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HEDIS®

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What is HEDIS®?  
HEDIS® is a set of standardized performance measures designed to ensure that the public has the information it needs to reliably compare the performance of managed health care plans. It is one component of a larger accountability system and complements the National Committee for Quality Assurance (NCQA) Accreditation Program. When combined, the results of NCQA accreditation and HEDIS® provide the most complete view of health plan quality currently available to purchasers and consumers.  
NCQA’s first HEDIS® set was released in 1993 and became a national standard for health plan performance reporting. HEDIS® 2005 contains 61 measures across 8 domains of care. Those domains are:  

Effectiveness of care

Access/availability of care

Satisfaction with the experience of care

Health plan stability

Use of services

Cost of care

Informed health care choices

Health plan descriptive information

 
The following are Medicaid HEDIS® measures in the three domains that measure specific areas in care and service.  
 
1. Effectiveness of Care Domain

Childhood immunization status

Adolescent immunization status

Appropriate treatment for children with upper respiratory infection

Appropriate testing for children with pharyngitis

Breast cancer screening

Cervical cancer screening

Chlamydia screening in women

Controlling high blood pressure

Beta-blocker treatment after a heart attack (first-year measure)

Cholesterol management after acute cardiovascular event

Comprehensive diabetes care

Use of imaging studies for low back pain

Medical assistance with smoking cessation

 
2. Access/availability of care domain

Adults’ access to preventive/ambulatory health services

Children and adolescents’ access to primary care practitioners

Prenatal and postpartum care

Annual dental visit

Initiation and engagement of alcohol and other drug dependence treatment

Claims timeliness

Call answer timeliness

Call abandonment

 
3. Use of services domain

Frequency of ongoing prenatal care

Well-child visits in the first 15 months of life

Well-child visits in the third, fourth, fifth, and sixth years of life

Adolescent well-care visits

Frequency of selected procedures

Inpatient utilization - general hospital/acute care

Ambulatory care

Inpatient utilization - non acute care

Discharges and average length of stay - maternity care

Births and average length of stay, newborns

Mental health utilization - inpatient discharges and average length of stay

Mental health utilization - percentage of members receiving inpatient and intermediate care and ambulatory services

Chemical dependency utilization - inpatient discharges and average length of stay

Identification of alcohol and other drug services

Outpatient drug utilization

 
NCQA accreditation requires an NCQA accredited Managed Care Organization (MCO) to annually submit audited results for all required HEDIS® measures relevant to that product line.  
Nineteen (19) of the 100 points scored for accreditation are attributed to HEDIS® measures. Each reporting year HEDIS® scores are recalculated along with Consumer Assessment of Health Plan Survey (CAHPS) scores. This recalculation can change the MCO’s accreditation category annually.  
HEDIS® is a registered trademark of the National Committee for Quality Assurance. 
 
Last Update: 11/13/06 Version: 1 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use