Understanding HEDIS Measures: What You Need to Know Heading into 2025 and Beyond

Today, healthcare organizations are increasing their focus on enhancing the quality of care to optimize patient outcomes. An essential element of these efforts is a set of measures known as the Healthcare Effectiveness Data and Information Set, or HEDIS. Sometimes mistakenly referred to as “HEIDS,” HEDIS is a well-established tool used to assess healthcare quality, governed by the National Committee for Quality Assurance (NCQA). HEDIS offers a comprehensive framework for healthcare providers, payers, and patients to gauge the quality and effectiveness of healthcare services. These measures serve as a benchmark for healthcare payers and providers to track improvements, compare performance, and enhance the care that they are providing to patients and members. In fact, more than 90% of healthcare payers participate in HEDIS. HEDIS measures support better clinical outcomes for members and patients while also enabling a better overall healthcare experience.

Why is HEDIS important? What is the difference between HEDIS measures and HEDIS scores? How are HEDIS measures changing in 2025 and beyond? What role do digital tools play in transforming care delivery to improve HEDIS scores?  What is the financial impact of HEDIS improvement for a plan or provider? Throughout this blog post, we address these important questions.

To read more about HEDIS measures, technical resources, submission timelines, and other information, visit the official NCQA website for HEDIS and Performance Measurement.

Here is an overview of what to expect in the blog:

Bonus: New to HEDIS? Check out our basic information overview section at the end:

While HEDIS measures refer to the specific set of criteria used to evaluate healthcare quality, access, and effectiveness of care, HEDIS scores reflect the performance of a provider or plan against these measures. An important component of HEDIS is the assessment of providers and plans in relation to these measures. There is a specific process by which plans and providers must gather and submit data related to each measure as part of their overall assessment. You can learn more about the assessment and submission process by visiting the official NCQA website on HEDIS Data Submission. The output of that assessment is HEDIS scores, typically expressed on a percentile scale. These values are crucial for benchmarking against peers and for demonstrating compliance with quality expectations. Organizations utilize HEDIS scores to identify areas for improvement, showcase their quality standards to stakeholders, and gain a competitive advantage in the marketplace.

HEDIS measures are continuously updated to align with the latest advancements in healthcare and evolving patient needs, ensuring that they remain a relevant tool for evaluating quality. For measurement year (MY) 2025, NCQA has added three new HEDIS measures, retired a few measures, and made updates across some existing measures. As a whole, the NCQA is continuing to transition to Electronic Clinical Data Systems (ECDS) Reporting for HEDIS. To learn more about this new reporting method, please visit the NCQA website dedicated to this update. 

The three new measures include:

The NCQA has retired some measures including the Pain Assessment indicator under the Care for Older Adults measure because it was not considering different types of pain or accurately assessing pain. Additionally, they retired the Antidepressant Medication Management measure since it does not address other, non-pharmacological components of care for depression. By retiring these measures, the NCQA is demonstrating their commitment to evolving HEDIS measures to align with current quality standards and clinical guidelines.

NCQA has made changes to quite a few measures. To start, they are now using administrative reporting for Diabetes Eye Examsto simplify reporting with a more precise data capture. They have expanded Mental Health Follow Up, to ensure comprehensive tracking of the patient. They have adjusted prescribing practices for Medication Use in Older Adults. They have excluded telehealth from Pediatric Well-Care Visits, encouraging in-person visits for developmental screenings. They are now assessing hepatitis B immunizations for adults 19-59 as part of the Adult Immunization Status measure. And as part of their consideration to improve quality across diverse populations, they expanded the Acute Hospital Utilization measure to include Medicaid for members aged 18-64. Additionally, they updated the Chlamydia screening in women to include transgender members recommended for the routine screening to Chlamydia Screening.

Where is HEDIS headed into the future? Some of the emerging themes that we could see influence HEDIS measures moving forward include: social determinants of health (SDOH), which consider the wider context of patients’ and members’ lives, especially those aspects that impact their healthcare access, affordability, and outcomes; health equity, which closely aligns with SDOH, helping to identify and address disparities in care based on race and ethnicity; and, telehealth, which has risen in usage since the pandemic, and has provided a more convenient way for members and patients to get access to care. According to a recent PwC survey, almost 2 out of 3 healthcare consumers in the Millenial and Gen Z generations prefer virtual visits, or telehealth, over in-person doctor visits. HEDIS will have to adapt measures to meet the needs of these generations and the generations to come.

HEDIS is expected to see further evolution, as healthcare providers and payers increasingly adopt electronic health records and data analytics, making it possible to gather and report data more efficiently. This shift is likely to improve the precision of HEDIS measures, facilitating better quality assessments and enabling more timely interventions that can lead to improved patient care and outcomes.

