Blue Review
A newsletter for contracting institutional and professional providers

July 2018

An In-depth Look at HEDIS®

At Blue Cross and Blue Shield of Illinois (BCBSIL), we understand that clinicians are always striving to provide the highest quality health care to their patients and our members. We also understand that “quality” is hard to define. Prioritization of an emerging or acute issue, potentially complicated by a challenging social dimension, often takes precedence over addressing routine or chronic management, and that prioritization naturally reflects a dedication to providing quality care. 

A population’s health may best be managed by measuring performance against established measures of quality that are known to align with important clinical outcomes, organizing processes to improve care delivery in areas in need of improvement, and tracking results over time. That is the purpose of the Healthcare Effectiveness Data and Information Set, or HEDIS, as it is more commonly known.

HEDIS is the evidence-based standard of quality measurement for population health. Currently consisting of 94 measures across seven domains of care, HEDIS is maintained by the National Committee for Quality Assurance (NCQA), the leading accrediting body for health insurance plans. HEDIS creates a common language of definitions that allow for a fair and scientific comparison across the broader population. These well-vetted specifications carefully outline how members that qualify for a measure are identified, including agreed-upon reasons for exclusion, and how patients meet the particular measure. Taken together as a denominator and a numerator, respectively, simple rates of performance can then be calculated. 

These measures have been developed through a scientific process in collaboration with experts, and many of the measures have been endorsed by the National Quality Forum, a national organization working to standardize clinical quality measurement. Given the complexity of the data collection efforts, health plans frequently use NCQA-certified vendors that specialize in this quality measurement process, and, regardless of whether health plans calculate the data themselves or rely on vendors, the whole process is audited by NCQA-certified auditors to help ensure data integrity.

As a clinician, you are probably familiar with many of the measures, such as Appropriate Testing for Children with Pharyngitis, or Follow-Up After Hospitalization for Mental Illness. Many health systems have organized their care to respond to health plan efforts to monitor and identify opportunities to improve the care provided to our members. While clinicians and health systems generally focus on raw rates of performance, these rates are standardized nationally into performance percentiles for comparison of performance across health plans. 

According to Dr. Elmer Abbo, a strategic medical director at BCBSIL and an internist who practiced as a hospitalist and palliative care physician before joining Blue Cross: “While HEDIS is ever evolving and remains a work in progress, it really represents the best ability we have as part of the larger, national health care system to understand the quality of care being provided at a national level, and accordingly, how we are doing as a health plan in taking care of our members in comparison to others.”

“As you can imagine, there is a tremendous amount of focus on the results. Just like clinicians in the office or at the bedside, everyone wants to understand how they are doing and to identify opportunities for improvement. It’s why we got into health care in the first place. At the end of the day, we want to know that our members are getting the care they need to ensure good results and that they are living better lives with our help.”

The results are also used by NCQA in their accreditation assessment of health plans. Half of the assessment is based on established standards of industry practice for health plans that are important structural markers of quality. There is a component of member satisfaction, which captures key elements of quality not otherwise easily observed, but more than one third of the accreditation assessment is based on HEDIS results. Thus, these measures that any clinician would recognize as important and valid markers of quality play a key role in determining health plan accreditation.

While health plans receive detailed results, NCQA publicly shares summarized results that combine both HEDIS and member satisfaction data in the Health Insurance Plan Ratings on their website at ncqa.org. Members and employers are increasingly reviewing these results when making choices about their health insurance coverage options. BCBSIL embraces this transparency and accountability to our members.

A limitation of quality measurement via HEDIS is that measurement is generally indirect, via an analysis of insurance reimbursement claims, rather than the direct review of medical records or extraction of actual clinical data from electronic health records (EHRs). Historically, NCQA has mitigated this with a laborious process of medical record chart collection and auditing to augment results obtained from a review of administrative claims with data obtained from direct medical record review. The data obtained for these measures are referred to in HEDIS as hybrid measures, since they blend administrative claim data with a sampling medical record review to get a reliable health plan performance estimate. In fact, the familiarity many office-based clinicians have with HEDIS comes from what may seem like a deluge of medical records requests that now come every late winter in what has become known as HEDIS or “chart chasing” season.

While hybrid measures are intensive to measure and thus an important focus of attention for clinicians and health plans, they actually represent the minority of HEDIS measures. Most HEDIS measures are purely administrative, that is based simply on reimbursement claim data, and so the measurement of many measures may be occurring without any obvious awareness of the typical clinician. Interestingly enough, since HEDIS is about quality measurement and not reimbursement, HEDIS utilizes any appropriate claim for a service as evidence of the provision of service regardless of payment. That’s right: Whether or not the claim was paid or denied is irrelevant for the purposes of HEDIS. 

Nevertheless, we are well aware that many, if not most, of the important aspects of care are not captured in administrative claims, and reviewing medical charts is not sustainable. The industry is increasingly looking to direct data sharing of electronic health data from providers with health plans, and as that process becomes increasingly common, a new era for quality measurement with more sophisticated and clinically robust measures will likely evolve.

BCBSIL is starting this process now. Through our partnership with Availity®, an all-payer bilateral data sharing and clinical operations platform, we are beginning to work with providers and electronic health record vendors to improve our data sharing capabilities. In the short term, this will help reduce the annual chart chasing burden on participating providers. In the long term, we look forward to working with others nationally to see how new more powerful methods of quality measurement across the spectrum of care can be developed and deployed.

In the meantime, working with the HEDIS measures we currently have, BCBSIL is beginning to provide certain network providers with access to a cloud-based platform that will allow self-directed queries of performance results across all of the HEDIS measures. Providers will be able to review performance on their own patients regardless of the insurance product and receive potential care gap reporting that is updated monthly to help facilitate the providers’ quality improvement efforts. We are excited by this opportunity to collaborate with you to further support the health and wellness of our members, your patients.