Quality Measures and the Role of CBOs: 

HEDIS

Tim McNeill, RN, MPH
Agenda 

1. HEDIS Measures Overview

2. Role of HEDIS to MCOs

3. Role of CBOs in HEDIS

4. How to use HEDIS Data in contracting
What Are HEDIS Measures?

3 

• Health Effectiveness Data and Information Set

• Tool used to measure performance of health plans

• 90% of all health insurance plans use HEDIS to 

measure performance

• HEDIS is the registered trademark of the National 

Committee for Quality Assurance (NCQA)

– NCQA is a 501 (c)(3) not-for-profit organization

– Founded in 1990 
Why Measure Health Plan Quality?

4 

• HEDIS allows a consumer to use a independent, 

neutral criteria to directly compare health insurance 

plans

• All NCQA accredited health plans must report HEDIS 

measures

• NCQA is contracted with CMS to accredit Medicare 

Advantage (MA) and Health Insurance Exchange 

plans
What Does HEDIS Measure?

5 

• HEDIS measures provide an indication of how health 

plans perform on specific quality measures

• Most of the measures indicate the status of clinical 

outcomes for the population of beneficiaries enrolled 

in the health plan – plan members

• HEDIS also includes the CAHPS Survey

– Consumer Assessment of Healthcare Providers and Systems

– Evaluates consumer experiences with health care
Why Are HEDIS Measures Important 

to MCOs?

6 

• HEDIS is one component of the NCQA accreditation 

process

• As an indicator of quality, HEDIS measures reflect the 

quality of care for the population

• Poor performance on HEDIS could negatively impact:

– NCQA Accreditation status

– New Member enrollment

– Retaining current members

– Federal (MA) and State (Medicaid) health plan contracts
How Does HEDIS Impact 

Physicians?

7 

• As we move to value-based payment models, 

MCOs are increasingly contracting with 

physician groups based on HEDIS outcome 

performance

– Pay for performance 

– Incentives to close “gaps in care”

– Preferred contracting status

– Larger patient panels
How Do Consumers Influence HEDIS 

Outcomes?

8 

• HEDIS measures indicate services that were 

rendered to the population. 

– Ordered services that were not rendered do not count 

– Consumer adherence or non-compliance are not accounted for 

and directly impact HEDIS outcomes
Common HEDIS Measures

9 

• Diabetes

– Hgb A1C, foot screening, retinopathy screening, LDL, etc.

• Preventive Health Care

– Colonoscopy screening

– Breast cancer screening

• Immunizations

– Flu, Pneumonia 
Example of Consumer Choice on 

HEDIS

10

• Retinopathy Screening for Diabetes

– Ms. Jones has an order for Retinopathy screening. 

Unfortunately, she was not educated about the importance of 

Retinopathy screening and feels that she just got her “Eyes 

Checked” and prescription glasses adjusted.

• Colonoscopy Screening 

– Ms. Jones lives alone in an assisted living facility. Has limited 

care giver support. Her inability to secure transportation 

caused her to “No Show” for her ordered colonoscopy screen
About HEDIA Measures

11

• HEDIS consists of 81 measures that cross 5 domains of 

care

• HEDIS Measures are updated annually

• New measures are introduced or modifications to 

current measures occur at the annual update
HEDIS Data Sources

12

• There are two data sources for HEDIS measures

– Primary

– Supplemental 

• The primary data source is claims data

• Supplemental data sources include the following:

– Laboratory result files

– Pharmacy data

– Electronic health record (EHR) vendor system files

– Data from NCQA Certified Measure Systems
Primary Data Source Utilization

13

• Claims data is the primary data source for HEDIS

• It provides a definitive source to validate that a service 

was provided

– Examples 

• Breast cancer screening

• All–cause readmissions
Example of the Impact of Data 

Source on HEDIS

14

• Data source example: Preventive Care - Flu shot

– Ms. Jones receives a flu shot at the local senior center during a 

immunization fair

– Ms. Jones sees her doctor and refuses the flu shot 

– No record of flu shot in claims data
Example of Primary Data Reporting

15

• Current HEDIS Measure: All-cause readmission

• All-cause readmission is calculated in the following 

manner:

(Count of 30-Day Readmissions – Planned Readmissions)

______________________________________________

 Count of Index Hospital Stays

• Claims data provides the outcome of this HEDIS measure for the 

population of health plan members, during the defined reporting 

period 
Unacceptable Data Sources

16

• Data sources that are not acceptable for HEDIS 

reporting include some of the following:

– Member health surveys

– Member completed Health Risk Assessments (HRAs)

– Beneficiary self-reported data collected through phone 

surveys 

– Data sources that are not reviewed or validated by a 

qualified practitioner

– Other data sources that are not collected in a NCQAcertified HEDIS reporting system or other certified 

Electronic Health Record system
When is HRA data accepted?

