HEDIS^® Measures

Provider Resources for Understanding Quality

The UnitedHealthcare Quality Reference Guide is designed to provide health plan Primary Care Providers (PCP) and Behavioral Health Providers with information on quality measures and what they mean for you and to the health plan.

The health plan requests collaboration with providers to improve the quality of care for our members and your patients. The information provided within this guide is an overarching view of quality as well as measure specifications and coding details. This resource guide will be updated annually or as changes are implemented.

• UnitedHealthcare Quality Reference Guide

Below is a breakout of key priority measures listed within the resource guide:

Adult

• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
• Controlling high Blood Pressure (CBP)
• Colorectal Cancer Screening (COL)
• Appropriate Testing for Pharyngitis (CWP)
• Use of Imaging Studies for Low Back Pain (LBP)
• Statin therapy for patients with cardiovascular disease – received therapy and 80% medication adherence (SPC)
• Appropriate Treatment for Upper Respiratory Infection (URI)

Diabetes

• Blood Pressure Control for Patients with Diabetes (BPD)
• Eye Exam for patients with Diabetes (EED)
• Hemoglobin A1c Control for Patients with Diabetes (HBD)
• Statin therapy for patients with diabetes – received therapy and 80% medication adherence (SPD)
• Kidney Health Evaluation for Patients with Diabetes (KED)

Women’s

• Breast Cancer Screening (BCS)
• Cervical Cancer Screening (CCS)
• Prenatal and Postpartum Care (PPC)

Pediatrics

• Appropriate Treatment for Upper Respiratory Infection (URI)
• Childhood Immunization Status (CIS)
• Appropriate Testing for Pharyngitis (CWP)
• Immunizations for Adolescents (IMA)
• Well-Child Visits in the First 30 Months of Life (W30)
• Child and Adolescent Well-Care Visits (WCV)
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

HEDIS Resources, HEDIS Lunch & Learn

• Coding Tool MY2022
• Coding and Closing Gaps in Care – Lunch & Learn MY2022
• Adult Measures – Lunch & Learn MY2022

Background

Health plan quality is tracked and measured by the National Committee for Quality Assurance (NCQA). Accreditation evaluates core systems and processes that make up a health plan, as well as actual results the plan achieves on key evaluations of the health care system. Providers play a vital role in helping the health plan meet accreditation goals. This in turn allows the health plan to set improvement goals and projects each year.

What is a performance measure?

A performance measure is a set of technical specifications that define how a rate is calculated for an important quality indicator. HEDIS is the most widely used set of performance measures in the managed care industry.

HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS was developed, and is maintained by the National Committee for Quality Assurance (NCQA). NCQA take HEDIS measurements very seriously. All measures that are implemented meet three key criteria: relevance, soundness and feasibility. NCQA takes great care in making sure that all measures address important issues, are scientifically sound and are not overly burdensome or costly to implement.

CAHPS^®

Health plans conduct a member satisfaction survey called the Consumer Assessment of Healthcare Providers and Systems (CAHPS). CAHPS is a member survey that gauges satisfaction with services provided by the health plan as well as member perception of provider accessibility, the patient-physician relationship and provider communication.

This survey is conducted annually and results are then compared with national benchmarks.

How can providers help?

• Open the lines of communication with your patients. Communicate thoroughly and in a way they can understand.
• Listen to your patients and make sure they understand what you have discussed/ordered, etc.
• Submit referrals and obtain authorizations as appropriate.
• Be aware of patient wait times and limit them when possible.
• Encourage preventive measures such as influenza and pneumococcal vaccines.

For further information on HEDIS, please see the details in the UHC Quality Reference Guide or feel free to reach out to the Quality, Strategy and Performance team at QSPOTeam@optum.com.