Improving HEDIS Quality Measures: Best Practices for Healthcare Administrators

What separates one healthcare provider from another? In 1991, the National Committee for Quality Assurance (NCQA), a private nonprofit organization committed to improving healthcare quality, sought to answer that question with the HMO Employer Data and Information Set (HEDIS), an auditing tool designed to inform healthcare payers and consumers about providers’ performance-related benchmarks. In 2007, the meaning of HEDIS was changed to Healthcare Effectiveness Data and Information Set. 

Today, more than 90% of health plans use HEDIS to evaluate provider care and collect performance data so that payers can make optimal choices about healthcare coverage. As the healthcare landscape shifts toward value-based care, HEDIS audits are invaluable for quantifying what payers want. For healthcare administrators, that means there are many opportunities for you to differentiate your organization from competitors.


Understanding HEDIS Quality Measures

HEDIS consists of more than 90 measures across six domains of healthcare quality— effectiveness, access, experience, utilization, descriptive information, and clinical data systems—used to evaluate hundreds of Medicare Advantage, Medicaid, and commercial health plans. Using HEDIS to measure the clinical quality of a health plan offers insight into the caliber of the healthcare services a consumer can access through it.

The NCQA uses HEDIS measures along with data derived from the Health Outcomes Survey and the Consumer Assessment of Healthcare Providers and Systems program to assign a weighted average Health Plan Rating (HPR) to every eligible participating health plan. The star-rating scale ranges from 0 to 5 and increases in half-point increments, with specific ratings based on a plan’s performance in these three subcategories:

  • Patient experience: patient-reported experiences relating to providers, plan services, and customer service
  • Prevention: the proportion of care recipients who received prevention measures, such as immunizations, screenings, and health advice
  • Treatment: the proportion of care recipients who received appropriate treatment measures—direct actions to resolve acute or chronic conditions—such as providing the correct ratio of medications to a patient with asthma

The broad objective of HEDIS and the associated HPRs is to evaluate whether healthcare providers and insurers are optimizing their resources to deliver high-quality care, information that can benefit players on all sides of the healthcare market. For consumers, HEDIS data and a high rating point to the likelihood of receiving top-notch care. For the healthcare providers and health plan administrators, the measures can help with identifying performance gaps, realizing improved outcomes, and encouraging consumers to choose one health plan over another. There’s also a financial incentive, as highly rated health plans have better chances of boosting their funding.


How to Improve HEDIS Quality Measures with Staffing and Technology

As you oversee operations in your role as a healthcare administrator, consider these best practices to improve your organization’s HEDIS quality measures.

  • Hire for and foster a culture of collaboration and communication.

Interdepartmental coordination is a common challenge among health plans, as pertinent data often becomes isolated in individual team silos. The solution to these departmental barriers is fostering a culture of collaboration and communication and hiring individuals with strong communication skills to promote it. Key member data should be accessible and shared across teams so that the entire organization can work toward meeting consumers’ needs. The consumer, too, should feel welcome to take part in the collaboration, triggered by proactive communication from staff. From consumers’ point of view, a concerted and proactively communicative effort by their health plan demonstrates prioritization of health outcomes, improves engagement, and offers superior levels of customer support, thereby improving HEDIS scores.

  • Leverage technology for data collection, analysis, and reporting.

Technology may prove integral to your organization’s endeavor to improve HEDIS quality measures. Electronic health records, for example, are essential for centralizing and sharing access to important patient health data. Bear in mind, also, that reporting and data analysis are mainstays of HEDIS compliance that can be both time-consuming and capable of causing delays if poorly executed. Leveraging advanced tech tools such as artificial intelligence and natural language processing—and building a team of individuals familiar with these technologies—can not only expedite these processes but also help to ensure accuracy.

  • Ensure you have the right staff in place to support tech initiatives.

As we alluded to above, tech is only as good as the people who use it, and a health plan needs sufficient staff to satisfy the high level of administrative work required for data collection, analysis, and reporting. Identifying experienced and capable talent is a labor- intensive process, but you can overcome these challenges by partnering with a dedicated staffing agency who has tools and screening processes to vet candidates’ soft skills and hard skills. If that agency is well-seasoned in the care management space, you can be confident that you have an ally who knows what you need and how to get it for you, including communicative, technological-savvy clinical and non-clinical healthcare talent.


Medix is a staffing agency that specializes in healthcare and healthcare technology. Get in touch with us to discover how we can help you build your most flexible and talented team.

Work with a Trusted Healthcare and Life Sciences Staffing Agency.

We help companies find great talent — and great talent find great jobs.