incentives to the practice. Pharmacists should be engaged in HEDIS metrics impacting their ACO and/or PCMH to improve quality of care. Pharmacists are involved in some HEDIS measures including statin therapy for patients with cardiovascular disease and diabetes, medication reconciliation post-discharge, comprehensive diabetes care, and controlling high blood pressure.1 Pharmacist-initiated improvement in HEDIS measures leading to incentive payments can be part of the
financial justification for increased pharmacist services. Involved organizations/oversight: HEDIS is administered and overseen by the National Committee for Quality Assurance (NCQA) to improve the quality of health care. HEDIS is used by CMS, other health insurance plans, and health care organizations nationwide.1,2 Resources:
Contributing author: Neeloufar Fakourfar, PharmD, BCACP Chapman University School of Pharmacy Next Article Hospital Outpatient Prospective Payment System (HOPPS) What type of healthcare organization uses measures found in the Healthcare Effectiveness Data and Information Set HEDIS?HEDIS refers to a widely used set of performance measures in the managed care industry. More than 90 percent of health plans—HMOs, POS plans, and PPOs—use HEDIS to measure performance.
What are HEDIS measures used for?HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance. HEDIS Measures relate to many significant public health issues, such as cancer, heart disease, smoking, asthma, and diabetes.
How is the Healthcare Effectiveness Data and Information Set HEDIS used quizlet?The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service.
What data is collected for HEDIS?HEDIS data is collected through a combination of surveys, medical record audits, and claims data. The data collected provides information regarding customer satisfaction, specific health care measures, and structural components that ensure quality of care.
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What type of healthcare organization uses measures found in the Healthcare Effectiveness data and Information Set hedis )?
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