17

• A Health Risk Assessment that is reviewed and 

completed by a practitioner – with the member present – 

is an acceptable supplemental data source

• A community-based organization (CBO) working with a 

practitioner can support the collection of HRA data, but 

it must be completed and reviewed by the practitioner – 

with the member present
CBO Support of HEDIS Measures

• CBOs can support the capture and reporting of 

HEDIS measures

• CBOs must be aware of the current HEDIS 

measures and support the collection of necessary 

data

• Data must be collected and reported using an 

acceptable data source in order to be present a 

value-added service to a health plan
Key takeaway for HEDIS 

reporting 

• Claims data is always a primary data source

• Supporting consumer completion of indicated tasks that are 

billed to their insurance automatically helps the completion 

of HEDIS

• If a CBO wishes to support capturing HEDIS measures 

using a supplemental data source, it must be reviewed by a 

practitioner, with the member present
Example of CBO Supplemental 

Data Capture for HEDIS

• Comprehensive Medication Review (CMR)

– New HEDIS Measure (Also linked to MA star ratings)

– CBO can support data collection, but it must be reviewed 

and validated by a pharmacist for each qualifying member

– Requires a detailed, individual review of the following 

elements with the member present

• Medical history

• Prescribed medications

• Medication adherence

• Over the Counter (OTC)/herbal supplement/vitamin 

usage 
CMR Unacceptable Example 1

• Comprehensive Medication Review (CMR)

– CBO collects list of hospital discharge medications as part of 

a care transitions intervention

– CBO screens the list of prescribed medications using the 

Beers Criteria for Potentially Inappropriate Medication Use 

in Older Adults

– CBO refers “High Alerts” to local pharmacist to review

– Pharmacist addresses high alerts and conducts a general 

review of the discharge medication list without the member 

present
Problems for Meeting HEDIS 

Requirements for Example 1

• Pharmacist only addresses Beers alerts

• Comprehensive review of the following elements not 

completed

– Medical History, Medication Adherence, OTCs, Herbals, 

Supplements

• All elements not directly reviewed by the pharmacist --

with the member 

• Total interaction not documented in certified system
CMR Unacceptable Example 2

• Comprehensive Medication Review (CMR)

– CBO collects list of hospital discharge medications as part of 

a care transitions intervention

– CBO screens the list of prescribed medications using the 

Beers Criteria for Potentially Inappropriate Medication Use 

in Older Adults

– No alerts noted. Information documented in the CBO care 

transitions tracking software
Problems for Meeting HEDIS 

Requirements for Example 2 

• Comprehensive review, by the pharmacist, directly 

with the member not completed

• Comprehensive collection of each required data 

element not completed
HEDIS Measures that CBOs 

Services Could Influence

• All-Cause Readmissions

• Prevention

– Breast cancer, colorectal cancer, or glaucoma screening

• Comprehensive Diabetes Care

• Influenza

• Body Mass Index (BMI) Assessment

• Falls Risk Management in Older Adults

• Advanced Care Planning for Older Adults
Falls Risk Management

• Two Components of Fall Risk Management Measure:

• Discussing Fall Risk. The percentage of Medicare-enrolled 

adults 65 years of age and older with balance or walking 

problems or a fall in the past 12 months, who were seen by a 

practitioner in the past 12 months and who report discussing 

falls or problems with balance or walking with the practitioner. 

• Managing Fall Risk. The percentage of Medicare-enrolled 

adults 65 years of age and older who had a fall or had problems 

with balance or walking in the past 12 months, who were seen 

by a practitioner in the past 12 months and who report receiving 

fall risk intervention from the practitioner.
All-Cause Readmissions

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• 30-day readmission

• Numerator Description

– At least one acute readmission for any diagnosis within 30 days of 

the Index Discharge Date minus planned readmissions

– “What are examples of planned readmissions?” 

• Denominator Description

– Acute inpatient discharges for commercial members 18 to 64 years 

of age and Medicare members 18 years of age and older as of the 

Index Discharge Date who had one or more discharges on or 

between January 1 and December 1 of the measurement year
Contract Capture Strategy

28

• HEDIS is an important component of an overall health 

plan contracting strategy

• Your ability to support capturing and reporting HEDIS 

data-- along with a defined Return on Investment (ROI) 

should both be included in your presentations to health 

plans
More on ROI

29

• ROI should be part of a presentation to health plans (and 

other integrated care entities)

• How can you calculate ROI?

Net savings from changes in utilization

________________________________ = ROI

 Program costs
ROI Interpretation

30

• ROI greater than 1 (>1): greater than expected 

savings

• ROI less than 0 (<0): less than expected savings

• ROI between 0 and 1: Results are small or 

inconclusive

• Example: ROI of 2: $2.00 in reduced healthcare 

expenses produced for every $1.00 invested
All-Cause Readmissions (continued)

31

• Anywhere AAA CCTP cost calculation:

• CCTP Rate of $450 per eligible discharge

• 20,000 Eligible Discharges per year

• $450 X 20,000 = $9,000,000

• ROI Calculation:

$19,200,000 (Net Savings) / $9,000,000 (Cost to health plan) = 2.13
CCTP Contract Capture Strategy

32

• Anywhere AAA has a defined ROI of 2.13

• Anywhere AAA provides a value-added service that 

supports the following, in addition to the direct ROI:

– 100% of health plan funding for intervention, goes towards 

Medical Loss Ratio (MLR) requirement 

– Improved HEDIS outcomes for All-Cause Readmissions 

– Anywhere AAA will capture data in NCQA certified system 

– CCTP collaborates with local pharmacist that conducts FULL 

Comprehensive Medication Reviews (CMRs) with EACH 

individual member 

• CMR must meet all of the required elements to count for 

HEDIS
Assessing Health Pan HEDIS 

Performance 

33

• ACL Tip Sheet

• http://www.acl.gov/Programs/CIP/OICI/BusinessAcum

en/docs/HEDIS_Performace_Tip_Sheet_Final.pdf

• Review of the Care of Wisconsin HEDIS report 
Quality Webinar Series

34

• Next two webinars in this series:

– Medicare Advantage Star Ratings

– Accountable Care Organization Quality Measures
Questions 

• Tim McNeill, RN, MPH

• ACL/AoA Consultant

– Phone: (202) 344-5465

– E-mail: tmcneill@me.com