The health plan guide to HEDIS measures

With quality scores being tied not only to revenue but also member satisfaction, maximizing the efficiency and effectiveness of quality improvement efforts is key for every health plan. One of the most critical quality programs is the annual HEDIS^® measurement and reporting process, which serves as a major indicator of plan effectiveness and value for consumers.

Read on as we focus on the importance of HEDIS, key changes that have recently been made to the HEDIS program, and best practices for health plans to close care gaps, improve member experiences, and increase health equity.

What is HEDIS?

The Healthcare Effectiveness Data and Information Set (HEDIS) is used as a way to measure the effectiveness of care and service of plans within the healthcare industry. Centers for Medicare & Medicaid Services (CMS) align with National Committee for Quality Assurance (NCQA) to implement HEDIS measures as part of the Medicare Advantage Star Rating calculation. HEDIS measures assess plans for their quality of care, looking for areas of improvement, tracking the success of different enhancement strategies, and giving plans a standardized measurement to compare themselves with other plans. HEDIS data also helps plans to target care gaps and identify different methods to improve every year. Today, more than 90% of plans use it to assess performance year over year.

For HEDIS, there are more than 90 quality measures that are designed to allow clinical comparison across health plans. These measures are used for accreditation and in other programs such as state Medicaid assessments and Medicare Star Ratings. There are several different types of measures in the HEDIS measure set:

• Administrative: The bulk of measures fall into the administrative category. Administrative measures are calculated using claims, encounter, enrollment, and provider data.
• Survey: Survey measures, such as CAHPS^®, and Qualified Health Plan (QHP) for the Exchange line of business, measure patient experience by conducting surveys. There are only a handful of survey measures today.
• Hybrid: Hybrid measures use claims data supplemented with manual retrieval and abstraction. These measures allow for medical record review to increase rates on a sampled portion of the measures population, since what they are measuring is not always or easily captured via claims data.
• Digital/ECDS: Now, we have the future of quality measures: digital and Electronic Clinical Data Systems (ECDS) measures. ECDS measures are a subset of digital measures and rely on electronically gathered data to stratify measure results. The quantity of digital and ECDS measures increase each year as we march toward a digital future, while administrative and hybrid decline.

The constantly changing landscape of digital measure requirements imposed by NCQA and CMS means that each measure could be subject to rulemaking and changes each year. As more measure requirements become digital, sourcing clinical data will require a multi-faceted approach for success.

Annual HEDIS changes over the years

HEDIS measures can change each year, sometimes slightly and sometime significantly, to keep current with health research, population health trends, and emerging practices. After proposing each round of changes each February, NCQA holds a public comment period to get feedback from plans.

Some recent landmark changes include:

• Transitioning HEDIS reporting to ECDS. As technology has continued to evolve, HEDIS measures evolve as well, and part of that is NCQA’s plan to make HEDIS reporting completely digital by 2030. With each year, measures change to be more digital, and plans should be prepared to make this transition as they collect data.

• The Race and Ethnicity Stratification (RES) program.RES measures have been implemented by NCQA to address racial disparities in healthcare and to help increase health equity. Beginning with five measures in 2022, NCQA expanded its RES program for MY 2023 to include an additional eight measures. For MY 2024, NCQA proposed adding another five measures to the RES program, bringing the total to 18. It continues to grow each year, including a change in MY 2025 that negates the need for providers to cite sources of data related to race.

• Affirming gender-relevant care. HEDIS measures have undergone revisions for language limiting care to members of a singular gender and continue to change. For example, pregnancy and childbirth being expanded to include those who don’t identify as women. And changes to MY 2025 include an update to language around the Chlamydia Screening in Women (CHL) measure, which currently excludes members whose gender is not listed as “woman,” even if they are recommended for routine screening. The change looks to update this to be more inclusive of transgender and gender-diverse members.

Best practices for improving your HEDIS measure rates

With the constant changes and updates to HEDIS measures each year, staying on top of your plan’s HEDIS strategy is key to staying current and compliant with the latest healthcare trends. Take a look at some of the best practices we advise plans to consider while approaching HEDIS measures.

