The objective of this document is to provide a high level understanding of the Healthcare Effectiveness Data and Information Set (HEDIS), which is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. This document helps in understanding different components of the HEDIS in terms of the measure sets (what it is meant for health plans, changes to the previous year), different methods of collecting data for HEDIS and key requirements for reporting HEDIS

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16 October, 2017 | Author : Vaibhav Rai| Healthcare Business Analyst
Enhancing Competitive Advantage through
Improved HEDIS Reporting and NCQA Rankings
CitiusTech Thought
Leadership

2. 2
 The objective of this document is to provide a high level understanding of the Healthcare
Effectiveness Data and Information Set (HEDIS), which is a tool used by more than 90 percent of
America's health plans to measure performance on important dimensions of care and service
 This document helps in understanding different components of the HEDIS in terms of the
measure sets (what it is meant for health plans, changes to the previous year), different methods
of collecting data for HEDIS and key requirements for reporting HEDIS
 The process & timeline section helps in understanding key responsibilities of different
stakeholders involved over the time period starting from release of HEDIS measure specs to
posting of HEDIS ratings
 The document concludes with the summary of advantages and importance of HEDIS for health
plans in terms of financial, clinical, operational and competitive advantage and also few key
recommendations and best practice for health plans
Objectives

3. 3
Agenda
 Components of HEDIS
o HEDIS 2018 Measure Set and Difference from HEDIS 2017
o HEDIS Data Collection Methods
o Audit & Submission Requirements for HEDIS
 Process and Timelines of HEDIS 2018
 Business Proposition of HEDIS Measures
 HEDIS Best Practices and Recommendations

4. 4
 Healthcare Effectiveness Data and Information
Set - HEDIS® is the gold standard in healthcare
performance measurement, used by more than
90% of America’ health plans and many leading
employers and regulators on important
dimensions of care and service
 HEDIS® is maintained by NCQA, a not-for-profit
organization committed to evaluating and
publicly reporting on the quality of physicians,
HMOs, PPOs and other organizations
 Altogether, HEDIS consists of 95 measures across
7 domains of care (updated yearly)
 NCQA collects the HEDIS data to compare health
plan performance to other plans and to national
or regional benchmarks
 CMS also collects the Medicare HEDIS data in
order to provide HMO services for Medicare
enrollees under Medicare Advantage plan
Overview
Objectives:
 Useful for evaluating current
performance and setting goals
 Emphasis on physician
collaboration and patient
engagement
 Focus on quality outcomes to
help members getting the most
from their benefits and helping
payers for better use of limited
resources
 Close gaps in care and improve
overall quality
Stakeholders:
 Health Plans
 NCQA

5. 5
Components of HEDIS
Measure Set
 Every year, NCQA releases a measures list which includes measures which are added, deleted and revised
 Later in the year, NCQA releases the measure specification file which includes the details of inclusion /
exclusion criteria for each measure
Data Collection Methods
 HEDIS data is collected through surveys, medical charts & insurance claims for hospitalizations, medical office
visits and procedures
 Clinical measures use the administrative or hybrid data collection methodology as specified by NCQA
 Administrative data are electronic records of services, including insurance claims and registration systems from
hospitals, clinics, medical offices, pharmacies and labs
 Hybrid method is more costly, time-consuming and requires nurses or medical record reviewers who are
authorized to review confidential medical records
Reporting (Audit & Submission Requirement)
 HEDIS results must be audited by an NCQA-approved auditing firm for public reporting
 NCQA collects HEDIS survey results directly from health plans and PPOs through HOQ (Healthcare Organization
Questionnaire), and collects HEDIS non-survey results through IDSS (Interactive Data Submission System)
 NCQA's web site (link) includes a summary of HEDIS results by health plan

6. 6
HEDIS 2018 Measures Set
Domains
 Effectiveness of Care
 Access/Availability of Care
 Experience of Care
 Utilization & Risk Adjustment
Utilization
 Relative Resource Use
 Health Plan Descriptive
Information
 Measures collected using
Electronic Clinical Data Systems
Each measures specification file includes:-
 Summary of Changes, Description, Calculations,
Definitions
 Eligible Population Criteria – Includes details like
product line, age, continuous enrollment, allowable
gap, anchor gap, benefit, event/diagnosis which needs
to be considered for including a member in the eligible
population criteria
 Administrative Specification - Outlines the collection
and calculation of a measure using only administrative
data, and describes the eligible population, the
numerator requirements and any optional exclusion
allowed for the measure
 Hybrid Specification - Includes sampling requirements
for the denominator population, medical record
documentation requirements for the numerator and
any optional exclusion allowed for the measure
 Exclusion criteria, Notes, Data Elements for Reporting
HEDIS (2018) consists of total of 95 measures across 7 domains of care

