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Learn the Lingo: Key Terms for Navigating the Value Based Care World

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG.

Published on Wednesday, September 8, 2021

Healthcare Effectiveness Data and Information Set (HEDIS)

Definition: HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information needed for reliable comparison of health plan performance.1-3 Performance is evaluated using over 90 measurements across 6 domains of care: effectiveness of care, access/availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems.2 Claims and survey data are aggregated and analyzed retrospectively to depict the quality of care and customer service delivered to patients.1,2

How it relates to ACO/PCMH: HEDIS measures are commonly included as required metrics in value-based payment programs, such as MIPS, and quality rating programs (e.g., Star Ratings).3 HEDIS measures are used in evaluating the quality of care provided by health care practitioners, and meeting HEDIS measure targets is a factor in determining quality incentive payments.2,3 Many HEDIS measures are clinically focused on acute and chronic conditions, and some focus specifically on medications.1 Pharmacists’ medication- and health-related expertise can be leveraged to impact these measures to reach goals, resulting in incentives to the practice. Pharmacists should be engaged in HEDIS metrics impacting their ACO and/or PCMH to improve quality of care. Pharmacists are involved in some HEDIS measures including statin therapy for patients with cardiovascular disease and diabetes, medication reconciliation post-discharge, comprehensive diabetes care, and controlling high blood pressure.1 Pharmacist-initiated improvement in HEDIS measures leading to incentive payments can be part of the financial justification for increased pharmacist services.

Involved organizations/oversight: HEDIS is administered and overseen by the National Committee for Quality Assurance (NCQA) to improve the quality of health care. HEDIS is used by CMS, other health insurance plans, and health care organizations nationwide.1,2

Resources:

  1. CMS. Healthcare Effectiveness Data and Information Set (HEDIS). Available at: www.cms.gov/Medicare/Health-Plans/SpecialNeedsPlans/SNP-HEDIS
  2. NCQA. HEDIS measures and technical resources. Available at: www.ncqa.org/hedis/measures/
  3. Maurer J. What is HEDIS and what does it mean to you? Available at: https://magellanhealthinsights.com/2017/03/15/what-is-hedis-and-what-does-it-mean-to-you/

Contributing author:

Neeloufar Fakourfar, PharmD, BCACP

Chapman University School of Pharmacy

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