A year-round HEDIS strategy

There tends to be a conflict of timelines within HEDIS practices. Too often, plans find themselves spending so much time gathering data from the previous measurement year (MY), that efforts for the upcoming year or quality projects outside of HEDIS aren’t prioritized. By the time January rolls around, there is no longer any time to close gaps in care, engage members, or conduct outreach to providers that could impact scores. This is why a year-round strategy is crucial for safeguarding care plan adherence and quality bonuses. For plans looking to implement an “always-on” HEDIS strategy, consider these five things:

• Compare results. After each season ends, take time to analyze measure results and compare them to both internal goals and external competitors. Identify measures that didn’t meet projected targets and find areas for improvement. Work with vendors to pull a population size larger than the HEDIS target of 411 to get a clearer idea of real data and opportunities for closing care gaps. Use publicly available Star Ratings data to supplement your findings.
• Review supplemental data. The second half of the year is a perfect time to work with providers to create additional data sources. Take advantage of health information exchanges, immunization registries, and other resources for a fuller picture of population health. This increases the possibilities for clinical data exchange while decreasing administrative headache of manual chart retrieval. Doing so before HEDIS season kicks off also allows plans to secure data without pressure, and increases the possibility of completing these projects.
• Increase multichannel engagement. It can be challenging to locate medical histories and risk factors for new members, but making sure they don’t fall through the cracks is key. Identify members who haven’t scheduled a visit with their PCP and perform focused engagement efforts, leaning on analytical data to pinpoint high-risk members. Focus these efforts year-round so for better results, and make sure to deliver communications in a variety of ways—email, phone calls, texts, and traditional mail—for the greatest impact. Data centered on social determinants of health (SDoH) can also inform which method might be best for outreach to specific demographics.
• Establish a regular cadence for data operations. Over the course of the year, as data builds and care gaps are closed, plans should monitor gains as they occur over time with a monthly data run. Doing so creates opportunities to intervene and refocus the direction of the program—ultimately resulting in more chances to improve HEDIS scores. Consider running a monthly refresh for the latest data on care gaps for member engagement as well as proactive efforts for retrieval and abstraction. Consider year-round HEDIS campaigns as well, as plans can identify members who carry over from the previous year. Create two teams to focus on HEDIS activities as well as the submissions process so that both can work concurrently.
• Improve provider communication and education. In the effort to engage with members, take care not to neglect provider outreach as well. Consider a quality improvement tool to guide outreach efforts, such as configurable provider scorecards, to streamline the dissemination of summary performance and member-level care gap data to providers. Ensure that scorecards are kept current to remove retired measures and reflect changes to existing measures to help providers focus their efforts in the right areas and conduct periodic workshops to educate providers on HEDIS and Star Ratings updates.

Plans should start considering HEDIS season as a year-round concept to stay ahead of the curve and to avoid surprises when it’s submission time. A comprehensive HEDIS strategy helps to keep plans successful in a highly competitive marketplace.

Proactive efforts and ongoing HEDIS retrieval and abstraction results in better rates for administrative and hybrid measures using chart data as a supplemental data source. Rate improvement helps with Star Ratings, NCQA rankings, state programs, and value-based care arrangements with providers. By adopting these practical approaches throughout the measurement year, health plans will set themselves up for success once the reporting year begins and time counts the most.

Improving health equity with Race and Ethnicity Stratification (RES)

The NCQA has continued to expand its Race and Ethnicity Stratification (RES) program. Targeted member outreach is the bedrock of improving self-reported race and ethnicity data for health plans—but requires a thoughtful, systematic, and highly tailored approach to be successful. Plans should look to:

• Deploy multi-channel communications. Even within the same demographic groups, some members will prefer to respond to a quick text message, others will be more likely to trust a phone call from an agent, and still others will prefer to log into a secure web portal to share data with their health plan. Plans can’t afford to invest in only one approach to collect required information on race and ethnicity. Solutions such as Cotiviti’s Eliza enable plans to capture self-reported data through health risk assessments (HRAs) and other outreach campaigns through a wide variety of channels. With clear messaging, plans can introduce the importance of collecting the data and explaining how it will be used to advance health equity.
• Communicate with cultural awareness and empathy. Hiring call center agents who speak the same languages as your members is an obvious starting point, but building trust with all the communities served by your plan goes well beyond simply adapting to language barriers. From enrollment to disenrollment, plans must understand the unique cultures of the members they serve. A message that resonates with English-speaking communities may fall flat or worse, actually offend your members if simply translated into Spanish, Chinese, or Tagalog without hiring people from those backgrounds to help you understand your members’ unique cultures.
• Build partnerships with local businesses and community organizations. It’s one thing to send a text message or email and hope the member pays attention to it—it’s quite another to get out into the community to physically meet members where they are. From partnerships with laundromats to grocery stores, health plans are finding unique and innovative ways to not only close care gaps but also demonstrate empathy and build trust with their members.