7. 7
Effectiveness of
Care
 55 measures
 Quality of clinical care
 Impact of care delivered
 Added 5 new measures - Transition of Care, Follow-Up after Emergency
department visit for people with high-risk multiple chronic conditions, Use
of Opioids at High Dosage, Use of Opioids From Multiple Providers, Medicare
Health Outcomes Survey
 Retired 1 measure - Aspirin Use and Discussion
Utilization and
Risk Adjusted
Utilization
 15 Measures
 Assess how a health plan manages and expends its resources
Experience of
Care
 3 measures
 Member satisfaction survey
 Retired one measure
HEDIS 2018 Measures Set and Difference from HEDIS 2017

8. 8
Health Plan
Descriptive
Information
 6 Measures
 Plan’s structure, staffing, enrollment characteristics and ability to provide
effective care
 Retired one measure on weeks of pregnancy at time of enrollment
Access/
Availability of
Care
 6 Measures
 Assess how many members use basic plan services
 Retired one measure - Call answer timeliness
 Added one measure - Use of first-line psychosocial care for children and
adolescents on antipsychotics
Relative Resource
Use
 5 Measures
 Indicate how intensively health plans use resources
 To standardize total cost of care across different clinical areas
Measures
collected Using
Electronic Clinical
Data Systems
HEDIS 2018 Measures Set and Difference from HEDIS 2017
 5 Measures
 Assess the quality of depression care
 This data is challenging to collect through typical HEDIS reporting methods
 Added 3 new measures on Depression Screening and follow-up for
Adolescents and Adults, Unhealthy Alcohol Use Screening and Follow-Up,
Pneumococcal Vaccination Coverage for Older Adult

9. 9
HEDIS 2018 Measures Set and Difference from HEDIS 2017
Domains (2018) Description 2018 2017
Effectiveness of Care
 Quality of clinical care
 Impact of care delivered
55
Retired: 1
Added: 5
51
Retired: 1
Added: 2
Experience of Care  Member satisfaction survey
3
Retired: 1
4
Access/Availability of
Care
 Assess how many members use basic plan services
6
Retired: 1
Added: 1
6
Retired: 1
Utilizatio
n and
Relative
Resource
Use
Utilization
and Risk
Adjusted
Utilization
 Assess how a health plan manages and expends its
resources
15 15
Relative
Resource
Use
 Indicate how intensively health plans use resources
 To standardize total cost of care across different
clinical areas
5 5
Health Plan Descriptive
Information
 Plan’s structure, staffing and enrollment
characteristics and ability to provide effective care
6
Retired: 1
7
Retired: 1
Measures collected using
electronic clinical data
systems
 Assess the quality of depression care
 This data is challenging to collect through typical
HEDIS reporting methods
5
Added: 3
2
Added: 1
TOTAL 95 91

10. 10
HEDIS Data Collection Methods
Administrative
Method
Claims and encounter data are used to identify the eligible population and numerator.
Most of the measure also allows to use supplemental data along with claims &
encounter data.
Hybrid Method
This method involves drawing of a systematic sample of members from eligible
population & retrieving medical charts from providers for the members who do not
meet the numerator criteria through administrative data.
Survey Method
For survey measures, data is collected directly from the certified survey vendor. Data is
obtained from member & provider survey via the Healthcare Organization
Questionnaire (HOQ).
Electronic Clinical
Data Systems
New initiative from NCQA for health plan quality reporting in HEDIS which expand the
use of electronic data (EHRs, clinical registries, HIEs, administrative claims systems etc.)
to encourage interoperability for quality measurement.
Data Collection Methods
Each measure specifies the data collection method(s) that must be used. If a measure includes both the
Administrative and Hybrid methods, either method may be used.
Supplemental Data Uses
When administrative or medical record data are not available, organizations may use other sources to collect
data about their members and about delivery of health services to their members. Examples include lab result,
pharmacy data, EHR, immunization data, data from provider portals, HIEs and provider abstraction forms.

