The HEDIS Hunt: Addressing care gaps to improve quality ratings

With all of the documentation requirements and paperwork (electronic or not) that physicians have to do, it’s no wonder that doctors spend twice as much time filling out forms than they do with patients.

Requirements for the Healthcare Effectiveness Data and Information Set (HEDIS) have long been criticized for contributing to the burden on physicians and taking time away from patients. HEDIS doesn’t even track outcomes, leading many doctors to question its true effectiveness—even though it has that word in the acronym.

Despite all the protests, HEDIS is here to stay. And there are hints that accepting HEDIS works. According to a recent Humana study, providers in value-based agreements achieved 26% higher HEDIS scores compared to providers in standard agreements, resulting in 7% fewer ER visits, 6% fewer hospital inpatient admissions and 15% lower medical costs. This study seems to draw a correlation between improved HEDIS measures and healthier outcomes.

Based on this, those who embrace HEDIS as a tool to improve quality of care will increase the likelihood of improved outcomes. We call this the HEDIS hunt—a daunting adventure where analytics gives you strength and your companions are those with the most skin in the quality game: payers, providers and the patient.

Arm Yourself with Analytics

The path to improved HEDIS measures cannot be traveled without advanced analytics. Regardless of who takes the lead—though typically the payer—using analytics to identify patients with care gaps that impact quality measures is a critical first step.

Each quality measure has certain eligibility requirements (e.g., age and gender) and exclusions (e.g., a pregnancy diagnosis excludes patients from a BMI screening). These parameters can be used to identify eligible patients with a care gap to be documented and closed by providers. For example, HEDIS requires that women 50-74 years of age receive a mammogram to screen for breast cancer, provided they have not had a mastectomy. The eligible population is identified according to these filters, and then reconciled with billing code data to determine whether the required screening has been performed to date. For those patients who have not been coded for this screening, a care gap is created and communicated to providers for closure.

Beyond gap identification, these analytics are most valuable when they are made actionable. Providers require real-time data to address quality measures at point-of-care. This is somewhat possible through the problem list on the patient’s chart in an electronic medical record (EMR) system, but that is not always the most efficient solution, nor is it always real-time. Population health management platforms or tools help aggregate, display and record outcomes of quality measures and offer shared accessibility for the providers involved in a patient’s care (e.g., payers, primary care physicians, specialists, nurse practitioners, dieticians, psychiatrists, etc.).

Read our story on the successes of a care management platform for a regional ACO in the Midwest that reduced total cost of care for its 170,000 attributed lives by 3.5% in year one and 5% in year two.

The Role of the Payer

It can be argued that payers have the most to gain from improved HEDIS measures, especially financially. Because quality ratings allow consumers to compare health plans apples-to-apples, a higher rating better positions a plan competitively and helps grow membership. But improving HEDIS measures relies heavily on the provider to execute. It is the payer’s responsibility to facilitate provider engagement in quality measurement.

Payers must arm providers with the right information at point-of-care to close gaps. This is where the right analytics and a shared database or platform comes in. Once data can be shared, payers should implement incentives to impact provider behavior. For example, building contracts with a value-based component that financially incentivizes providers to close quality gaps. Contracts may also include incentives to adopt IT solutions that collect and report HEDIS data. With the right incentives, providers are more likely to participate in a HEDIS gap closure campaign.

Patient engagement is another critical element of improving quality ratings. Payers can improve patient’s involvement in their care by taking responsibility for outreach and education. Many patients may not know that they need to visit the doctor annually or receive certain screenings at a higher frequency—it is up to someone within the care team to educate patients on the right behaviors.

The Role of the Provider

The strategic imperative for payers to improve HEDIS measures is clear. But what about providers? The correlation isn’t always as strong. Ultimately, performing the activities required by HEDIS should keep patients healthier, help identify potential risks earlier to intervene, and prevent deterioration and complication of symptoms for chronic conditions. That is one source of motivation for providers.

Efficiency is another motivator. Knowing and understanding the requirements for HEDIS measures and having access to patient-specific information in real time makes providers more efficient when delivering high-quality care.

But even so, providers are increasingly at risk for improving quality and outcomes. In a world of value-based care, providers are held accountable for meeting quality measures and achieving better outcomes through financial incentives, bonuses or risk-based arrangements. Starting the practice of better HEDIS measurement now will help providers perform better in the long-term.

To become more effective and high-performing in HEDIS, providers should focus on achieving accurate documentation of quality measures within the appropriate timeframes. This includes using the right codes for screenings as well as exclusions on the patient’s charts and submitting the right billing codes. It’s important to note that some quality measures have a deadline—for example, the HEDIS measure for Child Immunization Status requires that a child receive all necessary immunizations before two years of age. It is not enough to only code correctly; the screenings and measurements must also be done in a timely manner.

The Role of the Patient

While the primary responsibility for quality measurement and performance falls on payers and providers, the patient cannot be ignored. A more engaged patient will be more willing and likely to pursue the necessary screenings and preventative visits required by HEDIS.

How can you create a more engaged patient? Some state Medicaid programs have implemented beneficiary incentive programs that provide gift cards, cash, meals, childcare, transportation and other benefits as incentives for healthy behaviors, such as gym memberships, quitting smoking, decreasing cholesterol and blood pressure rates, and more. The more invested a patient becomes in their own health, the higher chance you have of performing better on quality measures.


A HEDIS quality performance improvement effort is a complex initiative with multiple stakeholders. It requires advanced data analytics to prioritize the right gaps to close at the right time and with the right patients and providers. However, proactively addressing care gaps has huge downstream benefits, including preventing hectic and administratively burdensome chart chase campaigns.

With the right data informed by analytics, communicated to providers so they have information at their fingertips, providers will be better equipped to submit claims with the right coding that captures HEDIS data. And when that happens, everyone wins.

Contact us to learn more about the role Texture Health plays in impacting your HEDIS improvement campaigns.

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