When engaging providers, plans should also work with their networks to encourage adoption of improved coding, including the use of Z codes to capture SDOH factors that impact care outcomes. Once race, ethnicity, and SDOH data are sourced, use them not only to meet HEDIS reporting requirements but to fuel action plans and health equity initiatives year-round. As plans start to build their data analyses, the insights gained from these combined efforts can be used to tailor interventions and address disparities as they are identified.

How to transition your health plan to a digital HEDIS reality

Technology continues to advance within the healthcare industry, making ECDS and digital data more and more common. NCQA has made clear that digital measurement is here to stay, slowly outdating some hybrid measures over the years and transitioning to digital measurements instead. Though the transition from hybrid to ECDS has been slow, it is accelerating. In MY 2024 and MY 2025, several traditional HEDIS hybrid measures are shifting to digital or will drop the hybrid component altogether, with measures including colorectal cancer screening (COL), immunizations for adolescents (IMA), childhood immunization status (CIS), and cervical cancer screening (CCS) moving to ECDS-only reporting. These four measures account for around 30% of hybrid activity today. Transitioning these measures to digital should indicate that now is the time to devise a data strategy to maintain and improve rates in the digital future.

The transition to digital measurement and the retirement of traditional hybrid measures such as COL is causing concern on how to boost and maintain rates. Furthermore, many plans do not feel they have access to the data they need to maintain their current rates in a fully digital state. Cotiviti analyzed the average MY 2022 hybrid lift for clients—the difference in measure rate after hybrid chart review—and found that plans may be more prepared for the transition to ECDS than they realize, at least for the measures that have already been proposed or confirmed (Figure 1).

The relative size of the bubble containing the measure indicates the average lift Cotiviti clients received after hybrid chart review was completed. Measures outlined in pink are confirmed or proposed for retirement or transition to ECDS reporting in MY 2024 and MY 2025. These measures saw the lowest hybrid lift and suggested that NCQA is following a “low-hanging fruit” approach by first transitioning measures that will not be as impacted when chart review is removed before moving to a fully digital state by 2030.

In the meantime, plans can prepare by:

• Gathering supplemental data. Traditional supplemental sources like labs and immunization registries already have high adoption. Instead, plans should focus energy on digital supplemental data gathering and year-round chart review. Year-round insights can gauge measure performance, influence care gap closure, and positively influence provider behavior. With any year-round project, it is important to prioritize the measures and target membership that will likely yield meaningful results. Prospective HEDIS measurement and reporting is a critical activity for continuous improvement of performance during the transition to digital measures.
• Choosing data partners. For network and vendor partners, health plans should analyze their market relative to the organizations that are currently sharing data with the partner for payment and operations exchange purposes. Analyze market and volume relative to the partner and be aware of minimums and licensing fees.
• Laying a firm foundation. Find digital success by starting simple: ask what data is readily available, which tools are needed to gather the data, and which measures propose a high value. Evaluate the current state of technology to set reasonable goals for the future that align across the organization. Focus energy on year-round efforts such as supplemental retrieval and abstraction, as well as digital supplemental data gathering. Build a solid foundation with room to adapt and grow as measures continue to digitize during this journey.

The evolving landscape of HEDIS requires a sophisticated program to understand the complexity of quality compliance. Implement a year-round measurement and reporting system with Cotiviti. Reduce abrasion with minimal disruption to providers and their staff and achieve the highest number of compliant components possible within any reporting time frame.

How to close care gaps for better HEDIS measure results

When health plans can successfully engage their members, they form a vital connection that enables members to make more informed healthcare decisions in the future, such as scheduling often-ignored preventive care screenings. To accomplish this critical goal, plans need to invest in a true multi-channel approach that recognizes each member as a unique individual.

We will walk through four areas where health plans can achieve meaningful progress by focusing on outreach to specific populations.

Read on as we tackle key quality measures tied to each of these populations as well as how an individualized approach to member outreach can get members to take action.