11. 11
HEDIS Data Collection Methods: Hybrid Method
Medical Record Review
 Out of 95 measures, there are 17 measures which can be collected using the hybrid method.
Hybrid method requires organization to draw sample from the eligible population
 Out of this 17 Hybrid measures,
• 9 measures have membership-dependent denominators – means the eligible population will
be determined by membership data only
• 8 measures have claim-dependent denominators- means the eligible population will be
determined by membership & claims data
 Once the eligible population is determined, sample of 411 or 548, as provided by NCQA needs to
be drawn from that population
 Organizations then review the administrative data to determine if members in the systematic
sample meet the numerator criteria or not
 For members who do not meet the numerator criteria, medical charts are retrieved from the
providers
 Retrieving medical chart is a exhaustive process known as Medical Record Review, organization
needs to identify what charts needs to be retrieved and from which provider they need to be
retrieved
 Record update process done through medical charts is known as Abstraction process which is
verified during the audits

12. 12
Audit Requirement for HEDIS (1/2)
Offsite Audit
To promote accurate, reliable and publicly reportable data, NCQA requires health plans to
validate HEDIS data by an independent NCQA Licensed Compliance Audit Organization
Offsite Audit Process
 Roadmap completion- responding to the list of questions from audit vendor
 Survey Sample frame validation- A Certified Auditor validates the survey sample frame before
drawing the final sample and administers the survey
 Core Set Measure selection- Auditor will review all measures not included in the certification
program and any measure that failed certification which will be reported by the organization
 Source Code Review- Prepare set of data with known results for validating algorithm
calculation of source code
 Medical Record Review (MRR) Validation- Auditor ensure sample is created correctly or it has
passed the measure certification process and MRR data entry or uploading process for adding
MRR data is correct
The organization collects measure data, while the audit team schedules and conducts the following
activities which are part of two step process – Offsite Audit and Onsite Audit.

13. 13
Onsite Audit
A concurrent audit lets the auditor detect errors in the data collection process while there is
time for the organization to correct its methods and minimize the possibility of biased rates
Onsite Audit Process
 During the site visit, the auditor
• Conducts interviews, reviews systems, processes and measure-specific-data collection
• Performs queries for specific data flows to validate beginning-to-end accuracy; and
assesses the level of the organization’s data completeness.
 The length and content of onsite visits depends on the size and structure of the organization
and the number of delegated vendors or offsite facilities relevant to measure reporting
 The team concludes the onsite visit with a closing session, where it shares initial findings
Audit Requirement for HEDIS (2/2)

14. 14
Submission Requirement for HEDIS
 HEDIS results (in NCQA defined formats) need to be submitted to NCQA for health plans to receive final rankings
from NCQA and to be included in Quality Compass* for comparative health plan performance analyses
 HEDIS non-survey data is submitted through IDSS (Interactive Data Submission System). HEDIS survey results are
retrieved directly from health plans and PPOs through HOQ (Healthcare Organization Questionnaire)
*tool used for selecting a health plan, conducting competitor analysis, examining quality improvement and benchmarking plan performance.
File Type Submitted
to
Description
IDSS file XML NCQA
 Consolidated XML file including results for each measure
 Health plan needs to submit separate XML files for each
product line (Commercial/Medicaid/Medicare/Marketplace)
NCQA Patient-
Level-Detail
(PLD) file
Fixed-width
text file
HEDIS
Compliance
Auditor
 Patient level data including details for each measure
(applicable/not applicable, compliant/not compliant)
 Health Plan need to submit separate PLD files for each product
line (Commercial/Medicaid/Medicare/Marketplace)
 It is a method of validating that the counts of individual
members match the measure totals in the Interactive Data
Submission System (IDSS)
CMS PLD file
Fixed-width
text file
CMS
CMS Plan All-
Cause
Readmissions
(PCR) file
Fixed-width
text file CMS
 Apart from submitting PLD files to CMS mentioned above,
health plans also need to collect ‘Plan All-Cause Readmissions
(PCR)’ measure result as a separate file and should be
submitted in the same manner as PLD files
File Formats for Submission

15. 15
Process and Timelines of HEDIS 2018
Jul ’17
Oct ’17
Nov ’17
Dec ’17
Jan ’18
Feb ’18
Apr ’18
May ’18
Jun ’18
Aug ’18
Sep ’18
Oct ’18
 Release of
technical
specifications
 Start of
measure
cert.
testing
 Certification
of survey
sample frame,
hybrid
measures and
sampling
methodology
 Posting of
XML
templates,
validations
and data
dictionaries
 Release of
2018 HOQ
 Submission
of final
HOQ for
IDSS access
 Release of 2018 IDSS for
loading and validation
 Distribution of survey
measure submission IDs
 Provision of
preliminary
rates (XML
format) to
Payer
 Submission of
member level
data
 Demonstration of
XML file
uploading
 Sending of plan
confirmation via
HOQ
 Confirmation on
State, enrollment
and accreditation
info.
 Confirmation
on rating and
accreditation
info.
 Sending of projected
ratings
Legend
Activity –
NCQA
Activity –
HealthPlan
Activity –
HEDIS
Vendor
 Drawing of
samples (for
hybrid measures)
 Availability of CAHPS
survey results
 Submission of final
HEDIS results
 Freeze on ratings
data
 Posting of
final health
plan ratings
 Provision of
supplemental data
impact reports
and final XML files
to Payer

