HEDIS: Healthcare Effectiveness Data and Information Set
HEDIS is the industry-standard performance measurement set administered by NCQA, used by more than 90% of US health plans to measure performance in care delivery, patient safety, and member experience across 90+ standardised measures.
What is HEDIS?
The Healthcare Effectiveness Data and Information Set (HEDIS) is developed and maintained by the National Committee for Quality Assurance (NCQA). First developed in 1991, HEDIS has become the universal currency for health plan quality measurement in the United States. Plans reporting HEDIS results cover more than 190 million Americans.
The 8 HEDIS Domains
- Effectiveness of Care
- Access/Availability of Care
- Experience of Care
- Utilization and Risk Adjusted Utilization
- Health Plan Descriptive Information
- Measures Reported Using Electronic Clinical Data Systems (ECDS)
- Measures Collected Via Survey
- Behavioral Health
HEDIS and Medicare Advantage Star Ratings
HEDIS measures make up a substantial portion of the CMS Medicare Advantage Star Rating system, which determines quality bonus payments for MA plans. Plans achieving 4+ stars receive Quality Bonus Payments (QBPs) that can amount to hundreds of millions of dollars. Plans at 5 stars receive additional bonuses and can enroll members year-round outside of open enrollment. HEDIS performance therefore directly drives MA plan revenue and competitive positioning.
Key Clinical HEDIS Measures
Important HEDIS measures include: Controlling High Blood Pressure (CBP), Comprehensive Diabetes Care (CDC — which includes A1C control, eye exams, and kidney disease monitoring), Colorectal Cancer Screening (COL), Breast Cancer Screening (BCS), Childhood Immunization Status (CIS), and Antidepressant Medication Management (AMM). Each measure has a precisely defined numerator, denominator, and exclusions — and small improvements in high-weight measures can meaningfully shift a plan's overall star rating.
Why HEDIS Analytics Matters
HEDIS measurement relies on both administrative data (claims) and hybrid medical record review. Identifying care gaps in advance of the measurement year — before the record review window — allows practices and health plans to close gaps through appropriate clinical outreach rather than retrospective chart review. Provider-level HEDIS performance also increasingly influences value-based contract performance and shared savings distributions.