The colorectal cancer screening (COL) HEDIS measure

Colorectal cancer can be screened through numerous methods including colonoscopy, virtual colonoscopy using computed tomography, fecal occult blood test (FOBT), sigmoidoscopy, and DNA stool test. There are even options for home testing, such as a fecal immunochemical tests (FIT). Plans should consider optimizing their quality scores while improving the health of their member population by:

• Offering multiple screening options. Plans should make members aware that home testing options such as FITs and other alternatives to a colonoscopy are available. One study found that only 38% of participants who had just a colonoscopy recommended completed their screening, compared to 67.2% who were recommended an FOBT and 68.8% who were given a choice between a colonoscopy or FOBT. Educating members on all the available options increases the likelihood of screening and catching cancer sooner.
• Deploying tailored communications instead of a single message. As noted in one 2022 study, “a key challenge in developing cancer screening messages is ensuring that patients perceive information about their cancer risk as personally relevant.” Researchers found that sending targeted messages to participants increased their intention to be screened for colorectal cancer. This is also reflected in Cotiviti’s own client data. Members who received targeted communications about colorectal cancer screening through the Eliza® consumer engagement solution had a 4.3% higher rate of gap closure than those who were unengaged.
• Collaborating with both providers and IT departments to prepare for the ECDS transition. Plans should save chart review results in HEDIS reporting tools to use as supplemental data and bring internal IT stakeholders together to create a repository to house historical colorectal cancer screenings. This ensures future access to this valuable data. It’s wise to work together externally with providers to gain historical data on members, helping to select the right metrics, benchmarks, and reporting to close care gaps.

Early treatment for colorectal cancer leads to much higher survival rates. Through effective member and provider engagement, coupled with robust quality measurement and reporting tools, health plans can make a tangible impact to their members’ long-term health.

The osteoporosis screening in older women (OSW) HEDIS measure

Scheduling follow-up care after a fracture is a critical component to the HEDIS and Star Ratings measures for osteoporosis, and members within the measure population who have experienced a fracture should have a bone mass density test or a prescription to treat osteoporosis within six months of the date of fracture. Since this measure often has a small denominator, ensuring this gap is closed for as many qualifying members as possible can significantly improve measure scores. Plans should also pay attention to the Osteoporosis Screening in Older Women (OSW) HEDIS measure, which was added in 2020 to improve prevention efforts. 

Here are some things plans can do to improve preventative care through member engagement efforts, as well as gain better quality scores in the process:

• Start with overall health. Early osteoporosis prevention starts with regular annual wellness visits and health screenings with an emphasis on a healthy diet and regular exercise. Educate members on the benefits of staying active, eating a variety of healthy foods, and maintaining a good weight, as all these things can be a great start to ensuring better bone density.  Don’t forget to remind members about adjacent efforts such as vision screening and quitting smoking. Poor vision can lead to a higher risk of trips and falls, and smoking has been related to increased overall osteoporosis risk. 
• Investing in multichannel outreach. Part of communicating all of these care reminders to members is choosing the right method. Remembering that most people regularly encounter multichannel experiences with other industries should be a reminder to plans that they shouldn’t shy away from technological possibilities like digital ads, mobile apps, and self-serve tools. Consider how to go beyond basic communication and branch into interactive voice response (IVR), secure digital, live agent, mail, or text.
• Eliminating communication barriers. Part of executing multichannel outreach correctly is remembering to send out the right message at the right time. While it’s easier said than done, member engagement efforts that are timely, personalized, and offer the right resources increase the likelihood of a member scheduling a screening or wellness visit. And multichannel means trying a few methods in different rhythms for best results. Cotiviti’s own research showed that a combination of IVR, email, and texting produced an engagement rate that was 35.7% better than direct mail alone, 45% better than texting alone, 33% better than email alone, and 17% better than IVR alone. 

Childhood immunizations HEDIS measures

Health plans can help to boost immunization rates by addressing possible barriers to immunization and by bolstering provider support. Measuring and benchmarking quality measures related to immunizations for HEDIS reporting provides health plans with a blueprint on how to improve immunizations. The ECDS measure standard also offers a method to better collect and report structured electronic clinical data for HEDIS quality measurement, enabling plans to better understand where to allocate resources and what members to target to improve quality.