16. 16
Business Proposition of HEDIS Measures
 Guide P4P Measures
 Part of CMS Star which can
impact health plans revenue
by up to 5% for Quality Bonus
Payments and up to 70% as
part of rebates of difference in
plan bid and benchmark
 Part of NCQA accreditation;
the industry’s gold standard
 Ensures effectiveness of care
 Improved clinical and quality
outcomes
 Ensures health plans are
offering quality preventive
care and service to members
 Increased insight on patient
disease, comorbidity and care
management
Financial & Clinical
 Ensures availability of care
 Focus on processes of care
and are directly actionable
for quality improvement
activities
 Patient feedback is turned
into actionable intelligence
 Enhanced care
coordination
 Improvement in resource
utilization
 Actionable intelligence to
improve operational
performance
Operational
 NCQA ratings published on
consumer reports
 Gateway to health
Insurance Marketplace
 Allows plan-to-plan
comparisons by quality,
national & regional
benchmarks apart from
price (Quality Compass)
 Can qualify plans to
provide HMO services to
MA enrolees
 Centrepiece of most health
plan "report cards"
 Higher member retention
Competitive
Advantage

17. 17
HEDIS Best Practices and Recommendations (1/2)
Readiness
 Evaluate previous season performance for key areas of improvement
before starting for new season
 Keep track of annual changes to HEDIS measurement, timelines &
reporting requirements
Process
Improvement
 Reduce burden of provider by efficient & intelligent chart chasing –
analyzing provider chart submission pattern, configurable intelligence to
chase provider with highest likelihood of success, avoiding duplicating
request
 Identify claims submitted without proper ICD or CPT codes that count
towards the measure
Data
Completeness
 Have better relationships with provider network to ensure timely
acquisition of electronic data resulting in more efficient data acquiring
than manual chart review
 Invest in data: Enrich data lake by adding more layers of data by capturing
data from different sources (EHR, Lab, Provider Portals, HIEs)

18. 18
HEDIS Best Practices and Recommendations
Technology
 Enable continuous monitoring of quality results – real-time actionable
information, target measures with the greatest impact by leveraging a
modern CQM engine
 Introduce technology enabled engagement programs focused on members
mobile lifestyle
 Focus on workflow-driven technology solution investments reusable
across other areas, e.g., chart chase solutions that span across HEDIS, HCC
improvement, pended claims etc.
Right
Workforce
 Information sharing between all teams is most important for teams to
work efficiently
 Chart retrieval & abstraction teams should be well trained in prioritization
of outreach as well as interpreting charts to make sure to capture accurate
chart information
Focusing on the above parameters can easily help any health plan tackle the key challenges
faced in HEDIS improvement like managing different interconnected teams, inefficient chart
chasing, quality tracking etc.

19. 19
References
 Summary of Table of Measures, Product Lines and Changes
http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2018/HEDIS%202018%20Measures.pdf?ver=20
17-06-28-134644-370
 HEDIS Measures for Accreditation Scoring in 2018
https://www.ncqa.org/Portals/0/Policy%20Updates/Corrections/2018/HEDISMeasuresandPoints
forReportingYear%202018.pdf?ver=2017-05-15-204422-673
 Measure Specs
http://store.ncqa.org/index.php/catalog/product/view/id/2816/s/hedis-2018-volume-2-hard-
copy/
 Health Insurance Plan Rankings
http://healthinsuranceratings.ncqa.org/2016/Default.aspx
 Accreditation Levels
https://reportcards.ncqa.org/#/health-plans/list
 Ratings 2017
https://www.ncqa.org/Portals/0/Report%20Cards/Health%20Plan%20Ratings/Ratings2016FAQs_
Final_3.17.16.pdf?ver=2016-03-21-160657-990
 http://www2.citiustech.com/NCQA-HEDIS-2017-Volume-5

20. 20
About CitiusTech
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CAGR over last 5 years
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Healthcare customers
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Author:
Vaibhav Rai
Healthcare Business Analyst
thoughtleaders@citiustech.com
Thank You