Fall, winter bring cooler weather and HEDIS Season

By Natalie Godwin

November brings cooler nights, changing leaves, pumpkin spice EVERYTHING and, of course, the kickoff to HEDIS® season. Amid eating too much turkey and stuffing, many of our Healthcare Quality Assurance colleagues also are entering the HEDIS MY 2020 data submission season.

What is HEDIS?

For the uninitiated, Healthcare Effectiveness Data and Information Set (HEDIS) is one of the most common performance improvement tools within healthcare. According to the National Committee for Quality Assurance (NCQA), which administers HEDIS, nearly 200 million Americans are enrolled in a health plan that reports HEDIS results for more than ninety measures within six domains of care:

  • Effectiveness of Care
  • Access/Availability of Care
  • Experience of Care
  • Utilization and Risk-Adjusted Utilization
  • Health Plan Descriptive Information
  • Measures Collected Using Electronic Clinical Data Systems

What’s Changing?

As we all know within healthcare, the only constant is change, and HEDIS is no different. HEDIS is being renamed to HEDIS MY 2020 to reflect the measurement year, marking an enormous change in the industry. This is impacting the current HEDIS® season, too, as it’s now known as HEDIS Measurement Year (MY) 2020. (Get more information on the latest HEDIS measures.)

The specifications apply to quality data measured for the 2020 year and should be submitted to NCQA in June 2021. The change was made to ease the confusion of measurement year versus reporting year. As NCQA transitions to this new naming convention, there will be two certifications completed in 2021. The HEDIS MY 2020 certification will be completed on the regular schedule with Administrative Measure certification complete by February 15, 2021. The HEDIS MY 2021 certification will begin in April 2021 and will be completed on October 1, 2021.

Beginning with HEDIS MY 2022 and going forward, the certification will begin in April with certification due July 1. This change allows health plans to receive the measure specifications eleven months sooner, which allows them the opportunity to understand the measure changes and implement logic updates before implementation and measurement.

Health plans will continue to submit their annual report through the Interactive Data Submission System (IDSS). However, another change is that IDSS has been updated to a new format. The data elements under the HEDIS measures will have a more relational, modular, reusable, and meaningful name and structure with this new format. The IDSS data submission process will no longer require manual entry: all data will be uploaded based on the XML format identified by NCQA. The IDSS data continue to supplement the direct survey results from the Healthcare Organization Questionnaire (HOQ). The HEDIS data then helps calculate statistics and benchmarks and sets standards for NCQA Accreditation. Commercial data may also be included in Quality Compass, with permission. Quality Compass data is leveraged for comparative health plan performance analyses. With the change in submissions and new format changes, our friends in quality assurance may need extra whipped cream on their pumpkin pies.

The Future of HEDIS

As we continue to look to the future of HEDIS and the constant focus on more efficient data collection and reporting, there are six major tenets to keep in mind:

  1. Flexibility: Users can modify measures without changing their clinical intent
  2. Accuracy: Ensuring appropriate license agreements and measure results are calculated based on the HEDIS user
  3. Ease: Digital measures download directly into users’ data systems
  4. Insight: Electronic Clinical Data Systems (ECDS) create better insights for managing the health of individuals and groups
  5. Time: Updated schedule allows users access to measure specifications sooner, giving the user time to update logic and educate stakeholders
  6. Access: Adjustments to 40 HEDIS measures to better integrate telehealth into traditional healthcare modalities 

Of these major themes, none is timelier than telehealth. Following its surge in prevalence during the COVID-19 pandemic, telehealth access became more important than ever as a care option. This HEDIS focus ensures that as telehealth is enhanced and utilized more often that there are safeguards to eliminate waste and fraud and protect patient safety and privacy. This will continue to be important as telehealth is optimized and fully integrated into healthcare systems and patient care.

Change has been more profound this year than ever. The pandemic has caused the healthcare industry to reexamine how and where it provides healthcare services. As the leaves change in the fall in tandem with a new HEDIS season, I am encouraged by the changes in certification. HEDIS is the most widely used performance improvement tool and helps guide the quality and improvement of healthcare by measuring the quality of care in categories such as access to care, behavioral health and diabetes care.

HEDIS changes reflect a more technologically robust healthcare world and ensure more accuracy and greater insights into the future. So, let’s grab a mug of our favorite pumpkin spice delight and toast to this season of HEDIS and the future of healthcare.

Get details about the MedeAnalytics Quality Management solution, which can help you report HEDIS measures.


About the Author

Natalie Godwin brings more than 17 years of payer and provider healthcare experience to the MedeAnalytics Product Consulting team, where, as a director, she focuses on value-based performance management, and cost and operations. She uses her industry roles to work with clients and guide product development in hospital supply chain, hospital throughputs, population health, care management, quality and outcomes improvement as well as payer operations.