Improving Healthcare Effectiveness Data and Information Set (HEDIS) Scores with Data Management

Healthcare seems to be at the forefront of the global consciousness as of late. From the COVID-19 pandemic to the Medicare for all debate, all eyes are on the future of healthcare in the US.

Not surprising, the Healthcare Payer sector is one of the most highly competitive industries in the US and, as such, organizations are tasked with not only being efficient but also maintaining a high standard in quality of care.

In recent years, Payer organizations and governing bodies have turned to data analytics and health economics to differentiate Payers and Providers in a systematic and standardized way. The most popular health plan performance metric is the Healthcare Effectiveness Data and Information Set (HEDIS).

HEDIS measures are heavily regulated and meticulously compiled by the National Committee for Quality Assurance (NCQA) in collaboration with the Centers for Medicare & Medicaid Services (CMS). A health plan's performance on HEDIS metrics is directly related to their CMS Star ratings, which are available to all members when they are choosing their healthcare and insurance providers.

Overall, the goal of HEDIS metrics is to provide patients with an objective measurement of a Payer’s effectiveness of care. HEDIS is comprised of ~90 metrics across 6 domains, which gather and analyze patient care information from Payers and Providers against industry standard best practices. HEDIS scores effect both commercial (HMO) and public (Medicare & Medicaid) health plans. And, according to NCQA, 90% of U.S. health plans rely on HEDIS measures to compare healthcare performance with other health plans.

HEDIS Incentives

Payer organizations recognize that there are widespread benefits that stretch beyond a competitive advantage for providing highly effective care. Higher HEDIS and CMS Star ratings are also associated with accelerated payer reimbursement programs, can save money through performance-based Provider reimbursements, and can highlight gaps and inefficiencies in care.

Accelerated Reimbursements

HEDIS is now recognized as the #1 standard of Payer reimbursement from federal and state agencies. Consider this, there are about 20-25 HEDIS measures that are directly tied to reimbursement. Each of those measures carries millions of dollars. Needless to say, we’re talking about a lot of money. The higher a health plan’s CMS Star ratings are, the more they are reimbursed for providing a higher quality of care. Additionally, if Star ratings fall below acceptable thresholds for 3 or more years a health plan can be forced to shut down.

Saving Money

With the goal of increasing HEDIS scores to attract more customers and provide a higher level of care, Payers have devised a pay for performance (P4P) model that financially incentivizes Providers to meet certain performance measures by incorporating more preventive care services such as cancer screenings, children well visits, and blood pressure management. In the same light, the P4P model is also setup to penalize Providers for poor outcomes and gaps in care.

By aligning better member outcomes with medical performance, Payers are shrinking the gaps in the level of care, therefore, ensuring that members are receiving preventative care and reducing the need for expensive surgeries and readmissions. This, in turn, saves money for commercial health plan customers, as well as publicly funded healthcare programs. Payers can then apply these savings to various organizational initiatives that can help further improve patient outcomes.

Highlighting Gaps in Care

Another advantage of incorporating HEDIS evaluations is that by their very nature HEDIS metrics will identify deficiencies. While HEDIS certainly rewards positive outcomes, it is also important to remember that it's a performance improvement tool which allows Payers to recognize any weaknesses in their services. As I mentioned earlier, improving HEDIS scores has everything to do with closing gaps, so by highlighting deficiencies, Payers can now shift resources accordingly to improve in those areas.

Improving HEDIS Scores

So far, we’ve examined the positive incentives associated with incorporating a HEDIS program. However, HEDIS evaluations are an annual endeavor. It is important that health plans continue to seek ways of improving their scores year-to-year. One certain way of doing this would be to implement a proper data management system.

According to the U.S. Census, there were over 300 million insured individuals in 2019. HEDIS metrics rely on data collected from all areas of the enterprise, from claims to member preference information. Without proper data management, HEDIS metrics can easily be skewed or completely incorrect. If the data isn’t properly managed, Payers can suffer financial penalties or, in some cases, even be forced to shut down for continuous violations. Here are a few key areas where proper data management can improve HEDIS scores:


  • Data Integration – Consolidating data sources will reduce complexity and make it easier to collect and connect the necessary data for HEDIS metrics.
  • Data Centralization – Delivering a single source of truth supports data governance and master data management. Additionally, health plans can be confident in the data they are using to calculate HEDIS scores, and annual HEDIS audits will run smoothly if all data is centralized, and transformations are clearly defined.
  • Data Modernization – Migrating from legacy to a modern cloud-based platforms can support the increased size of data seen in a growing organization and also accommodate the complex algorithms that HEDIS metrics are based on.
  • Analytics tools – Adopting proper business intelligence (BI) tools to securely share and develop data reports and dashboards can encourage targeted analytics to identify underlying causes of gaps in care.


At Data Ideology we have supported several Payer organizations with their HEDIS initiatives by utilizing these very same data practices. Our unique experience in this area, combined with our methodologies, have yielded consistent positive outcomes for these organizations. By creating a custom framework that optimizes an organization’s data life cycle we, in turn, help Health Plans maximize HEDIS evaluations and CMS Star ratings and, more importantly, enhance member satisfaction. Reach out to our Healthcare experts now for a quick, no-hassle data assessment.  

Written by Toby George

Co-Founder & Chief Executive Officer at Data Ideology

Toby George is the CEO and Co-Founder of Data Ideology with over 16 years of experience in developing and executing data management strategies, Business Intelligence methodologies, and complex analytic solutions.


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