As part of this observance, let's explore the key quality measures and data sources related to immunizations. The HEDIS program includes numerous measures for immunization status for both children and adults, all of which have transitioned or will soon transition to the NCQA’s ECDS standard. These include:

• Childhood Immunization Status (CIS, CIS-E): This measure assesses the percentage of children who have received numerous recommended vaccines by their second birthday, including DTaP, polio, MMR, chicken pox, and more. The measure calculates rates for each vaccine and specific combination rates. NCQA transitioned this measure to ECDS only and retired hybrid reporting for Measure Year (MY) 2025.
• Adult Immunization Status (AIS-E): This measure evaluates the percentage of members 19 years and older who are up to date on recommended routine vaccines including flu, Tdap, zoster, and pneumococcal. The AIS-E measure utilizes r the ECDS reporting standard and uses data from electronic sources such as administrative claims, HIEs, case management registries, and EHRs.
• Immunizations for Adolescents (IMA, IMA-E): This measure assesses adolescents who have received one dose of meningococcal vaccine, one Tdap vaccine, and the complete HPV series by their 13th birthday. NCQA transitioned this measure to ECDS only and retired hybrid reporting for MY 2025.
• Prenatal Immunization Status (PRS-E): This measure calculates the percentage of deliveries in which women received flu and Tdap vaccinations during the measurement period. It was the first ECDS-reported measure to be publicly reported in MY 2020.

While immunization registries can be a helpful source of supplemental data, they may already be highly utilized by some plans, along with other traditional supplemental sources. Plans should explore new supplemental sources such as Continuity of Care Documents (CCDs) to augment their claims data and boost rates. A strong focus on supplemental data drives down the need for in-season chart review and will make the transition to ECDS smoother.

SPC and SPD cardiovascular HEDIS measures

Consistent medication usage is a key factor in preventative measures for cardiovascular health. Two HEDIS measures, Statin Therapy for Patients with Cardiovascular Disease (SPC) and Statin Therapy for Patients with Diabetes (SPD), play a significant role in assessing cholesterol management success. The measures focus on two critical aspects of cardiovascular health. SPC targets males aged 21–75 and females aged 40–75 with clinical atherosclerotic cardiovascular disease (ASCVD) who adhere to statin therapy. SPD is directed towards men 21–75 years old and women aged 40–75 with ASCVD who received and adhered to statin therapy.

Health plans can help close the gap in medication usage contributing to cardiovascular issues with improved member engagement and better outreach. Plans should consider:

• Improving cholesterol management and statins. Cholesterol management begins by monitoring two types of cholesterol: high-density lipoproteins (HDL), or the “good” cholesterol, and low-density lipoproteins (LDL), which increases the risk of heart disease in high amounts. Lifestyle factors contributing to high cholesterol levels include poor diet, obesity, smoking, drinking alcohol, and lack of exercise. Factors beyond personal control, like aging, genetics, and pre-existing medical conditions also contribute to high cholesterol levels. Making informed choices regarding diet, regular physical activity, maintaining a healthy weight, and moderating alcohol intake are equally essential steps. Members should also undergo regular cholesterol testing, visit with medical providers regularly, and adhere to prescribed medications.
• Making the connection with members. Improving the rates of Americans checking their cholesterol levels and adhering to treatment plans requires a multi-step approach. Educating members about preventive care from the start helps uncover opportunities for early interventions before conditions escalate. Plans should also take time and value to understand member demographics and identify those most likely to be impacted by high cholesterol. This makes it easier to support them with culturally competent communications that they are more likely to respond to, thereby driving improvements in quality, HOS/CAHPS® survey results, and member outcomes. Plans should consider member education and communications about appointment scheduling, as well as reminders for crucial HEDIS and Star Ratings measures such as medication adherence for high blood pressure and cholesterol health.

As health trends continue to change and HEDIS measures continue to be modified, take care to notice which gaps in care can be closed for improved population outcomes within your own plan’s structure.

Building an overall HEDIS quality strategy

Preparing for HEDIS measures is a key part of a good quality strategy, but it isn’t the only part. Put your plan first by preparing for HEDIS measures and Star Ratings, closing care gaps, optimizing member engagement, provider engagement, and more. Consider taking these steps as you build your overall quality strategy:

• Take a pulse check on your readiness for digital measurement
• Devise a roadmap for data acquisition, data cleansing and mapping, and data storage
• Perform monthly proactive data runs
• Focus energy on digital supplemental data gathering and year-round chart review
• Prioritize working with a DAV-certified vendor
• Talk to any network and vendor partners about who is contributing data for your use cases

Of course, these are just the preliminary steps to get started in building a better HEDIS quality strategy. Enlisting the help of a trusted vendor can help speed your improvement and get the answers you need to close care gaps and benefit member health.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.
CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).