Additionally, with the increasing use of digital tools for communication, payers and providers are able to encourage members and patients to follow through on their preventive screenings and other care management plans that influence HEDIS, resulting in a positive change to their HEDIS scores.

In fact, Relay’s healthcare payer clients have used our mobile engagement channel to communicate important screening reminders, help with diabetes care management, and improve compliance through appointment scheduling and medication adherence. Try out Relay’s solution by clicking the link below:

From a financial perspective, HEDIS scores have many benefits, both in increasing revenue, through reimbursement models and incentives, while also providing cost savings benefits through adherence to certain measures like preventive care or follow up after hospitalizations or emergency room visits. When payers and providers prioritize these measures with their patients and members, they prevent more serious and costly conditions and reduce readmission rates, both of which have significant cost benefits.

Also, higher HEDIS scores indicate quality care, which can attract new members and retain existing ones. In competitive markets, health payers with better quality scores are more appealing to patients, especially those with access to Medicare or employer-sponsored plans. And specifically, Medicare Advantage plans with high Star Ratings, which are influenced by HEDIS scores, can market those scores, attracting aging-in members to join their plan.

On the other hand, low HEDIS scores can lead to penalties and reduced reimbursements. Organizations with low scores may need to evaluate their organization and invest in better technology, staff, and other resources, resulting in additional costs. Lastly, lower scores make a payer or provider look less desirable for a consumer as compared to competitors who perform better on their HEDIS scores.

Given the financial impact that high HEDIS scores can have on a healthcare organization, HEDIS improvement is always top of mind for providers and payers. Below, we break down some of the most impactful strategies that healthcare payers and providers can implement to improve their HEDIS scores.

Communication and engagement are critical to the improvement of HEDIS scores. By created targeted communications that are personalized to a patient or member and their specific needs, healthcare payers and providers can inform patients and members about upcoming screenings, immunizations, care management tools, and other important resources. Through these communications, healthcare payers and providers can drive preventive care screenings and improve overall compliance, leading to better scores.

It’s important to consider the channels by which payers and providers communicate this information to members and patients. Meeting members and patients where they are, using digital engagement platforms is key to ensuring that this important information is consumed by the patient or member. Because of the sensitivity of the information being shared by a payer or provider, utilizing a HIPAA compliant communication platform can effectively drive this engagement. Check out our blog post all about HIPAA compliant texting and the best practices that payers and providers should consider when messaging their member and patient populations.

These platforms enable providers to connect with patients through secure messaging, appointment reminders, and personalized health content, fostering an interactive environment that encourages patients to take an active role in their healthcare. Studies have shown that patients who receive tailored digital communications are more likely to take preventive actions, such as completing colorectal cancer screenings or scheduling annual wellness visits, directly impacting HEDIS scores.

Using effective communication and engagement tools is the best way to get in front of patients and members to promote positive behaviors that influence HEDIS measures. In fact, one Relay healthcare payer client reported that by delivering tailored messages to members using the Relay Feed, they were able to improve upon 16 out of 24 HEDIS measures. Read more about Relay’s strategy for HEDIS improvement in our eBook “Relay’s Approach to Improving HEDIS Scores.

Using digital channels, as well as other forms of communication, healthcare payers and providers can promote preventive care, like general well visits, cancer screenings, and immunizations. Many health payers and providers have also found success in organizing health events that promote and encourage specific screenings while educating patients and members on those benefits.

Another important facet of HEDIS measures are those tied to hospital discharge follow up and reducing hospital readmission rates. Payers and providers must work to develop care transition plans that are communicated to members and patients, while also educating them on the cost of readmission and other options if they need additional support, like telehealth and urgent care. Payers and providers can use those same digital channels to communicate care transition plans as well as education to improve HEDIS scores.

Providing better access to care is another key strategy to improve HEDIS scores. By extending clinic hours, providing virtual options to members and patients, like telehealth, payers and providers expand their capabilities and can serve harder to reach populations, like those in rural areas which may be underserved.

Offering disease management programs for chronic diseases, like diabetes, can help drive adherence to care plans and educate patients and members on the best ways to manage their condition. These programs can also be delivered via digital communication channels, since they are where most members and patients are engaging today.

SDOH include challenges with transportation to appointments, food insecurity, and housing stability, which all can interfere with patient and member care. By offering services to help patients and members to reduce these barriers to care, payers and providers may see an uptick in things like appointment compliance and immunizations.

While encouraging members and patients to undergo specific screenings and immunizations, that effort is pointless without having proper data collection and tracking. EHRs or Electronic Health Records can serve as a guide for providers to monitor patient care gaps and alert them when patients are due for specific services. Providers can also use the data from an EHR for HEDIS reporting.

Lastly, payers and providers should conduct regular data reviews of HEDIS data to understand trends, gaps, and areas for improvement. By regularly reviewing the data and ensuring that it is organized, payers and providers will be ready when it comes time to submit the data for HEDIS measurement.

When should payers and providers implement improvement strategies? Enter HEDIS season. HEDIS Season refers to the time, typically between February and May, when providers submit their patient health records for HEDIS scoring. However, preparing for HEDIS season is a year-round affair. To get ahead of data submission, healthcare organizations should take a proactive and strategic approach that ensures they are well-equipped to achieve optimal outcomes year-round. For example, one way to get ahead is to integrate HEDIS measure tracking into the organization’s daily operations rather than treating it as a periodic task. This continuous focus allows healthcare providers and payers to identify areas for improvement early and implement timely interventions to address gaps in care. Another strategy includes leveraging previous patient and member data to glean insights into trends and measure the impact of specific interventions over time.

It’s important to hold regular training sessions with involved team members to maintain awareness and understand any changes in HEDIS requirements to ensure that everyone is aligned to those specific quality improvement goals.

Finally, fostering relationships with patients through effective communication and education initiatives can significantly enhance member and patient health literacy and engagement, resulting in better adherence to care plans and, ultimately, improved HEDIS performance. Here is where using HIPAA compliant digital tools designed to better engage with members and patients can be an effective strategy for outreach and communication to drive results.

HEDIS measures are paramount in guiding healthcare providers and payers toward delivering high-quality, effective, and accessible care. These measures not only enable the monitoring and improvement of healthcare services, but also serve as a benchmark for evaluating performance in various domains, including preventive care and chronic disease management. By integrating HEDIS measures into their operational frameworks, healthcare organizations can enhance patient outcomes and satisfaction, while also meeting the rigorous standards for healthcare quality. Healthcare organizations should continuously look to prioritize HEDIS improvement, as this can significantly bolster their ability to thrive in a competitive, value-based care environment. To learn more about Relay’s methodology for improving HEDIS scores, take a look at our Ebook, “Relay’s Approach to Improving HEDIS Scores.”

For more comprehensive information about HEDIS, you can refer to the official NCQA website dedicated to HEDIS.

HEDIS measures consist of over 90 measures that sit across six critical domains of care: effectiveness of care, access/availability of care, experience of care, utilization, health plan descriptive information, and risk adjustment utilization. Among the most common measures, HEDIS tracks performance in areas such as preventive care, chronic disease management, and mental health services, reflecting its broader aim to prioritize proactive and holistic health management. These measures create a consistent framework for maintaining and enhancing care quality, enabling healthcare payers and providers to benchmark their performance and strive for continuous improvement. Payers and providers can use HEDIS measures as point of reference for developing strategies that not only improve patient care, but also assist payers and providers in meeting regulatory and financial goals.

HEDIS measures help healthcare providers track and enhance the quality of care they deliver. By utilizing these measures, providers can gain insights into their own service performance, allowing them to benchmark against peers and strive toward clinical excellence. Additionally, as value-based care programs are increasingly prioritized, HEDIS measures offer an essential methodology for participation, promoting a shift from volume-based to value-based care.

For payers, HEDIS measures are equally crucial as they inform key decisions regarding healthcare coverage and reimbursement models, ensuring financial resources are allocated to plans that demonstrate superior care quality. Additionally, they can provide insights into care gaps and areas of improvement within the payer to help lead to better health outcomes and lower long-term costs. Scores received against HEDIS measures allow payers to compare their performance against other health payers using a standardized set of measures, fostering competitive improvement within the industry. Additionally, High HEDIS scores can differentiate payers in competitive markets, attracting and retaining members by demonstrating a commitment to quality.

Patients and members are the ultimate benefactors, as HEDIS measures ensure they receive high-quality care tailored to their needs. Because of HEDIS, patient outcomes are improved, and satisfaction is heightened, reinforcing trust with their healthcare providers, systems, and payers. For patients and members, scores related to HEDIS measures serve as a reflection of a healthcare organization’s effectiveness in delivering patient care or a payer’s effectiveness at implementing preventive healthcare initiatives.

To learn more about how Relay can help with your member engagement, reach out to sales@relaynetwork.com

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Change Healthcare, “Improving HEDIS Scores Can Help Increase Revenue for Payers”

McKinsey, 2024, “Consumers rule: Driving healthcare growth with a consumer-led strategy”

PwC, “2024 US Healthcare Consumer Insights and Engagement Survey”

NCQA, HEDIS Data Submission

NCQA, HEDIS